 The place. A computer center at a United States Army base, somewhere in the south. The woman, Captain Karen Barnett. Computer center, Captain Barnett speaking. May I help you? Captain Barnett? Yes, speaking. This is Ms. Tindall, the nurse from the medical clinic. Do you have a minute or two that I could speak with you? Sure, Ms. Tindall. Very good. Dr. Adams has had a chance to review the results of the lab studies that you had on your last clinic appointment. And he can't seem to find an explanation for your complaint of persistent lower abdominal pain. All of your lab results were within normal limits. Your blood sugar was just a little bit high, but still within the normal range. May I ask you, are you still having problems with the abdominal pain? Yes, I am. I see. In view of your complaint and your history of hypertension, Dr. Adams feels that a workup is necessary at this time. Well, what is this workup going to entail? Well, to begin with, we've scheduled you for some tests first thing in the morning. You'll need to come by the clinic first, however. See the doctor. And then pick up your orders so that you can be admitted to the hospital this afternoon. Admitted? How long is this going to be for? You may have to be here for several days, and I would advise that you bring a few things along with you. Several days. I'm going to have to make some arrangements, but I'll be there this afternoon, okay? Oh, excuse me, Colonel. I just need to talk to you. I just received a phone call from the hospital about the physical that I took. Some problem? Well, they don't really know, so they want me to check into the hospital this afternoon. No problem. Tomorrow, I'll give you a ring at the hospital and see how you're doing. In the meanwhile, don't worry about missing a few days of work, okay? Okay, thank you very much, sir. Good luck. While missing a few days at work is a big concern for Captain Barnett, she also has a more personal concern. With her husband in Korea and her mother in another city, who would take care of her children in the evenings when the daycare center was closed? Hello? I'm surprised hearing you this time today. Is something wrong? Something wrong with the kids? No, they're fine. In fact, I was calling to see if you could come down and watch them for a few days. I have to go in the hospital this afternoon for a few tests. And I don't have anyone else to take care of the kids for me. The hospital? Did they say what was wrong with you? I don't know. The nurse in the clinic said that my tests were all normal, except my blood sugar. It was on the high side of normal. I wonder if that means that I have diabetes. You know, that wouldn't explain the stomach pain. Anyway, I need to have it checked out. Can you come up and help me with the kids? Sure, honey. I sure hope it's not diabetes. That's what your Aunt Mary had. Karen, I'll be glad to come and take care of the kids. The problem is, I'll have to find out if your father was working late tonight. If he is, we won't be able to get there until about 5.30 or 6. Is that all right? Still have to do. I'll make other arrangements until you get here. I'm sorry, honey. We'll get there as quickly as possible. In the meantime, I guess I can read you at the post-hospital. Right. And thanks again, Mom. Bye. Bye, honey. I sure hope it's not diabetes. That's what your Aunt Mary had. If the thought of diabetes wasn't enough, Captain Barnett also has some more immediate concerns. She needs to get in touch with her husband in Korea. But first, where could she find someone at the last minute to take care of her two and four-year-olds? Between the time she normally picks them up at the daycare center and the time her mother arrives. Helping Captain Barnett handle the problems related to this unexpected hospital stay will soon become a nursing concern for some Army nurse. Perhaps even you. Good afternoon, Medical Clinic. Ms. Tendall speaking. Mrs. Tendall, this is Captain Barnett again. I'm having some difficulties making arrangements for this afternoon. What's the latest I can get there and still be admitted? Well, we closed at 16.30. What seems to be the problem? Well, I haven't been able to find anyone to take care of the kids this afternoon. One's two and the other's four. And my husband's in Korea. My mother's coming from out of town to take care of them while I'm in the hospital. But she won't be able to get here until 5.30. The daycare school that the children are in closes at four o'clock. You know, we have a post-nursery that stays open until 1800, and they take children by the hour for patients. Do you suppose you could pick your children up from where they are now, take them to the nursery, and then have your mother pick them up from there? Yes, I guess that will work. And I still have time to let mother know before she leaves. I guess we can expect to see you before 16.30 then. Okay, and thanks a lot, Ms. Tendall. You've been a great help already. No problem, Captain. That's what we're here for. Bye. Ms. Tendall just used the nursing process and that brief telephone interaction. You might say that our identified problem is the stress of unexpected hospitalization indicated by the patient's concerns regarding immediate care of her children. The nursing goal is to reduce overt stressors for the patient, if possible, and the method of achieving that is to try to solve as many of the contributing situations as possible. This sort of interaction is par for the day, something nurses do all the time. Assess the situation, identify the problem, and intervene to resolve the problem. Ms. Tendall is aware of her patient's needs and her own nursing actions. And by documenting even this brief interaction, she conveys useful information regarding the patient and her needs to nurses on the ward. Shortly after Captain Barnett's admission to the hospital, the nurse assigned to care for