The Nursing Process & the CNA

In my experience working as a CNA in a nursing home, I rarely heard the term “Nursing Process”; I often heard about care plans- but that was about as descriptive as things would get. I remember asking a nurse- “Just what is a care plan, anyway?”- and she didn’t know how to answer me! So I have spent a long time researching this elusive term- “Nursing Process”- and trying to figure out exactly where the CNA fits in with it.

First, the medical team is broken into several layers. At the top is the patient- who has an illness, or condition requiring on going care. The Doctors are next- we all know they are well educated and have spent years learning how to diagnose and treat problems, illnesses, disease etc. Doctors, Physician Assistants and Nurse Practitioners are the only person within the medical team who can actually diagnose. We have doctors, nurses and then us- CNA’s!

So this brings us to the next point: A patient, client, resident is admitted to a nursing unit. This can be in a hospital, nursing home, rehab center, even to the patient’s own home. Nurses are called upon to perform several steps to assist with the healthful and positive outcomes for these patients. The nursing process is a relatively new thing; in the 1960′s team based nursing came into fashion, but nurses had no way to let other team members know what to do with patients.
A process, based upon what scientists use, was developed. Over the years this process has been refined to what we know today.

The nursing process is divided into five steps.
1) Assessment
2) Nursing Diagnoses
3) Planning
4) Intervention
5) Evaluation

Where does the work of the CNA fall here, you may ask yourself? Let’s see if we can find some pretty common things CNA’s are asked to do, that are a part of helping the nurses with this process. It is assumed here that the patient/resident/client has a top level diagnoses from an MD, and a treatment plan is in place from the MD. This plan would include medications, treatments, special diets, procedures ordered by a doctor.

Step One: Assessment

Assessment involves continuous data collection to identify a patient’s actual and potential health problems. This data should be as objective as possible, and nurses should be as non-judgmental as possible as well. To perform the assessment, nurses should:
· Get Nursing History from patient
· Perform a physical examination
· Review lab and medical information

The nursing history is mostly subjective data. Often, the patient’s perception of his health problems makes up a large portion of the health history. Nurses should find out how the patient coped with a similar illness, what interventions worked, didn’t work etc.

A physical exam is the next step. This is where the CNA often assists the nurse. When we are asked to get heights and weights, vital signs, record food/fluid intake and output, it is almost always for the purpose of assessment. Although CNA’s do not make assessments, nurses depend upon us to report timely and accurate data. Things we see, smell, hear, feel and touch should be reported.

Nurses should perform a thorough exam by doing the following:
· Body Inspection- observation of patient- direct and indirect
· Palpation- feeling body regions for masses, smoothness, and muscle tone
· Percussion-using fingers in a tapping motion to feel for abnormal sounds over body regions
· Auscultation- listening for sounds over body regions such as lungs, bowels…

Nurses are taught skills to perform a physical assessment in their schools.

Step Two: Nursing Diagnoses

Nurses are licensed to identify and treat certain human reactions and potential health problems associated with the illness, disease etc.
As we see, nurses have a huge responsibility when it comes to giving accurate diagnoses of a health/potential health problem. All the care given is based upon the proper Dx, the proper plan of care being written and the right interventions.
Based upon all the data collected- both subjective and objective, the nurse next will form a nursing diagnoses drawing from the above list of possible problems.

It is these terms in the list that we will often see when we look at a care plan. It isn’t something that comes lightly for nurses- this is one of the big reasons they need a college degree. Assessment is a big part of being a nurse, and it is an even bigger part of what we, CNA’s, do. It is absolutely vital that we report back accurate information. The care a patient gets, and hence the outcome of his health, depends upon good sound information.

