6.1 The Nursing Process, Nursing Diagnosis & Holistic Health Assessment
Key Takeaways
The nursing process cycles through assessment, diagnosis, planning, implementation and evaluation; assess before acting unless the client is in immediate danger.
The abdomen is examined in the order inspection, auscultation, percussion, palpation, so that handling does not alter bowel sounds.
A PES nursing diagnosis states the Problem, its Etiology (related to) and the Signs and symptoms (as evidenced by); risk diagnoses have no signs yet.
Client goals must be SMART and describe the client's behaviour, for example clear breath sounds within 48 hours.
The CARICOM Blueprint frames assessment around physiological and psychosocial basic needs and the life-cycle age groups.
The Nursing Process, Nursing Diagnosis and Holistic Health Assessment
Nursing Practice competency 2 is to use the nursing process as the framework for safe, ethical and effective care. Competencies 7–9 cover selecting valid assessment tools, collecting data systematically, and interpreting data to choose interventions. The CARICOM Blueprint calls the nursing process "the scientific methodology used by nurses to deliver nursing care". Its four phases are assessment, planning, implementation and evaluation, and many textbooks add diagnosis as a separate step (ADPIE). Almost every clinical item on the RENR is a step in this cycle, so knowing which step a question tests is half the answer.
The Five Steps
| Step | What the nurse does | Typical RENR verb |
|---|---|---|
| Assessment | Collects subjective and objective data systematically; validates findings | "What should the nurse assess first?" |
| Diagnosis | Analyses data and states the client's actual or potential problem | "Which nursing diagnosis has priority?" |
| Planning | Sets priorities and SMART client-centred goals; chooses interventions | "Which outcome is appropriate?" |
| Implementation | Carries out, delegates and documents interventions | "Which action should the nurse take?" |
| Evaluation | Compares the client's response with the goal; continues, modifies or ends the plan | "Which finding shows the goal is met?" |
Rule: assess before you act, unless the client is in immediate danger. If a stem gives too little data to choose an intervention, the keyed answer is usually an assessment.
Assessment: Collecting Data
- Subjective data come from the client or family: symptoms, feelings, history ("I feel dizzy").
- Objective data are observed or measured: vital signs, wound appearance, laboratory results.
- Primary sources are the client. Secondary sources are family, records and other staff.
- Methods: interview, observation, physical examination and review of records.
Physical Examination Techniques
Use inspection, palpation, percussion and auscultation, in that order, except for the abdomen. There the order is inspection, auscultation, percussion, palpation, because handling the abdomen can change bowel sounds.
Normal Adult Values to Know
| Measure | Normal adult range |
|---|---|
| Temperature (oral) | About 36.5–37.5 °C |
| Pulse | 60–100 beats/min |
| Respirations | 12–20 breaths/min |
| Blood pressure | Below 120/80 mmHg (optimal) |
| SpO2 | 95–100% on room air (88–92% target in chronic CO2 retainers) |
| Urine output | At least 0.5 mL/kg/h (about 30 mL/h for an average adult) |
Pain: The "Fifth Vital Sign"
Assess pain with a validated tool:
- the 0–10 numeric rating scale for adults who can self-report;
- Wong-Baker FACES for children aged about 3 and older or for language barriers; and
- FLACC (Face, Legs, Activity, Cry, Consolability) for infants and non-verbal clients.
Explore pain with PQRST: Provokes/Palliates, Quality, Region/Radiation, Severity and Timing. The client's report is the most reliable indicator of pain.
Holistic Frameworks From the Blueprint
The CARICOM Blueprint organises assessment around basic needs:
- Physiological: oxygen; nutrition; elimination; activity, rest and comfort; sexuality; and safety and security.
- Psychosocial: love and belonging, self-esteem and self-actualisation.
Assess the factors affecting need satisfaction (biological, psychosocial, lifestyle and health care organisation) and the client's life-cycle stage (Section 1.1). A focused assessment examines one problem in depth. A comprehensive assessment covers all needs at admission.
Diagnosis: Stating the Problem
A nursing diagnosis describes the client's response to a health problem, which nurses can treat independently. A medical diagnosis names a disease. "Pneumonia" is medical. "Ineffective airway clearance" is nursing.
The PES format (NANDA International style) for an actual diagnosis is:
- Problem: Ineffective airway clearance
- Etiology, "related to": thick tracheobronchial secretions
- Signs and symptoms, "as evidenced by": coarse crackles and an ineffective cough
A risk diagnosis has no signs or symptoms yet: Risk for impaired skin integrity related to immobility. Health-promotion and syndrome diagnoses also exist.
Prioritising diagnoses:
- airway, breathing and circulation come first;
- then other physiological needs;
- then safety and security; and
- then psychosocial needs (Maslow, Section 4.1).
Actual problems usually come before risks, but a high-risk safety problem can outrank a minor actual one.
Planning: Goals and Interventions
Goals are client-centred and SMART: "The client will cough up secretions and have clear breath sounds in both lung bases within 48 hours." Write the goal about the client's behaviour, not the nurse's ("the nurse will teach…" is an intervention, not a goal). Interventions can be:
- independent: repositioning, teaching, deep breathing and coughing;
- dependent: carrying out prescribed medicines; or
- collaborative: with physiotherapy, dietetics or social work.
The written care plan links diagnosis, goal, interventions with rationales, and evaluation.
Implementation and Evaluation
Implement safely, reassess before each intervention (vital signs before an antihypertensive, for example), delegate within scope (Section 4.2) and document the client's response. During evaluation, if the goal is not met, ask why. The data may have been incomplete, the diagnosis wrong, the goal unrealistic or the interventions ineffective. Then revise the plan.
Worked Example From the Blueprint: Diabetes Mellitus
The CARICOM Blueprint shows the nursing process applied to a client with diabetes. The problem list includes:
- actual problems: decreased peripheral circulation, sensory alteration, sexual dysfunction, ineffective coping and imbalanced nutrition;
- potential problems: risk for injury, infection, impaired skin integrity and complications such as kidney failure and hypoglycaemia.
Teaching covers dietary and drug therapy, care of the feet, eyes, nails and skin, exercise, sexuality, infection prevention, follow-up, travel, eating out and blood glucose monitoring. Community resources include diabetic clinics and associations, referral services and continuity of care. Evaluation asks whether the expected outcomes were achieved and the problems relieved.
Which statement is a correctly written nursing diagnosis in PES format?
Ineffective airway clearance related to thick secretions as evidenced by crackles
The nurse will suction the client every 2 hours and record the secretions
Client will have clear breath sounds
Pneumonia related to bacterial infection as evidenced by fever and infiltrates on chest X-ray
The nurse is examining the abdomen of a client admitted with abdominal pain. In what order should the techniques be used?
Palpation, percussion, auscultation, inspection
Inspection, auscultation, percussion, palpation
Auscultation, inspection, palpation, percussion
Inspection, palpation, percussion, auscultation
Which goal statement is best written for a client recovering from abdominal surgery?
The client will cough with splinting and have clear lung bases by postoperative day 2
The nurse will teach splinting and coughing every shift until the client is discharged
Maintain adequate respiratory function
The client will understand the importance of deep breathing and coughing after surgery
A client reports feeling "a bit dizzy" after rising from bed. No other data are given. What should the nurse do first?
Ask the client to walk to the bathroom to see if the dizziness passes
Document that the client has orthostatic hypotension
Measure lying and standing blood pressure and pulse
Give the prescribed antihypertensive dose early
Sections you finish are checked off in the contents.