her, Lieutenant Morgan, prepares to begin a nursing care plan. Watch carefully as Lieutenant Morgan uses the forms that make up the clinical nursing record in carrying out and documenting the nursing process. To begin, the assessment, step one. Lieutenant Morgan uses the nursing assessment and care plan form, DA 3888. Essentially, this form contains a series of questions concerning demographic data, admission data, and nursing history. The answer should give you a better insight into the patient's background. If possible, the nurse should ask the questions of the patient and record the answers in the patient's own words. However, the patient is only one source. If necessary, you can obtain much of the information from relatives, friends, medical records, and other members of the health care team. Be sure to specify the source of this data and the space provided on the form. The remainder of the form contains a list of questions to give you a picture of the patient's physical and social problems. While this list may be used verbatim, the questions are intended as a guide to the interview. At the discretion of the nurse, the questions may be rephrased to suit the patient's age, personality, or level of understanding. It is important that the nurse conducts this initial interview. Some assessment, planning, and even intervention can and often does occur during this interaction. Let's watch. I saw a note in your clinical records mentioning your husband was stationed in Korea. Have you tried to contact him yet about your hospitalization? Yeah, I did, but when I finally got through to him, his unit was out in the field on maneuvers. I didn't leave a message because I didn't want him to think that it was worse than it really is. If you'd like me to, I can get the red cross to try to get through to your husband. What do you think? I'd appreciate that. Thanks. Okay, I'll start working on that as soon as we're finished here. But first, I need to ask you a few more questions about your health. What made you first decide to go for a checkup? Well, I've been having a lot of stomach pain recently. I have to go to the bathroom more often than I used to have to go. I have to urinate every couple of hours. I guess that's why I've been so thirsty recently. I've also been so tired. I haven't had enough energy to do anything. And oh, by the way, I've lost a lot of weight recently and I haven't even been on a diet. What do you think these symptoms mean? Well, I don't really know. The thought of diabetes did cross my mind because the nurse in the clinic mentioned that my blood sugar was on the high side of normal. I guess if it turned out to be diabetes, I'd have to take shots like my aunt did. You know, I remember reading somewhere that you can take pills now. I'd rather take pills. I can't imagine giving myself an injection daily. The thought of giving myself a shot just kind of scares me. I can understand your concern about that. Let's talk about treatment after we have the tests done and we have the diagnosis established. Just bear in mind that we're here to help you to get through whatever needs to be done, okay? All right. Now, have you ever been hospitalized before? Just when I was pregnant. Are you through with your cut? Oh, yeah, thanks a lot. Did you have any particular problems during your pregnancies? They mentioned that my blood sugar was high one time, but they didn't say anything else about it afterwards. Do you recall how much your babies weighed at birth? Chris weighed ten pounds and four ounces and Erica weighed eleven pounds and four ounces. Did anyone mention those birth weights were a little high? Yes, but I didn't think too much about it because big babies run in our family. Would you like to see the kids? Yeah. Oh, they're cute. How old are they? Well, Chris is four and Erica is two. Before I came in the hospital, were you taking any medications or treatments? I was just taking diazide for my blood pressure. I was taking one twice a day. Do you have any allergies to food or medications? No, I'm not allergic to anything. How often and at what times of the day do you normally eat? I usually skip breakfast, but I make sure that the kids eat well. And I must confess that since my husband left for Korea, I don't fix dinner the way I used to. It's a lot easier to stop and get a hamburger or a pizza for the kids and myself. You said before that you lost weight suddenly. Was it more than five pounds in, say, the last three months? Yes, quite a bit more. I lost about ten pounds in three weeks. I've weighed more than I'd like for a long time now, so I was quite happy with the weight loss. But then it happened so suddenly. I wasn't dieting and with the stomach pain and everything, I began to worry. So that's why I came in for a physical. Other than frequency, do you have any problems with urination? No. Any burning? No, I just have to go a lot. Do you have any trouble sleeping? You know, in spite of being tired, I do. I just can't seem to get to bed early at night. I stay up late reading, doing things around the house and watching TV. And then the kids get me up early every morning. I have to feed them, get them dressed and to a daycare center before I come to work in the morning. Do you do anything special to help you to sleep at night? No, no, no. Do you drink alcoholic beverages? A little socially at happy hour now and then. Can you be more specific than that? Well, when my husband was home, we used to have a glass of wine with dinner every night. But since he's been gone, I don't drink anything at night. Maybe a soda or something like that. I go to the club on Friday with friends for a drink or two, but never more than two drinks. Seems like things have changed quite a bit since your husband's been gone. Does that create any special problems for you? You know, I really do miss him a lot more than I thought. I'm having a hard time adjusting