THE NURSING PROCESS

• Nurses use the problem-solving process to identify human responses and to plan, implement, and evaluate nursing care.

• When scientific problem solving is used within the context of nursing, it is known as the nursing process.

• The nursing process contains five steps: assessment, analysis/nursing diagnosis, planning, implementation, and evaluation.

• Because the nursing process incorporates critical thinking used by nurses to meet patients’ needs, items on nursing examinations are designed to test the use of this process.

• Test items are not written haphazardly.

• They are carefully designed to test your knowledge of a specific concept, skill, theory, or fact, from the perspective of one of the five steps of the nursing process.

• When reading an item, being able to identify its place within the nursing process should contribute to your ability to recognize what the test item is asking.

• To do this, you must focus on the critical words within the item.

ASSESSMENT

• During assessment, data must be accurately collected, verified, and communicated.

• Assessment items are designed to test your knowledge of information, theories, principles, and skills related to the assessment of the patient.

• This establishes the foundation on which nurses base the subsequent steps in the nursing process.

Assessment questions ask you to:

• Obtain vital statistics• Perform a physical assessment• Collect specimens• Identify patient adaptations that are

objective or subjective• Identify patient adaptations that are verbal

or nonverbal

• Identify adaptations that are expected (normal) or unexpected (abnormal)

• Use various data collection methods• Identify sources of data• Verify critical findings• Identify commonalities and differences in

response to illness• Communicate information about

assessments to appropriate members of the health team

• The critical words within a test item that indicate that the item is focused on assessment include these: inspect, identify, verify, observe, determine, notify, check, inform, question, communicate, verbal and nonverbal, signs and symptoms, stressors, adaptations, sources, perceptions, and assess

Most testing errors that occur on assessment items occur because options are selected that:

• Collect insufficient data• Have data that are inaccurately collected• Use unscientific methods of data

collection• Rely on a secondary source rather than

the primary source, the patient• Contain irrelevant data

• Fail to verify data• Reflect bias or prejudice• Fail to accurately communicate data

COLLECTING DATAMethods of Data

Collection

• Collecting data is the first part of ASSESSMENT.

• The nurse collects data through specific methods of data collection, such as performing a physical examination, interviewing, and reviewing records.

• A physical examination includes the assessment techniques of inspection, palpation, auscultation, and percussion.

• Also, it includes obtaining the vital signs and recognizing acceptable and unacceptable parameters of obtained values.

• Interviewing collects data using a formal approach (e.g., obtaining a health history) or an informal approach (e.g., exploring feelings while providing other nursing care).

• Review of records includes consideration of reports such as the results of laboratory tests, diagnostic procedures, and assessments or consultations by other members of the health team.

• While making rounds, the nurse finds a patient on the floor in the hall. What should be the nurse’s initial response?

(a) Inspect the patient for injury(b) Transfer the patient back to bed(c) Move the patient to the closest chair(d) Report the incident to the nursing supervisor

• This item tests your ability to recognize that, in an emergency situation, the nurse must first assess (inspect) the condition of the patient.

• This principle is basic to any emergency response by a nurse.

• Moving a patient before an assessment could worsen an injury, this item demonstrates how a basic concept related to assessment can be tested.

• What should the nurse do to avoid patient accidents?

a) Keep an over bed table in front of a sitting patient

b) Determine the strength of a patient before walking

c) Provide a cane for ambulation if the patient is weak

d) Apply a vest restraint when a patient uses a wheelchair

• This item tests your ability to recognize the concept that the nurse must assess a patient before implementing care.

• The three distractors are all concerned with implementing care.

• This question also tests your ability to recognize physical examination as a method of collecting data about the status of a patient.

Sources of Data• Data can be gathered not only by different

methods but also from different sources.

• Sources of data available to the nurse include those that are primary, secondary, and tertiary.

• There is only one primary source, the patient.

• The patient is the most valuable source of information because the data collected are the most current and specific to the patient.

• A secondary source produces information from someplace other than the patient.

• A family member is a secondary source who can contribute information about the patient’s likes and dislikes, ethnic and cultural background, similarities and differences in behavior, and functioning before and during the health problem.

• The patient’s medical record (chart) is another example of a secondary source.

• It is a legal document containing information that concerns the patient’s physical, psychosocial, religious, and economic history and documents the patient’s physical and emotional adaptations

• Controversy surrounds the labeling of diagnostic test results in a chart as being from either primary or secondary sources.

• Although the chart itself is a secondary source, diagnostic test results are direct objective measurements of the patient’s status and therefore are considered by some health-care providers to be a primary source.

• The nurse must remember that the information in a chart is history and does not reflect the current status of the patient because the patient is dynamic and constantly changing.

• Secondary sources are valuable for

gathering supplementary information about a patient.

• A tertiary source provides information from outside the specific patient’s frame of reference.

• Examples of tertiary sources include textbooks, the nurse’s experience, and accepted commonalities among patients with similar adaptations.

• The nurse’s or other health team members’ responses to the patient are tertiary sources of patient data.

