Medical-surgical nursing is a nursing specialty area concerned with the care of adult patients in a wide range of clinical setting. Medical-surgical nursing deals with the nursing care of adults who are at risk or experiencing pathophysiologic disorders who may require therapeutic medical or surgical interventions. It deals with any illness or disease that affects the physiology of adults. When the illness interferes with the normal physiology, the patient is said to have a medical problem and called as a medical patient. When the problem is treated with surgery, the individual becomes a surgical patient
Psychosomatic illness is an important aspect of medical-surgical nursing because physical illness lead to psychological and social problems and vice versa.
Medical-surgical nursing is a fast developing specialty and its practice is different from other nursing disciplines. It is a very vast and complex specialty covering from head to foot. There are numerous super specialties and sub specialties under medical-surgical nursing.
EVOLUTION OF MEDICINE AND SURGERY
It is believed that medicine was conceived in sympathy and born out of necessity and the first doctor was the first man and the first woman, the first nurse. During the Vedic period in India two medical systems originated namely—Ayurveda and Siddha. Ayurveda was founded by Dhanvanthary (God of Medicine) as written in Atharvaveda, one among the four Vedas. In Ayurveda, Athreya (800 BC) Charaka (200 BC) and Susrutha (800–400 AD) were the famous scholars. Charaka wrote Charaka Samhitha which contains the description of more than 500 drugs (Fig. 1.1). He was considered as the Father of Indian Medicine. Susrutha (Fig. 1.2) compiled in his book various methods of excision of tumors amputations, cataract surgery, repair of hernia and plastic surgery. He is considered as the Father of Indian Surgery.
According to the theory of Ayurveda, human body has three doshas (vata, pitta and kapha). Imbalance of these three doshas give rise to various diseases. Allopathic system of medicine originated from greek medicine. Asclepius was the leader of Greek Medicine and flourished from 450 to 136 BC (Fig. 1.3). In Greek mythology the rod/staff of Asclepius consisting of a serpent coiled around a rod is the ancient Greek symbol associated with medicine. The snake symbolizes rejuvenation and renewal of youth as it casts off its skin. He had two daughters namely Hygeia and Panacea. Hygeia was considered as the Goddess of Health (Fig. 1.4) and Panacea as the Goddess of Medicine.
The Greek physician Hippocrates (460–370 BC) known as Father of Medicine challenged the tradition of magic in medicine and implicated application of clinical methods in medicine (Fig. 1.5). During the middle ages (500–1500 AD) the practice of medicine reverted back to primitive medicine and hence this period is called the ‘dark ages of medicine’. The spread of Christianity lead to the establishment of religious institution known as monasteries which rendered active medical and nursing care to the sick.
The period following 1500 AD was marked by revolutions. Dr Ambroise Pare French Army Surgeon advanced the art of surgery and earned the title The Father of Surgery. The 17th and 18th centuries witnessed many discoveries like William Harvey's discovery of circulation of blood (1628), Antony van Leeuwenhoek microscope (1670) and Edward Jenner's vaccination against smallpox (1796). The great sanitary awakening in the mid nineteenth century was a historic milestone in the development of medicine which lead to the enactment of the Public Health Act of 1848.
In 1873, Louis Pasteur put forward germ theory of disease and it was followed by the golden age of bacteriology. The later part of 19th century was marked by discoveries in preventive medicine.
Towards the end of the 19th century two branches of medicine namely curative and preventive medicine was evolved. Thereafter medicine moved faster towards specialization and a scientific approach to disease.
Recent advances in each branch of medicine and surgery are given under the respective chapters.
HISTORY OF MEDICAL-SURGICAL NURSING
Traditionally medical-surgical nursing was the first level position that most nurses viewed as a stepping stone to specialty areas. It is the foundation of all nursing practice. Many years ago majority of the nurses worked in general medical and surgical wards of the hospital and everyone was a medical surgical nurse.
Today medical-surgical nursing has evolved from an entry level position to a distinct speciality. It is viewed as the foundation and backbone of every hospital. It has become one of the most challenging and demanding nursing speciality.
Medical surgical nurses are the largest group of practicing professionals. They work in a variety of settings—inpatient clinics, emergency departments, surgical centers, home health care, critical care units, rehabilitation centers, etc. Medical-surgical nurses also known as adult health nurses specialized in the care of adults with a known or potential physiologic alteration. Comprehensive total patient care rather than a focus on a particular organ or problem is an important aspect of this speciality.
National League of Nursing Education (NLNE) curriculum guide considered medical nursing, surgical nursing and disease prevention as separate topics. But during 1930 it was recommended that medical and surgical nursing be taught as a single disciplinary course because the division of the two was considered an artificial distinction.
In 1937, the NLNE guide recommended for a combined course of medical and surgical nursing. In 1960, the nursing curriculum emphasized the interdisciplinary study and practice of medical and surgical nursing.
During 1960's and 1970's nursing care standards were developed for many speciailties. The American Nurses Association (ANA) published standards of medical-surgical nursing practice in 1974. In 1980, ANA published a statement on the scope of medical-surgical nursing practice. In 1991, the Academy of Medical-Surgical Nurses (AMSN) was formed which is an independent professional organization for medical-surgical nurses. In 1996, AMSN published its own scope and standards of medical-surgical nursing practice which was revised in 2000.
Both ANA and AMSN documents recommended that not only clinical nurse specialist, but a medical surgical nurses also participate in research and utilize research findings in their practice.
CARING FOR MEDICAL-SURGICAL PATIENTS
Role and Functions of the Nurse
Medical-surgical nurse have a vast set of skills:
- They are knowledgeable in all aspects of adult health.
- They have excellent assessment, organizational, technical and prioritization skills.
- They educate patients, families and peers about self-care practices and promotion of health.
- Collaborates with other health team, members in planning and delivering comprehensive care to patients.
- Serve as patient advocate.
- Understand the importance of assessing and improving the quality of care delivered.
- Support and guide patients to identify what is best for them.
- Manage the care of patients with multiple medical and surgical diagnosis.
- Updates knowledge and skill through continuing education.
