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https://infirmiere-canadienne.com/blogs/ic-contenu/2019/09/16/application-de-la-demarche-de-soins-dans-un-servic

Sep 16, 2019, By: Heather Ead

The acuity of patient care in the hospital setting has grown significantly over the last 10 years. For the nurse who works on an acute medical-surgical unit, it can be challenging to address the demands of post-operative assessment and care, as well as common medical challenges such as advanced age, obesity, and co-morbid disease. The 79-year-old female who has just had a hip fracture repair is not just “a hip” patient, but may also be an individual with diabetes, osteoporosis, hypertension, alcohol use disorder, asthma, obstructive sleep apnea, or early-stage dementia. This article outlines how the nursing process must be embedded in patient care to ensure optimal outcomes for acute and complex patients.

Nursing students are introduced to the nursing process during academic preparation. The nursing process is a stepped approach to assess and care for patients. It is a tool for both students and nurses to help ensure a consistent and strategic approach to patient care. The steps of the nursing process include assessment, nursing diagnosis, planning, intervention, and evaluation. These five steps are used cyclically and repeatedly during patient care. The sequence must be followed from start to finish to ensure that the needs of the patient are addressed (Morris, 2006).

Step 1—Assessment

In the first step of the nursing process, the nurse gathers key information in completing a comprehensive patient assessment. This can be viewed as the most important step of the nursing process, as it determines the direction of care by judging how the patient is responding to and compensating for a surgical event, anesthesia, and increased physiologic demands. Some of the components of a post-operative assessment include obtaining vital signs, pain score, assessing breath sounds, fluid intake and output, level of consciousness, the surgical site, and more (see List 1 below).

Step 2—Diagnosis

Based on the assessment, the nurse will next identify a nursing diagnosis. For example, if the assessment identifies the presence of tachycardia, tachypnea, a pain score of 8/10, and a reluctance to mobilize, the nurse may diagnose the presence of pain. Part of the assessment is to identify the type and source of pain. For example, in the patient who has undergone a surgery to repair a fractured hip, the pain may be localized, acute, and post-operative in nature, versus stemming from complications such as compartment syndrome, deep-vein thrombosis, or chronic pain syndrome. Establishing a nursing diagnosis then leads to the third step of the nursing process: the planning phase.

Step 3—Planning

In the third step, the nurse plans how to address the problem identified. With a diagnosis of pain, the nurse can establish a plan to use pharmacological and non-pharmacological interventions, as appropriate. The nurse would involve the patient and/or family, as appropriate, in selecting the intervention(s), to ensure that consent has been obtained. Involvement of the patient may also include providing health teaching on strategies to prevent and manage post-operative pain.

Step 4—Intervention

The fourth step is intervention: to act upon the plan. This includes implementing the plan and documenting the care provided.

Step 5—Evaluation

In the fifth step, the nurse evaluates how effective the nursing interventions were in addressing the nursing diagnosis. To complete the evaluation, the nurse determines whether data such as the pain score, vital signs, and other parameters are within defined limits. Evaluation is the final step in the nursing process, yet it directs the nurse back to the first step of assessment.

Overall, the nursing process provides a valuable framework that engages critical thinking, continual assessment, and reassessment of the patient’s status. This is particularly important if red flags are identified in the evaluation step that may suggest the onset of a post-operative or other complication. In the orthopedic population, unresolved or worsening pain is often the first sign of impaired circulation, which may be related to the trauma (for example, a high-velocity injury leading to compartment syndrome) or to the treatment (bandages impairing circulation, or anticoagulation causing internal bleeding). List 1 (below) illustrates the value of the first step of the nursing process; a comprehensive assessment can help ensure early intervention and de-escalation of clinical concerns, while avoiding complications stemming from delays and situations of failure to treat.

Accurate vital signs critical

One of the most important components of the assessment is obtaining an accurate set of vital signs. This includes temperature, heart rate, respiratory rate, blood pressure, oxygen saturation level, and pain score. Across acute surgical settings, there is variance in the protocols that direct how frequently vital signs are to be assessed (Zeitz, 2003). At Trillium Health Partners in Mississauga, Ontario, clinical order sets are used to direct nurses on care processes such as wound care, medications, monitoring of lab values, and vital signs. Every 2 years these clinical order sets are reviewed and updated. This typically involves ensuring that the current processes meet the standards of care and best practice recommendations. This biannual revision process includes a review of the literature and external site surveys. Recently, this involved verifying that the clinical order sets were up to date with respect to how frequently nurses are directed to obtain vital signs in post-operative care.

Key themes

A literature review identified a few key themes. It was noted that collection of vital signs generally included a pattern of hourly vitals for the first 4 hours, then a reduction to every 4 hours. Despite some variance in both the literature and in the external site review, overall the most common pattern identified was that post-operative vital signs were assessed every 4 hours (Zeitz & McCutheon, 2002). However, another theme identified was the paucity of research outlining a clear standard for the frequency of taking vital signs. This theme reinforces the importance of applying the nursing process and critical thinking to facilitate early identification of concerns regarding a patient’s status. Embedding the nursing process in care supports a comprehensive approach and strategy, and can mitigate delayed interventions, failure to treat, and the related negative sequelae. Nurses have an important role in the development of policies and procedures; their input supports the policy and aligns with the systematic and comprehensive approach recognized in the nursing process (Zeitz & McCutheon, 2002).