Step Three: Care Planning
The Care Plan is a term we should all be familiar with. We all should know that the care plan is the bible for nursing care of patients, but what else should we know about this document? It is a legal document promising care being delivered as written; the nurse can get into huge amounts of trouble if her care plan isn’t followed. The care plan is designed to assist team members in delivering high quality, consistent care that is needed. Time spent performing tasks and care that is not needed results in wastes of money, resources. Effective care plans take into account unit staffing patterns, patient wishes and abilities, and should reflect who the patient is. A good nurse will seek the opinion of the CNA when writing the care plan. CNA’s can offer invaluable insights into the patient’s abilities and desires. All facilities should encourage CNA participation in care plan conferences.

Cookie cutter care plans are easily recognizable:
· they have the same nursing Dx
· they have the same interventions for all patients (seen often in nursing homes, where all residents have been known to be on a two hour bladder program)
· they don’t work!

A good care plan will be specific, realistic, clear and brief. It doesn’t need to be a long novel.
Anyone who is expected to deliver care from a care plan should be able to read the plan and understand it, including the patient when applicable, as well as the patient’s family.

Step Four: Interventions
This is where the CNA really comes into play! Often, the interventions are WHAT we do. All that turning, repositioning, toileting- are all interventions listed in the care plan. Also, a great amount of the documenting we do is designed to assist the nurse with evaluating these interventions. So it really makes sense to document accurately- in time- if an intervention IS NOT working, it will be noted (and perhaps removed from future care plans). Interventions can be anything from special baths to back rubs to repositioning, to toileting, to using special creams and lotions, to offering certain supplements. Often, an intervention must have an MD order along with it. This is kind of strange I think- if nurses are allowed to formulate their own Dx then they shouldn’t need an MD’s order to carry out some of the treatments to reach the goals. The most important part a CNA can play in this intervention stage is to accurately report all reactions to the interventions. Be as specific and objective as possible.

Step Five: Evaluation
This is the final step in the nursing process. This is the time when nurses look at their care plans and check to see if the plan has “worked” in solving the patients’ health issues, concerns, etc. As stated before, a good plan will work and a poor plan will not. Nurses will check to see if the interventions have been effective- they look at subjective as well as objective data. This is when they will see your good documentation! For example, if a patient were incontinent, and the patient wasn’t so until recent illness, the nurse might try a timed program approach to help the patient gain control again. IF the initial voiding assessments, done by the CNA, were not accurate (i.e.- CNA just wrote in times she guessed patient voided)- and the nurse put the resident on a two-hour program…when patient actually needed to go every hour- you can see how this intervention would fail.

The nursing process doesn’t end here- it continues until the patient is discharged or passes on or whatever. Sometimes a patient goes home with a care plan, and this is especially challenging for staff. If the nurse never saw the home environment, then chances are good that the care plan won’t work. Usually home health nurses do the plans for this population.

Some thoughts to ponder…
As I said in the beginning of this page, I never knew what the nursing process was. I still have my books from my CNA classes, and I have several newer additions. It wasn’t until very recently that CNA’s were taught this process. This is too bad. I fear there are too many CNA’s out there who do not have a clue how important their work is. All the work, the documenting- would certainly take on a new meaning if CNA’s really understood their role, within the nursing process, as a whole. It would make a good in-service for any facility to offer: Nursing Process- What Is it?

Even of greater concern for me is the apparent lack of concern on the part of nurses who are charged with this process. Never mind those who don’t seem to know what it is, but what about those who DO know, yet follow their own approaches to deliver care. Hmm. I challenge all CNA’s to hold their nurses up to the standard when it comes to the Nursing Process. After all, if our work is to have any meaning at all, then the Process should be the standard. When a new patient is admitted onto a unit you work on, watch to see if a complete physical assessment is done by the nurse; see if any of the things you are asked to do may have a part in the assessment. Ask questions. Expect answers that make sense to you. A lot is at stake here, the patient’s well-being. See if all your good documenting is worthwhile. Ask the nurses what will become of the notes you have written- those flow sheets should become a tool, not some paper put into a chart.

See if the system really works, or if it is just another process that is meaningless.


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