Expanding Roles of Medical-Surgical Nurses
- Critical care nursing: Nurses specialized in this field deal with patients having life-threatening problems. The nurses often handle sophisticated equipment. High tech–high touch care is expected from the critical care nurses.
- Geriatric nursing: Geriatric nurses take care of the elderly patients. They have extensive knowledge about special care needed in rehabilitating and maintaining the health of the elderly.
- Informatics nursing: Informatics nurses combines nursing science with information management. They work in clinical area ensuring that the nurse are provided with complete and accurate information about patients’ health needs and nursing requirement.
- Disaster nursing: It is concerned with the adaptation of nursing skills in recognizing and meeting the needs and problems resulting from a disaster.
- Flight or transport nursing: Specially trained nurses provide intensive nursing care to critically ill patients transporting by helicopter or ambulance.
- Trauma nursing: Nurses specialized in trauma care units work in close collaboration with skilled trauma professionals.
- Forensic nursing: Nurses specialized with field work with law enforcement officials and forensic department to aid in the investigation of crimes, accidental death, etc.
- Tele nursing: It is sharing information using electronic means, e.g. through teleconferencing or video conferencing.
- Wound and ostomy nursing: Ostomy nurses provide care to patients with stoma, vascular and pressure wounds draining wounds and fistulas.
- Space nurses: The first nurse at NASA was Dolores O'Hara. An international organization called the Space Nursing Society was formed in 1991. Space nurses are responsible for setting up the armed Lab and dedicated the examine and monitor astronaut's health. Other roles include:
- Infusion nursing
- Dialysis nursing
- Cardiac cath lab nursing
- Diabetic nursing
- Palliative or hospice nursing
- Transplant nursing
- Toxicology nursing
- Genetic nursing.
Advanced Practice Roles
- Ambulatory care is one arena for nursing practice outside hospitals. The term ambulatory care is applied to day care centers that serve walk in clients who return to their homes or workplace at the end of the visit. Education, health counseling, health maintenance, prevention and primary care are the main functions of the ambulatory care nurse.
- Clinical nurse specialists are the largest group of advanced practice nurses. They function as educators, practitioners, researchers, consultants and mangers.
- Managed care and clinical pathway.
A recent trend in medical-surgical nursing is managed care which is a method of organizing health care delivery and coordinating the care by various members of the health care team in a timely manner.
Clinical pathways serve as an interdisciplinary care plan and a tool for assessing the progress of patients. The pathway indicates the major events of care such as the investigations, medical treatment, nursing intervention, etc. that must occur within specific time frames. The care received are continually assessed from admission till discharge and also in home care and community settings.
THEORIES OF CAUSATION OF ILLNESS
Supernatural Theories of Disease
In ancient days medicine was dominated by magic and religious beliefs. As the knowledge of the primitive man was limited he believed that diseases are caused due to wrath of gods and goddesses (deistic theory), the influence of stars, planets and fate (fatalistic theory) and so on. All these theories are called supernatural theories.
Theory of Hippocrates
Hippocrates was a great Greek Physician who lived during the period 370–460 BC. His writings were compiled into a book named Hippocratism which is the basis for the present allopathic medical system.
A great saying of Hippocrates is ‘where there is love for mankind there is love for the art of mankind’. According to his theory, the human body is composed of four substances which he called the four humors: blood, phlegm, yellow bile and black bile. If there is any imbalance in these four humors, it leads to illness. The ancient Greek atomic theory identified only 4 atoms. They were atom of earth, air, fire and water. Each atom possessed two or the four qualities of wetness, dryness, warmth and coldness. Earth was cold and dry, air was hot and wet, water was cold and wet and fire was hot and dry. According to Hippocrates, each humor was made up of one type of atom. Thus blood was made up of air and possessed the properties of being hot and wet, phlegm was made up of water, yellow bile of fire and black bile of earth.
Hippocrates theory was elaborated by Galen, a Roman Physician. Galen added two new humors to Hippocrates's four humors. There two elements were named as temperament and procatarctic factors. Procatarctic factors refers to the lifestyles of the person. According to Galen an excess of each of the humors was associated not only with particular disease but also with a particular personality type.
For example, person with an inborn excess of blood is said to have a sanguine temperament, characterized by cheerful manner and optimistic attitude. Similarly, the phlegmatic person over supplied with cold watery phlegm is passive and dull. An excess of black bile produced a melancholic temperament sadness and depression. Yellow bile is excess produced a choleric personally, i.e. easily aroused to anger, hot temper and irritability.
Galen said that disease is due to three factors.
- Predisposing factors
- Exciting factors
Theory of Contagion
Fracastorius (1483–1553 AD): An Italian physician proposed the theory of contagion. He recognized that syphilis was transmitted from persons to person through sexual contact.
In India Ronald Ross (British surgeon) demonstrated the presence of Plasmodium in the gut of mosquitos. He proposed a theory that same diseases are spread by vectors mosquitos, housefly, etc. Nineteenth century was considered as the golden period of bacteriology.
Germ theory was formulated by Louis Pasteur. He found that diseases are due to invasion of microorganism in the human body. During the period of Louis Pasteur, a lot of microorganisms were discovered, Gonococci (1847), Typhoid bacilli (1880), Tuberculosis bacillus (1882), Vibrio cholera (1853), Diphtheria (1884). According to germ theory there is one single specific cause for every disease. It refers one-to-one relationship between causative agent and disease.
Theory of Epidemiological Triad
This triad consists of the agent, host and the environment.
- Agent harmful organisms or organic or inorganic substances which causes the disease.
- Host in the human body. Disease occurs when agent invades the body. Everyone exposed to the agent need not get the disease.
- If the environment is favorable and conducive, it facilitates the interaction between host and environment.
This theory is not applicable to the causation of non-communicable diseases like hypertension, cardiovascular disease, diabetes, etc.
A variety of factors are identified for the causation of a disease.
- Genetic: Some diseases are genetic in origin and they are linked to the genes. Down's syndrome and thalassemia are few examples of inherited genetic defect. Hemophilia is a disease linked to the ‘X’ chromosomes in the cell and transmitted from one generation to the other. Heredity is a non-modifiable risk factor in diseases like hypertension, diabetic mellitus and heart disease.