A review of the literature, as well as nursing associations and governing bodies, does not outline a specific directive on best practice in the frequency of obtaining vital signs. The Academy of Medical-Surgical Nurses recognizes this variance in vital signs routines, from every 15 minutes for the first hour, to every 4 hours once the patient is stable (AMSN, 2019). As in the cyclical nature of the nursing process, one must circle back to the patient and apply the nursing process to identify the patient’s current needs. Obtaining vital signs is a basic and quick assessment that nurses complete as part of a comprehensive assessment. A proactive approach to care and use of the nursing process can ensure early identification of complications and avoid failure to rescue and the resulting negative sequelae (Watkins, Whisman, & Booker, 2015).

While the organization’s policy directs the frequency of vital sign assessments, nurses may also be required to take additional vital signs, such as before providing additional analgesic or cardiac medications. Routine assessment of vital signs is a key step in the nursing process to help identify trends and patterns. This can be helpful in the early identification of complications such as hypotensive shock or infection, or a cardiac event such as atrial fibrillation or pulmonary embolism.

Invaluable tool

Although the five steps of the nursing process may flow naturally for experienced nurses, one should never become complacent. All nurses must ensure that this stepped approach is embedded in their practice. While there may be a sense of repetition with post-operative routines, each patient is a unique individual in how they present and respond to a surgical procedure. The nursing process is an invaluable tool that helps us to not lose sight of this central fact. Application of the nursing process supports high-quality patient care and helps nurses avoid falling into the trap of a reactive and task-focused approach to care.

In the stressful environment of acute health care, there is risk for gaps in situational awareness related to human factors, cognitive overload, interruptions, and distractions. However, the nursing process can help us maintain vigilance in our focus on patient safety and optimal care outcomes (Ead, 2015). We are seeing the use of technology in facilitating early identification and communication of clinical complications. Electronic documentation tools can allow input of the patient assessment to provide a calculated score, which triggers the appropriate action based on the severity of the score. For example, if the nurse inputs a low pulse, blood pressure, and level of consciousness, the calculated score indicates that communication with the physician and/or medical emergency team is warranted. These early warning systems align with the nursing process and support excellent patient care.

Nursing staff collaborate with many health care disciplines and act as gatekeepers for the patient’s well-being. As the length of patient stay in hospital continues to shorten while our patient population ages and becomes more complex, it is vital that nurses maintain the basic principles taught in college and university. While the literature does not offer clear guidance with respect to the optimal frequency of monitoring post-operative vital signs, the nursing process provides direction to continually assess, plan, implement, and reassess the patient’s status.

Take a moment to consider the challenges you face in patient care, and how resources such as policies, procedures, and clinical order sets are part of your nursing tool belt. If you identify a gap in one of these resources, use the nursing process to advocate for a review to ensure that care protocols are up to date in your clinical setting. It has been identified that nurses largely drive practices and policies in patient care (Zeitz & McCutheon, 2002). Nurses must continue to influence and set high standards of care to ensure that our complex surgical patient population receives the best care possible.

List 1 - An outline of the steps in the nursing process

• Assessment
  • Temperature
  • Pulse
  • Respiratory rate and effort
  • O₂ saturation
  • Blood pressure
  • Level of consciousness
  • Urinary output
  • Sensation & motor control (e.g., Bromage score)
  • Pain score
  • Appearance of skin (e.g., evidence of hypoxemia, fluid retention, pressure injury, etc.)
• Diagnosis
  • Diagnosis is based on the assessment
• Planning
  • Plan of care developed
• Intervention
  • Application of relevant policy and procedures, e.g., alert medical emergency team according to assessment scoring criteria, to intervene as appropriate
• Evaluation
  • Reassessment of initial data in step 1; how have the interventions addressed the nursing diagnosis?

References

Academy of Medical-Surgical Nurses (ASMN). (2019). Question: What are the standards and frequency recommendations for taking “routine” and “post-operative” vital signs?.

Ead, H. (2015). Change fatigue in healthcare professionals: An issue of workload or human factors engineering? Journal of Perianesthesia Nursing, 30, 504–515.

Morris, K. (2006). Using the decision-making process. Ohio Nurses Review, 6, 22–23.

Watkins, T., Whisman, L., & Booker, P. (2015). Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit. Journal of Clinical Nursing, 25, 278–281.

Zeitz, K. (2003). Nursing observations during the first 24 hours after a surgical procedure: What do we do? Journal of Clinical Nursing, 14, 334–343.

Zeitz, K., & McCutheon, H. (2002). Policies that drive nursing practice of postoperative observations. International Journal of Nursing Studies, 39, 831–839.

Heather Ead, RN, MHS is a Clinical Educator at Trillium Health Partners in Mississauga, Ontario.