without him. But right now I'm worried about the kids. I left him at the post-nursery until my mother gets here, and I haven't heard from her yet. My youngest really threw a tantrum when I left her there. I just hope she settles down by now. I can call the nursery to see how things are going. They can give me a call when your mother picks up the children, and then I can let you know. That'd be great if you had the time. It won't take a minute. I'll do that right before I talk to the people at the Red Cross. Do you have any other health problems? Well, you know about my blood pressure. I've been hypertensive for some time now. Anything else? Nothing else. I hope. When all the questions have been asked, and the nurse has gained all the information she can by using the nursing assessment and care plan form, she will go back to the nurse's station and begin to develop a nursing care plan specifically for her patient. We are now ready to take up the second step in the nursing process. Planning. Every nurse should begin the step by reviewing the data. This information will help you identify the problems of the patient. The primary problem right now seems to be her anxiety. She's concerned about the care of her children. About notifying her husband. Of course, about the possibility of having diabetes. If she is diabetic, she doesn't know the first thing about handling her disease. Once the problems are identified by the nurse, long and short-term goals can be established. To hasten the achievement of these particular short-term goals, Lieutenant Morgan moves immediately to the implementation step of the nursing process. Mrs. Fuller, this is Lieutenant Morgan calling from the hospital. I have a patient who was just admitted, a Captain Karen Barnett. Her children are there temporarily at the post-nursery. Her mother's coming by to pick them up this afternoon. Right now, she's really concerned about how they're doing. She is? Oh, good. She'll be relieved to hear that. Thank you. Bye-bye. Red Cross Office, Mrs. Sears speaking may I help you? Mrs. Sears? This is Lieutenant Morgan. I'm calling from the hospital to see if you can notify next-of-kin for a patient who was just admitted. His name, John Barnett. Captain. Second Infantry Division in Korea. No, it's not an emergency. She wasn't able to get in touch with him before she was admitted. Okay, Mrs. Sears. We'll be waiting for the call. Thank you. Goodbye. How are you doing with your new patient? Pretty well. I've just taken care of a few things that should make her a little more at ease. But she seems more than a little concerned with the possibility of diabetes. And with good reason, the doctor has ordered a two-hour post-prangial on her for in the morning. Well, I'll be seeing her in a few minutes. I'll talk to her about it then. Since a two-hour post-prangial has been scheduled for the morning, Lieutenant Morgan will plan to explain the procedure to Captain Barnett this afternoon so that the captain will know what to expect as well as what she must do to participate in the procedure. This should help achieve the goal of reducing the patient's anxiety level by getting her involved in her own care, thereby giving her a sense of control. It will also help achieve the goal of increasing the patient's knowledge of diabetes. Assuming the diagnosis is confirmed, the nursing plan will have to include adequate instructions for Captain Barnett about her condition and how to manage it. Instruction should include the physiology of diabetes, its complications, and the treatment, which will involve a change in diet and some regulation of activity. If diet alone will not suffice to control her diabetes, she will need to learn how to give herself insulin injections. The patient will have to be instructed in the proper technique of giving herself the medication. It's important that she's able to do this for herself. The patient must learn the symptoms of insulin shock and hypoglycemia and the emergency measures she can carry out to prevent these reactions. The plan must include time for instructions on proper foot care, which will include the treatment of corns and calluses and the aids in treatment for poor circulation and treatment for abrasions of the skin. She will have learned how to perform fractional urines by herself by the time she leaves the hospital. Along with giving information and teaching new skills, the nursing goal during this phase of the nursing plan is to help the patient become aware of the tremendous changes in her living patterns and to assist her in accepting these changes so that she can live as normal a life as possible. Throughout Captain Barnett's stay in the hospital, the nurse must be attuned to any cues expressed by the patient regarding her emotional state and help her to cope with the situation and deal with all the difficulties surrounding such a major upheaval in her life. When the situation permits, it is beneficial if the nurse preparing the nursing plan can discuss the plan with the head nurse and nursing staff. Their input can be of invaluable assistance to the nurse. Their participation may also assure the nurse of their cooperation and assistance in implementing and evaluating the plan. The staff's knowledge of the goals the patient is expected to achieve will help them to assist the nurse as the plan is being concurrently evaluated. During this planning phase, some consideration must be given to the continuing care of the patient when the patient is discharged and becomes an outpatient. A referral will be forwarded to the community health nurse who will use it as a basis for planning nursing care when Captain Barnett is an outpatient. More than likely, Captain Barnett also will need regular appointments for lab tests at the outpatient clinic to monitor her blood sugar level. Although Lieutenant Morgan has taken initial action for the family problems, the