- Congenital: Individuals are born with a particular disease, e.g. congenital heart disease, cleft palate and cleft lip.
- Inflammation: Conditions caused due to response of body cells and tissues to injury occurring at any part of the body, e.g. sprain, friction on the skin, etc.
- Accidents and disasters: Disasters are natural and man-made. Natural disasters include flood, hurricane, lightening, cyclone and thunder. Bomb blast is an example of manmade disaster.
- Degenerative: Diseases are caused due to the degeneration of body cells and tissues. Such diseases begin in early middle age and progress to old age, e.g. neurologic disorders, osteoarthritis.
- Metabolic causes: Diseases are caused due to deficiency of enzymes and hormones or due to over activity of hormones, e.g. endocrine disorders.
- Neoplasm: Diseases are also caused due to abnormal growth of cells, e.g. tumor—benign and malignant.
- Allergic disorders: Disorders are caused due to reaching of the body to a foreign proton substance.
- Autoimmune disease: In some individuals the body produce antibodies which affect its own body, e.g. rheumatoid arthritis, systemic lupus erythematosus.
- Psychosomatic illness: Certain diseases affect the body and mind, e.g. anxiety and stress can lead to certain skin conditions, gastric conditions, etc.
- Iatrogenic illness: Means physician induced illness. In some people use of certain drugs like cortisone will lead to certain other diseases.
- Lifestyle factors: They are also called modifiable risk factors. Unhealthy lifestyle practices like smoking, alcoholism, obesity sedentary lifestyle, fast food culture can lead to diseases like hypertension, heart disease and diabetes mellitus.
THE CONCEPT OF ILLNESS
Illness is a deviation from a normal state of health, a deviation from normal functioning. Illness is a condition of the body or some part or organ of the body in which its function are disrupted or deranged.
—Oxford English Dictionary
Types of Illness
Illness can be classified into two major categories namely acute and chronic illness.
- Acute illness: Acute illness occurs suddenly and has a short duration. The condition usually gets cured if specific treatment is given immediately. In acute illness the recovery is very fast.Acute respiratory infections like common cold sinusitis, pharyngitis, laryngitis, gastritis are examples of acute illness. Acute illness may become chronic.
- Chronic illness: The signs and symptoms develop gradually. The disease has a long duration. In chronic illness, there may be impairment or disability which requires long-term rehabilitation. The patient may have only a partial recovery.For example, chronic obstructive pulmonary disease, diabetes mellitus, heart disease, etc. Diseases such as asthma, rheumatoid arthritis are characterized by periods of recurrence.
Stages of Illness Behavior
Stage 1: Onset of symptoms: During the first stage of illness the person experience certain symptoms which are not usually seen in a normal healthy individual, e.g. pain, fever, cough, rashes, nausea, vomiting are the symptoms, which last for short time and are relieved by first aid and self-care, no further action is taken. If the symptoms are persisting the person enters the next stage.
Stage 2: Assuming sick role: During this stage the person accepts that he is sick and seeks medical assistance. Normal activities and social activities are avoided so that the person can take rest and concentrate on getting well.
State 3: Assuming a dependent role: During this stage the person may require assistance in carrying out the activities of daily living and follows the treatment plan given by the physician.
Stage 4: Stage of recovery and rehabilitation: Person gradually return to normal activities and tries to become independent. The person has to modify his lifestyle and make adjustments in functioning for leading a normal life.
Illness and Family
Reaction to illness may vary among individuals. Illness affects not only the individuals but also the whole family. An illness will disrupt the family routines, and role of family. The impact of illness on the family depends on the family member, who is ill, the seriousness and duration of the illness and the sociocultural influences of the family. If the chief earning member of the family is sick there is a serious threat to the financial resources. If the parents become sick, the reversal in the parent child roles is difficult for both parents and children. In case of chronic illness the entire family become strained. There will be feelings of frustration and grief in the family.
Causes of Anxiety in the Hospitalized Patient
- Strange environment: The hospital environment is totally different from that of his home. Patient has to wear hospital dress. He stays in a room or cubicle away from his near ones. In a general ward, patient has to use common toilets and bathrooms.
- Fear of unknown: Worried about the disease and its prognosis. Has to undergo various tests and investigation which are quite new.
- Restriction of visitors: Friends and members of family.
- Change in routines: Patient has to follow hospital routines.
- Strange people: Patient has to meet many people doctors, nurses, paramedical staff, etc. who are not familiar to him.
Meeting Psychological Needs
Meeting psychological needs of patients is one of the most important aspects of nursing care, which if often neglected. Illness and hospitalization will add to the stress of an individual. The nurse should be able to identify and meet these needs.
- Relieve anxiety and fear of the patient by proper explanation of procedures, treatment, etc.
- Provide privacy while doing procedures.
- Explain hospital routines and policies, visiting time, food timings, etc.
- Provide support to the patient as he undergoes hospitalization.
- Encourage patient to express the feelings of anxiety.
- Be a good listener. Be sensitive to the needs of patients with different disease conditions.
NURSING PROCESS: REVIEW
Nursing is basically a caring profession based on a humanistic philosophy. Nursing is caring with commitment, compassion, confidence, conscience, competence and courage. Nursing has been described as an art and science. The science of nursing is the knowledge base for the care that is given and the art of nursing is the skilled application of that knowledge to reach maximum health and quality of life.
Nursing is a profession undergoing rapid changes. These changes are related to the changes in the society and health care. Nursing is not only concerned with care of sick or ill but also includes prevention of illness, promotion and maintenance of health for individuals, families and communities.
History of Nursing Process
Nursing process can be seen throughout the history of nursing. Since the beginning of mankind each individual needed nurturing which was provided primarily by the mother of the family. During the time of Hippocrates when the profession of medicine evolved the profession of nursing evolved simultaneously because every ill person needed someone to nurture him or her back to health.
Nursing was first described as a process by American nurse Lydia Hall in 1955.