• The nurse asks a patient’s wife specific questions about the patient’s health complaints before admission. When collecting this information, the nurse is seeking information from a:

(a) Primary source

(b) Tertiary source

(c) Subjective source

(d) Secondary source

• This item tests your ability to recognize that a family member is a secondary source of information.

• Secondary sources provide information that is supplemental to the information collected from the patient.

Types of Data

• The types of data collected when assessing a patient can be objective or subjective, verbal or nonverbal.

• Objective data are measurable assessments collected when the nurse uses sight, touch, smell, or hearing to acquire information.

• Examples of objective data include an excoriated perineal area, diaphoresis, ammonia odor of urine, crackles, and vital signs.

• Subjective data can be collected only when the patient shares feelings, perceptions, thoughts, and sensations about a health problem or concern.

• Examples of subjective data include patient statements about pain, shortness of breath, or feeling depressed.

• The nurse is performing a physical assessment of a newly admitted patient. Which patient statement communicates subjective data?

a) “I have sores between my toes.”b) “I dye my hair but it is really grey.”c) “My left leg drags on the floor when I

walk.” d) “My joints hurt when I get up in the

morning.”

• This item tests your ability to differentiate between subjective and objective data.

• The nurse should know the types of data collected for the purposes of future clustering and determining their significance.

• Any information that the patient shares regarding feelings, thoughts, and concerns is subjective.

• Any information that the nurse verifies using the senses (e.g., vision, hearing, smell, and touch) or via some form of instrumentation (e.g., thermometer, pulse oximetry, laboratory data) is objective.

• Communication can be verbal or nonverbal.

• Verbal data are collected via the spoken or written word.

• For example, statements made to the nurse by the patient are verbal data.

• Nonverbal data are collected via transmission of a message without words.

• Crying, a fearful facial expression, the appearance of the patient, and gestures are all examples of nonverbal data.

• What is an example of nonverbal communication?

a) A letter

b) Holding hands

c) Noise in the room

d) A telephone message

• This item tests your ability to recognize that holding hands is a form of nonverbal communication.

• Nonverbal communication does not use words.

• Touch, gestures, posture, and facial expressions are examples of nonverbal communication.

VERIFY DATA• After data are collected, they must be

verified.

• To verify data is to confirm information by collecting additional data, questioning orders, obtaining judgments and/or conclusions from other team members when appropriate, and by collecting data oneself rather than relying on technology.

• Verifying data ensures authenticity and accuracy.

• For example, when a vital statistic is outside the expected range, the nurse must substantiate the results first by collecting the data again and then collecting additional data to supplement the original information.

• The nurse takes the patient’s blood pressure and records a diastolic pressure of 120. What should the nurse do FIRST?

a) Retake the blood pressureb) Take the other vital signsc) Notify the nurse in charged) Notify the physician

• This item tests your ability to identify that you need to verify data when they are unexpectedly outside the acceptable range.

• Your first action should be to wait a minute and then retake the blood pressure.

• An error may have been made when taking the blood pressure.

COMMUNICATE INFORMATION ABOUT ASSESSMENTS• The last component of assessment

includes the nurse’s ability to communicate information obtained from assessment activities.

• Sharing vital information about a patient is essential if members of the health team are to be alerted to the most current status of the patient.

• Communication methods vary (e.g., progress notes, verbal notification, flow sheets); however, they all share the need to be accurate, concise, thorough, current, organized, and confidential.

• When assessing a patient with a fluid volume deficit, which assessment should the nurse document on the patient’s record?

a) Thready radial pulse and straw-colored urine

b) Straw-colored urine and decreased skin turgor

c) Urine specific gravity of 1.015 and thready radial pulse

d) Decreased skin turgor and a urine specific gravity of 1.035

• This item tests your ability to assess for patient adaptations related to a fluid volume deficit and document these adaptations on the patient’s record so that they can be communicated to other health team members.

Analysis/Nursing Diagnosis• Analysis, the second step of the nursing

process, is the most difficult component.

• Analysis requires that data be validated and clustered and that their significance be determined.

• To analyze data, you need a strong foundation in scientific principles related to nursing theory, social sciences, and physical sciences.

• You need to know the commonalities and differences in patients’ responses to various stresses.

• You need to use reasoning to apply your knowledge and experience when answering analysis items.

• After the initial analysis of data, sometimes additional data need to be collected and analyzed.

• Only after all the data have been analyzed should a nursing diagnosis be made.

Analysis questions ask you to:• Validate interrelationship of data• Cluster data

• Identify clustered data as meaningful• Interpret validated and clustered

data• Identify when additional data are

needed to further validate clustered data

• Identify nursing diagnoses

• Communicate nursing diagnoses to others

• The critical words within a test item that indicate that the item is focused on analysis/nursing diagnosis include these:

• valid, organize, categorize, cluster, reexamine, pattern, formulate, nursing diagnosis, reflect, relate, problem, interpret, contribute, relevant, decision, significant, deduction, statement, and analysis.

• Testing errors occur on analysis items when options are selected that:

• Omit data• Cluster data prematurely• Make a nursing diagnosis before all

significant data have been clustered• Force the nursing diagnosis to fit the

signs and symptoms collected