Purpose of Nursing Process
- Provide a systematic methodology for nursing practice
- Helps to provide individualized nursing care
- It unifies and standardizes nursing practice
- Give direction, guidance and meaning to nursing care
- Provide for continuity of care and reduce omissions
- Enhances communication and collaboration of health team members
- Promote creativity and flexibility in nursing practice
- Facilitates documentation of data
- Facilitates health, promotion, maintenance and restoration
Fig. 1.6: Steps of nursing processSource: pinrest.com
Steps of Nursing Process (Fig. 1.6)
- Assessment: Collects client health data.
- Nursing diagnosis: Analyzes assessment data to determine diagnoses.
- Planning: Develops plan of care and prescribes interventions to attain expected outcomes.
- Implementation: Implenents the interventions (action types) in the pain of care.
- Evaluation: Evaluates client's attainment of outcomes.
Characteristics of Nursing Process
- Patient centered
- Goal directed
- Systematic and provides an organized approach to nursing
- Based on scientific principles
- Adaptable to any practice setting
- Applicable to individuals, families and community groups
- Based on nurse-client relationship
- Provides continuous and ongoing evaluation.
Nursing process is the core and essence of nursing. It is a problem-solving approach that enable the nurse to provide care in an organized and scientific manner.
Nursing process has been defined and described in many different way by various authors.
Fuerest and Wolf: Nursing process is a set of actions or series of steps taken by the nurse to determine plan and implement nursing care.
Ann Marriner: Nursing process is the application of scientific problem-solving to nursing care. It is used to identify patients problems systematically and implement nursing care plan and evaluate the outcome of the care provided.
Luckman and Sorensen: Nursing process is defined as a system of interrelated and interdependent problem-solving steps directed towards meeting the needs of patients and the significant others.
Steps: The steps of nursing process are assessment, diagnoses, planning, implementation, documentation and evaluation.
Assessment involves collection of subjective and objective data from the patient, family, significant others, medical records, lab reports and other care providers, interview is used to obtain an objective picture of the patients personal and family health history. Physical examination uses inspection palpation percussion and auscultation to collect objective data about the patient.
Identification of Patients’ Needs and Problems
To be effective in identifying patients’ needs, the nurse must understand what the basic human needs are. Various theorists have put forward models to explain what the basic human needs are and to organize them in ways that encompass the whole human being. Studying these models can provide a framework within which to identify needs and can help in planning nursing care.
Maslow: A well-known model is the hierarchy of basic human needs developed by Abraham Maslow (Fig. 1.7). Maslow described a hierarchy, or pyramid, of needs with primary or physiologic needs at the base and secondary or nonphysiologic needs at the higher levels. Maslow states that the basic human needs are organized into a hierarchy of relative prepotency. Expressed simply, this means that new needs emerge when those lower on the hierarchy have been relatively well gratified.
While all needs are present at all times, a person will attempt to satisfy those needs lower on the hierarchy to at least a minimal degree before focusing on those higher up.
The needs described in Maslow's model are in ascending order:
- Physiological needs
- Survival needs, e.g. food, air, water, temperature, elimination, rest, pain avoidance.
- Stimulation needs, e.g. sex, activity, exploration, manipulation, novelty.
- Safety and security needs, e.g. safety, security, protection.
- Love needs, e.g. love, belonging, closeness, and intimacy.
- Esteem needs, e.g. value and respect from others, value and respect of self (self-esteem).
- Self-actualization needs, e.g. the process of making maximum use of one's abilities.
- Cognitive needs, e.g. seeking knowledge, discovering things, working with ideas, knowing and understanding.
- Aesthetic needs, e.g. the desire for beauty.
Kraegel and her associates developed a model of patient needs which they used in studying a system for providing patient care. This model identifies 22 needs within three broad classifications: physical, sociopsychological, and environment. Physical and sociopsychological needs are grouped as patient health needs (Table 1.1).
Virginia Henderson's Theory of Basic Human Needs
Henderson's definition states not only what nursing is but also gives some indication of how nursing should be practiced. The goal of nursing practice is always to encourage and facilitate patient independence.
Components of basic nursing (Virginia Henderson's 14 needs).
Assisting the patient with these functions or providing conditions that will enable him to:
- Breathe normally
- Eat and drink adequately
- Eliminate by all avenues of elimination
- Move and maintain desirable posture (walking, sitting, standing and lying)
- Sleep and rest
- Select suitable clothing, dress and undress
- Maintain body temperature within normal range
- Keep the body clean and well groomed and protect the skin
- Avoid dangers in the environment and avoid injuring others
- Communicate with others in expressing emotions, needs and fears
- Worship according to faith
- Work at something that provides a sense of accomplishment
- Play or participate in various form of recreation
- Learn, discover or satisfy the curiosity that leads to normal development and health.
Comparison of Models
As you study these models, you will notice some similarities in them. Compare the three models carefully and identify their similarities and differences.
Maslow, Henderson, and Kraegel are describing the same things. Each of their models are attempts to describe the elements of existence that are common to and necessary for all human beings. Basic human needs are conditions that must be either supplied or relieved. While methods of fulfilling may vary from person to person, and even from circumstance to circumstance in the same individual, the fact that all human beings have certain common needs remains true (Table 1.2).
Nursing problem is a term describing an obstacle that prevents a patient from experiencing satisfaction of a basic human need. Nursing action is directed toward the solution of nursing problems. The source of obstacles to need satisfaction are various.
Faye Abdella's 21 Nursing Problems
- To maintain good hygiene and physical comfort.
- To promote rest, sleep and optimum activity.
- To promote safety to prevention of accidents, injury or trauma, spread of infection.
- To maintain good body mechanics and prevent and correct deformities.
- To facilitate and maintain supply of oxygen.
- To facilitate and maintain nutrition.
- To facilitate and maintain elimination.
- To facilitate and maintain fluid and electrolyte balance.
- Recognize by physiological responses of the body to disease condition.
- Maintenance of regulatory mechanisms and its function.
- Maintenance of sensory function.
- Identify and accept the positive and negative reactions.
- Identify the interrelationship of emotional and organic illness.
- To facilitate and maintain effective verbal and nonverbal communication.
- To promote and maintain interpersonal relationship.
- To facilitate achievement of personal and spiritual goals.
- Create and maintain therapeutic environment.
- To facilitate awareness of self as an individual.
- To accept optimum possible needs in the light of both physical and emotional limitations.
- Use community resources to solve problem arising from illness.
- To understand the role of social problems as influencing factors in the causation of disease.
Nursing diagnosis is defined as the judgment or conclusion which occurs as a result of nursing assessment. It includes nursing problems that can be managed by independent nursing intervention.
Nursing diagnosis, the first taxonomy developed in nursing have fostered autonomy and accountability in nursing. NANDA International (NANDA-1) 2012 formerly known as North American Nursing Diagnosis Association is the official organization responsible for the formulation of the taxonomy of nursing diagnosis.
Diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses, for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. The taxonomy is published and being used worldwide.
The ICNP (International Classification for Nursing Practice) published by the International Council of Nurses has been accepted by the WHO (World Health Organization). ICNP is a nursing language which can be used by nurses to diagnose.
The NANDA-I system of nursing diagnosis provides for four categories.
- Actual diagnosis: A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. An example of an actual nursing diagnosis is: Sleep deprivation.
- Risk diagnosis: Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock.
- Health promotion diagnosis: A clinical judgment about a person's, family's or community's motivation and desire to increase well-being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
- Syndrome diagnosis: A clinical judgment describing a specific cluster of nursing diagnosis that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome.
The hierarchy of taxonomy of nursing practices is as follows.
Hierarchy of Taxonomy in Nursing Practice: A Unified Structure of Nursing Language
The Functional Domain
The functional domain includes diagnoses, outcomes, and interventions that promote basic needs and includes the following eight classes:
- Activity/exercise: Physical activity, including energy conservation and expenditure.
- Comfort: A sense of emotional, physical, and spiritual well-being and relative freedom from distress.
- Growth/development: Physical, emotional, and social growth and developmental milestones.
- Nutrition: Processes related to taking in, assimilating, and using nutrients.
- Self-care: Ability to accomplish basic and instrumental activities of daily living.
- Sexuality: Maintenance or modification of sexual identity and patterns.
- Sleep/rest: The quantity and quality of sleep, rest, and relaxation patterns.
- Values/beliefs: Ideas, goals, perceptions, and spiritual and other beliefs that influence choices or decisions.
The Physiologic Domain
The physiologic domain includes diagnoses, outcomes, and interventions to promote optimal biophysical health and includes the following ten classes:
- Cardiac function: Cardiac mechanisms used to maintain tissue perfusion.
- Elimination: Processes related to secretion and excretion of body wastes.
- Fluid/electrolyte: Regulation of fluid/electrolytes and acid-base balance.
- Neurocognition: Mechanisms related to the nervous system and neurocognitive functioning including memory, thinking, and judgment.
- Pharmacologic function: Effects (therapeutic and adverse) of medications or drugs and other pharmacologically active products.
- Physical regulation: Body temperature, endocrine, and immune system responses to regulate cellular processes.
- Reproduction: Processes related to human procreation and birth.
- Respiratory function: Ventilation adequate to maintain arterial blood and gases within normal limits.
- Sensation/perception: Intake and interpretation of information through the senses including seeing, hearing, touching, tasting, and smelling.
- Tissue integrity: Skin and mucous membrane, protection to support secretion, excretion, and healing.
The Psychosocial Domain
The psychosocial domain includes diagnoses, outcomes, and interventions to promote optimal mental and emotional health and social functioning and includes the following seven classes:
- Communication: Receiving, interpreting and expressing spoken, written, and nonverbal messages.
- Coping: Adjusting or adapting to stressful events.
- Emotional: A mental state of feeling that may influence perceptions of the world.
- Knowledge: Understanding and skill in applying information to promote, maintain, and restore health.
- Roles/relationships: Maintenance and/or modification of expected social behaviors and emotional connectedness with others.
- Self-perception: Awareness of one's body and personal identity.
The Environmental Domain
The environmental domain includes diagnoses, outcomes, and interventions that promote and protect the environmental health and safety of individuals, systems, and communities and includes the following three classes:
- Health care system: Social, political, and economic structures and processes for delivery of health care services.
- Populations: Aggregates of individuals or communities having characteristics in common.
- Risk management: Avoidance or control of identifiable health threats.
Diagnosis Statement (PES Format)
P – The problem
E – Etiology
S – The signs and symptoms/defining characteristics
The cause of the problem is usually stated using the term related to (due to can be used if the etiology is very sure).
S component can be connected to E statement through the use of the phrase as evidenced by, e.g. pain related to surgery as evidenced by facial expression, oral comments, body posture. Self care deficit related to decreased activity tolerance as evidenced by pain or discomfort depression, immobility.
For example, ineffective breathing pattern related to bronchospasm.
Comparison of Medical Diagnosis and Nursing Diagnosis (Commonalities and Differences)
- Medical diagnosis focus on the disease process, e.g. pneumonia, myocardial infarction where an nursing diagnosis focus on the patients response to the disease, e.g. pain related to cough, chest pain related to myocardial is chewing.
- Physicians place primary emphasis on identifying the current problem whereas in nursing diagnosis. Both the current and potential problems are also identified.
- The purpose of making a medical diagnosis and a nursing diagnosis is the same, i.e. planning the care of the patient.
- The same basic procedures are used to decide the diagnosis, i.e. physical assessment, interviewing, etc.
- There may be only one medical diagnosis each medical diagnosis will have a number of nursing diagnosis.
Guidelines for Writing a Nursing Diagnosis
- The nursing diagnosis is clear and concise. Clarity and conciseness facilitates communication among the health of the team members. The following terms are helpful in writing the diagnosis.For example: Alteration of, impairment of, lack of, difficulty in, deficit in, inadequate, diminished, inability, discomfort, potential for, failure to, insufficient, disturbance in. Adjectives that may be helpful in clarifying are severe, acute, chronic, intermittent, mild, maximum, minimum, moderate complete, partial.
- The nursing diagnosis is client centered, specific and accurate.
- The nursing diagnosis may be a descriptive statement, e.g. inability to sleep.
- The nursing diagnosis may be expressed as an etiological statement. One health problem may be related to several etiological factors, e.g. inability to sleep may be related to many factors.
- The nursing diagnosis provides direction for nursing interventions, e.g. impaired bowel movement related to decreased fluid intake/inactivity.
- Each diagnosis should confirm only problem.
It is the act of determining what can be done to assist the patient to solve his problem. It involves the development of a nursing plan based on the nursing diagnosis.
Planning is a Continuous Process
Planning involves the following activities:
- Setting priority
- Establishing objectives—short-term and long-term
- Determining nursing intervention.
Once the problems are identified they are placed in the order of importance. It is not possible to attend all the problems at the same time. So we have to decide which problem should be attended first. Actual and life threatening problems are given high priority. Maslow's hierarchy of needs provides one framework for prioritizing problems with importance being given first to physical needs. Once the basic needs are met, the higher level needs can be addressed.
The identification of patients problems lead to the development of goals or expected outcome to be attained by the patient. The goals should be realistic and attainable. The goals are patient centered and stated in terms of expected outcome. The expected outcome describe the behavior the patient is expected to obtain.
Short-term goals may be attained immediately whereas long-term goals takes a period of time.
A nursing objective is a short statement that describes in detailed behavioral terms, the expected outcome towards which specified nursing intervention is planned.
Characteristics of Objectives
- Nursing objectives are specific to a particular patient at a particular time
- Objectives are patient centered written in terms of patients behavior
- Objectives are written in simple, clear and concise language
- Objectives are known to the patient.
After establishing objectives the next step is to determine the nursing interventions which will help the patient to attain the expected outcome.
Nursing interventions (nursing orders) are planned nursing actions, recorded in the nursing care plan which will help to solve the patient's problems and to achieve the nursing objectives. Nursing orders should include a specific description (what, where, when, how much, how long,) and how the order should be carried out.
Nursing care plan is a written document that states the nursing interventions planned for a particular patient. A nursing care plan is written to facilitate the implementation of the nursing interventions.
There is no single correct format for nursing care plan. Format is developed suitable to the situation in which they are to be used.
Guidelines for writing nursing care plans
- Nursing care plans should focus on nursing problems and have a nursing approach.
- Nursing care plans are short and concise.
- It shows the patients’ needs and problems.
- The plan is dated and contain the signature of the responsible nurse.
- The nursing orders are renewed and updated periodically.
- The nursing interventions should be appropriate to the expected outcome.
- Plan should be flexible and subject to revision if the approaches are to be effective.
- Plans are written in terms of patient behavior.
- Plan includes preventive promotional and rehabilitative aspects of care, e.g. preventive turn the patient every 2 hours to prevent bedsore.
Promotive: Teach the patient about balanced diet to maintain adequate nutrition.
Rehabilitative: Assist the patient to ROM exercise in every 2 hours.
Plans for the patient's future are included. Discharge plan, health education, etc.
Advantages of Writing Nursing Care Plan
- A well written plan gives direction and guidance to nursing action.
- It is a source of information take who are concerned with the care of a patient
- It provides for continuity of care
- Facilitates individualized patient care
The implementation phase is the execution of the proposed plan of nursing care.
- Factors that must be considered for implementation
- Based on scientific principles and theory
- Must be individualized
- Provide for safety and comfort
- Provide for privacy
- Provide for patient participation.
- Areas of nursing implementation includes
- Health maintenance, health promotion, prevention of illness
- Restoration of health and rehabilitation.
- Types of nursing actions includes
- Dependent actions
- Interdependent actions
- Independent actions.
- Types of implementation: Although many nursing actions are independent, others are interdependent such as carrying out prescribe treatments, administering medication and the therapies and collaborating with other health care team members.
- The intervention include direct patient care.
- Supervision of care, coordination of care. Health teaching counseling and providing safety and comfort and referral services.
It is an important component of the nursing process. Patient assessments, observations and all nursing interventions should be charted as a permanent part of the patient's medical record, which is a legal record. Documentation helps to achieve continuity of care because it provides for communication among caregivers and is a record of the patient's progress. In addition, documentation provides a legal record of care provided and a means to verify services rendered for insurance payments.
The following should be documented:
- All treatments and care given, including medications
- Diagnostic procedures performed at the bedside, on the unit, or inside or outside the facility
- The patient's reaction to therapeutic and diagnostic procedures
- Observations of the patient
- Subjective and objective signs and symptoms experienced by the patient
- Evidence of changes in the patient's physical, psychosocial, and spiritual needs and status. Any unusual incidents such as falls or injuries that occur during the patient's stay in the health care facility.
Documentation should be factual, current, complete, organized, and accurate. Each page of the patient care sheet should have the patient's name and the date and time should be noted for each entry. Writing should be legible, using proper grammar, punctuation, and spelling. Fill all spaces, leaving no empty lines. Chart as soon after care is given as possible (never before care). Observations should be stated objectively, describing only what was seen, heard, felt, or smelled. Direct quotations from the patient regarding symptoms are very appropriate. Each time an entry is made, sign with your full name and title. Use only permanent ink, and make no use of erasers. If you make an error in charting, cross out the entry and write ‘error’ or ‘mistaken entry,’ followed by your initials. Increasingly,(patient records are entered and maintained in computerized charting systems. Some systems like COW (computer on wheels) allow documentation at the patient's bedside. Nurses’ notes may be composed by selecting from a menu of options related to the plan of care. Advantages of computerized charting include standardization of patient data, ease of retrieving data, and convenient storage. One disadvantage is the risk of information access by unauthorized persons.
Various formats are used for the documentation of patient care, including nurses’ notes, flow sheets, and problem-oriented medical records (POMR). Nurses’ notes traditionally consisted of pages of narrative recordings containing assessment data, interventions carried out by the nurse, and evaluation data collected.
The POMR is a method of record keeping that focuses on the patients problems. The data from the history, physical examination, diagnostic tests and medical diagnosis provide a foundation for problems formulated in the POMR.
SOAPIER is one format for charting.
S – Subjective information, how the patient perceives the problem.
O – Objective information, what the nurse observes about the patient.
A – Assessment, why the patient has the problem.
P – Plan or how the intervention is to be carried out.
I – Intervention or what specific care is given.
E – Evaluation, how effective was the plan or intervention.
R – Revision, what changes should be made in the original plan of care.
PIE charting is another common format which include problem, intervention and evaluation.
Nursing evaluation is a planned systematic comparison of the patient's health status with the defined goals and objectives. It is an ongoing deliberate activity, involving the patient, the nurse and other health members.
Possible outcomes of evaluation:
- The patient has responded as expected
- Short-term goals are achieved, but long-term goals are not yet
- Goals are not attained
- New problems have raised.
Guidelines for Evaluation
- The nurse continuously monitors and reassess the client's response to nursing actions.
- The client's response to nursing implementation is compared with the objectives to determine the extent to which the objectives have been achieved.
- The clients progress or lack of progress toward goal attainment is determined
- The nursing care plan is revised when the objectives are not adequately met (on the basis of evaluation).
Areas/Aspects to be Evaluated
Structure: Refers to the physical facilities, equipment, services, organizational pattern etc. Assess the facilities of the unit are adequate to provide the nursing care, whether staff is adequate and competent, whether equipment, adequate materials and supplies are available.
Process: Focuses on the nurses activities. Nursing actions within each component of the nursing process are to be evaluated. The following questions can be asked.
- Was the nursing actions appropriate?
- Was the techniques effective?
- Were the nursing action implemented efficiently?
Outcome: Refers to the changes in the clients behavior which include
- Psychological responses
- Knowledge gained as a result of education.
Health assessment of patients falls under the purview of both physicians and nurses.
GENERAL HEALTH ASSESSMENT
The nursing health assessment is an incredibly valuable tool nurses have in their collection of skills. Health assessment helps to identify, patient's symptoms and to discover any associated physical findings that will aid in the development of differential diagnoses. Assessment uses both subjective and objective data. Subjective assessment factors are those that are reported by the patient. Objective assessment data includes that which is observable and measurable.
Types of General Health Assessments
In general, there are four fundamental types of assessments that nurses perform:
- A comprehensive or complete health assessment: A comprehensive or complete health assessment usually begins with obtaining a thorough health history and physical examination. This type of assessment is usually performed in acute care settings on admission, once your patient is stable, or when a new patient presents to an outpatient clinic.
- An interval or a brief assessment: If the patient has been under your care for some time, a complete health history is usually not indicated. Nurses perform an interval or short assessment at this time. These assessments are usually performed at subsequent visits in an outpatient setting, at change of shift, when returning from tests, or upon transfer into the unit from another in-house unit.
- A problem-focused assessment: The third type of assessment is a problem-focused assessment. The problem-focused assessment is usually indicated after a comprehensive assessment has identified a potential health problem.
- An assessment for special populations: The fourth type of assessment is the assessment for special populations, including:
- Pregnant women
- The elderly.
Four basic techniques during physical examinations: inspection, auscultation, percussion, and palpation. These techniques should be used in an organized manner from least disturbing or invasive to most invasive to the patient.
The purpose of obtaining a health history is to assess patient's symptoms and how they developed. A complete history will serve as a guide to help identify potential or underlying illnesses or disease states. In addition to obtaining data about the patient's physical status, you will obtain information about many other factors that impact your patient's physical status including spiritual needs, cultural idiosyncrasies, and functional living status. The basic components of the complete health history (other than biographical information) include:
- Chief complaint
- Present health status
- Past health history
- Current lifestyle
- Psychosocial status
- Family history
- Review of systems.
Communication and IPR
Communication during the history and physical examination must be respectful and performed in a culturally-sensitive manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and tone of voice while interviewing the patient.
A review of systems can be incorporated during physical examination. While examining each body system, it is appropriate to ask certain questions that pertain to that system.
Nutritional assessment is the systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition related health issues that affect an individual.
The nutritional status of an individual is often the result of many inter-related factors. It is influenced by food intake, quantity and quality, and physical health. The spectrum of nutritional status spread from obesity to severe malnutrition.
Objectives of Nutritional Assessment
- Identify individuals or population groups at risk of becoming malnourished
- To develop health care programs that meet the community needs which are defined by the assessment
- To measure the effectiveness of the nutritional programs and intervention once initiated.
Methods of Nutritional Assessment
Nutrition is assessed by two types of methods; direct and indirect.
The direct methods deal with the individual and measure objective criteria, while indirect methods use community health indices that reflects nutritional influences.
Direct Methods of Nutritional Assessment
These are summarized as ABCD
- Anthropometric methods
- Biochemical, laboratory methods
- Clinical methods
- Dietary evaluation methods.
Indirect Methods of Nutritional Assessment
These include three categories:
- Ecological variables including crop production
- Economic factors, e.g. per capita income, population density and social habits
- Vital health statistics particularly infant and under 5 mortality and fertility index.
Anthropometry is the measurement of body height, weight and proportions.
It is an essential component of clinical examination of infants, children and pregnant women.
It is used to evaluate both under and over nutrition.
The measured values reflects the current nutritional status and do not differentiate between acute and chronic changes.
- Mid-arm circumference
- Skin fold thickness
- Head circumference
- Head/chest ratio
- Hip/waist ratio.
Measurements for Adults
The subject stands erect and bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault and height is recorded to the nearest 0.5 cm.
- Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable.
- Weigh in light clothes, no shoes
- Read to the nearest 100 g (0.1 kg).
Nutritional Indices in Adults
- The international standard for assessing body size in adults is the body mass index (BMI)
- BMI is computed using the following formula: BMI = Weight (kg)/ Height (m2)
- Evidence shows that high BMI (obesity level) is associated with type 2 diabetes and high risk of cardiovascular morbidity and mortality
- BMI (WHO - Classification)
- BMI < 18.5 = Underweight
- BMI 18.5–24.5= Healthy weight range
- BMI 25–30 = Overweight (grade 1 obesity)
- BMI > 30–40 = Obese (grade 2 obesity)
- BMI > 40 =Very obese (morbid or grade 3 obesity)
- Waist/hip ratio
Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm.
The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together.
The measurement should be taken at the end of a normal expiration.
Waist circumference predicts mortality better than any other anthropometric measurement.
It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified.
> 94 cm
> 80 cm
> 102 cm
> 88 cm
Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain.
Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes and CVS complications.
It is measured at the point of greatest circumference around hips and buttocks to the nearest 0.5 cm.
The subject should be standing and the measurer should squat beside him.
Both measurement should be taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.
Interpretation of Waist-hip Ratio (WHR)
- High risk WHR = > 0.80 for females and > 0.95 for males, i.e. waist measurement > 80% of hip measurement for women and > 95% for men indicates central (upper body) obesity and is considered high risk for diabetes and CVS disorders.
- A WHR below these cut-off levels is considered low risk.
Advantages of Anthropometry
- Objective with high specificity and sensitivity.
- Measures many variables of nutritional significance [height (Ht), weight (Wt), mid-arm circumference (MAC), head circumference (HC), skin fold thickness, waist and hip ratio and BMI].
- Readings are numerical and gradable on standard growth charts.
- Readings are reproducible.
- Non-expensive and need minimal training.
- Initial laboratory assessment
- Hemoglobin estimation is the most important test, and useful index of the overall state of nutrition. Beside anemia it also tells about protein and trace element nutrition.
- Stool examination for the presence of ova and/or intestinal parasites
- Urine dipstick and microscopy for albumin, sugar and blood
- Specific lab tests
- Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D)
- Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/hydroxyproline ratio)
- Analysis of hair, nails and skin for micro-nutrients.
It is an essential features of all nutritional surveys.
- It is the simplest and most practical method of ascertaining the nutritional status of a group of individuals. It utilizes a number of physical signs, (specific and non-specific), that are known to be associated with malnutrition and deficiency of vitamins and micronutrients.
- General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, and thyroid gland.
- Detection of relevant signs helps in establishing the nutritional diagnosis.
A person's disease state may increase the risk of malnutrition due to increased energy requirements; reduced energy intake; or increased nutritional losses. Examples of diseases/conditions where this may occur include:
- Chronic obstructive pulmonary disease
- Heart failure
- Gastrointestinal disorders such as Crohn's disease, liver disease, coeliac disease
- Neurological conditions such as stroke, Motor Neurone Disease, Parkinsons Disease, multiple sclerosis, dementia
- Burns, surgery or trauma
- Mental health conditions (such as depression).
Symptoms that may impact on a person's nutritional status either through reducing nutritional intake or increasing nutritional losses include:
- Altered bowel movements, e.g. diarrhea, constipation
- Upper gastrointestinal upset, e.g. reflux, bloating, nausea, and vomiting
- Early satiety
Good nutritional history should be obtained. An estimation of the total daily calorie intake, as well as overall quality of diet should be assessed. Asking the patient (or their family/care giver if patient unable) about their daily dietary intake will help understand patterns of eating, portion sizes, cooking methods and types of food and drink taken. Consider asking the following questions to help form a better understanding of the patients’ overall diet:
- What is the patients’ typical food and fluid intake? This can be recorded using food record charts; 24-hour recall; 3-day food diary; or typical day diet history.
- Is the patient eating 3 meals a day?
- Do they have dessert after at least one meal per day?
- Are they eating snacks in between meals?
- Are they eating smaller meals than they used to when they were feeling well?
- Are they having regular drinks, at least 6–8 glasses of fluid/day?
- Are they having nutritious drinks such as milky tea/coffee, fruit juice, milky drinks?
- Are they having carbohydrate foods (bread, potatoes, pasta, rice, breakfast cereals, etc.) and protein foods (meat, cheese, beans, egg, fish, milk and yoghurt) at each meal time? Portion sizes should be at least the size of the patient's fist and amount to 1/3 each on the plate (carbohydrate, protein, vegetables).
- Are they eating at least one portion of fruit or vegetable each day?
- If food is being blended, are they adding nutritious liquids such as milk, cream or gravy to aid blending, rather than water?
- Are they able to cook for themselves?
- Do they have a hot/cooked meal each day?
- Are they taking any nutritional supplements? Do they take them as recommended? Do they like them?
Nutritional intake of humans is assessed by five different methods. These are:
- 24 hours dietary recall
- Food frequency questionnaire
- Dietary history since early life
- Food dairy technique
- Observed food consumption
24 Hours Dietary Recall
A trained interviewer asks the subject to recall all food and drink taken in the previous 24 hours.
It is quick, easy, and depends on short-term memory, but may not be truly representative of the person's usual intake.
Food Frequency Questionnaire
In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency and quantity) per day, per week and per month.
It is an accurate method for assessing the nutritional status.
The information should be collected by a trained interviewer.
Details about usual intake, types, amount, frequency and timing needs to be obtained.
Cross-checking to verify data is important.
Food intake (types and amounts) should be recorded by the subject at the time of consumption.
The length of the collection period range between 1–7 days.
Reliable but difficult to maintain.
Observed Food Consumption
- The most unused method in clinical practice, but it is recommended for research purposes.
- The meal eaten by the individual is weighed and contents are exactly calculated.
- The method is characterized by having a high degree of accuracy but expensive and needs time and efforts.
- Interpretation of Dietary Data.
- Using the food pyramid and the basic food groups method.
- Different nutrients are classified into 5 groups (fat and oils, bread and cereals, milk products, meat-fish-poultry, vegetables and fruits)
- Determine the number of serving from each group and compare it with minimum requirement.
- The amount of energy and specific nutrients in each food consumed can be calculated using food composition tables and then compare it with the recommended daily intake.
- Evaluation by this method is expensive and time consuming, unless computing facilities are available.
Aged >60 years = 30 mL/kg body weight
Aged <60 years = 35 mL/kg body weight (Todorovic and Micklewright, 2011)
To conclude the nursing process is a road map for planning and providing comprehensive nursing care. It is the critical thinking ability of the nurse that makes the nursing process scientifically sound, flexible appropriate and individualized.
Obtaining a concise and effective health history and physical exam takes practice. It is not enough to simply ask questions and perform a physical exam. As the patient's nurse, you must critically analyze all of the data you have obtained, synthesize the data into relevant problem focuses, and identify a plan of care for your patient based upon this synthesis.
As the plan of care is being carried out, reassessments must occur on a periodic basis. The frequency of reassessments is unique to each patient based upon their diagnosis.
The ability of the nurse to efficiently and effectively obtain the health history and physical exam will ensure that appropriate plan of care will be enacted for all patients.
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