welfare of the children and getting in touch with Captain Barnett's husband. The implementation phase of the nursing process is only beginning. May I interrupt for a minute? Sure. I just spoke to the people at the nursery. They said that Chris and Erica calm down just beautifully after you left. I guess that behavior is pretty much expected. They also said that your mother called, she's in town and they're expecting her by to pick the children up in a little while. Well, that is good news. I know Mom won't have any problems with the kids. They mind her better than they mind me. I've also got some more good news. I've spoken to the people at the Red Cross who say they've gotten in touch with your husband. You should be hearing from him soon. I'll make sure that somebody brings you a phone in. You've really been on the ball. Well, thank you. Now, you've been scheduled for a two-hour post-parangela in the morning. Do you know what that is? No, I don't. Well, it's a very simple test to see how your body responds to food. In the morning, you have a blood sample done. Then you eat a good breakfast, noting the time you're finished. Two hours later, you have another blood sample done. When we get the results of the test, we should be able to figure out whether you have any reason to worry about diabetes. The outcome of Captain Barnett's test will determine what additional aspects of the nursing care plan will be put into effect and then logged in the clinical nursing record. In Captain Barnett's case, the test proved to be positive. Captain Barnett has diabetes. Daily insulin injections will be required. A diabetic diet will be prescribed. Captain Barnett? This is Captain Garrick, the dietician. She'll be talking to you about your diabetic diet. Will you stop by and see me before you leave the ward? Sure. Thanks. Hi, how are you today? Do you mind if I pull up the chair? We have a lot of talking to do. As the plan is put into action, it is essential that all members of the nursing staff properly document their nursing actions and the patient's response to these actions. This written documentation provides the basis for the fourth phase of the nursing process, evaluation. By Lieutenant Morgan's evaluating the nursing care given to Captain Barnett, she is in effect accepting the responsibility for these actions and further demonstrates her continuing interest and concern for the patient's well-being. Evaluation is not a one-time concern. To be effective, the evaluation process begins with implementation, continues throughout the patient's day, and must be performed until the goals are achieved. Only through continual evaluation will a nurse know whether or not the nursing care plan has developed is accomplishing what it was set down to do. If it is, and the patient is responding appropriately to nursing actions, then the nursing care plan is effective and implementation of the plan proceeds. If it is not achieving its goals and the patient is not responding, then the nurse must revise the original nursing plan. To do this, she must go through every step of the nursing process, again assessing, planning, implementing, and evaluating. Since the nursing process is a continuing process, every nurse must think in terms of these four steps if she is going to offer patients the best in nursing care. How are you doing? Oh, I'm doing just fine. Guess what? I'll be coming home the day after tomorrow. Oh, no, no, no. The nurses just want to make sure that I can take care of myself before they let me go. Oh, listen, Mom, my nurses just came in. Can I talk to you later? All right, then. Bye-bye. I was just telling my mother that I'm going home Wednesday. I figured she'd be glad to hear it. I think you were pretty happy to hear that yourself, right? Whatever gave you that idea? No, I'll be happy to go home. But still, it's not like wasted time here. I've learned so much. I just hope when I go home I'll remember everything and that I'll do it right. Well, you won't be doing it all by yourself. I'd like you to meet our community health nurse. Captain Burns, this is Captain Barnett. Nice to meet you. Hi. She'll be your primary source of support once you leave the hospital. And we thought it would be a good idea if you could meet each other before you go home. You know, three days after you get home from the hospital, by then you might have thought of some questions or concerns that you didn't think of here in the hospital. That's great. I'm glad I'm not going to be discharged to sink a swim, as they say. That's exactly what we're trying to avoid. So I'll give you a call when you get home and we'll set up a definite time. I guess around 10 o'clock in the morning. As we said earlier, the nursing process is a continuing process. Captain Burns is already beginning to formulate her contributions to the nursing care plan. We'll see you in a few days. Okay. Bye-bye. Is there anybody else that you want to see while we're here? No, I'm on my way to a home visit. When she's comfortable at home with her own plan of care, then we'll start screening her children for diabetes. What are you doing? Well, I think I've got about everything packed. Not quite. I brought your starter kit. It's got needles and syringes and everything else you'll need. I don't need to forget that, do I? Well, and the weather's getting warm now. Don't forget to keep your insulin in a cool place. Keep it in the butter compartment of the refrigerator so it won't freeze. Okay, I'll remember that. Good. And before I forget, there are a couple of other items. Your first outpatient clinic appointment is for Wednesday next week at 1,500 hours. The dietitian will see you then to find out how you're doing with your diet at home. Do you have any questions about the procedures you've learned? No, I think I understand most of it. I'm sure you'll do just fine. It takes a little time to adjust to it all though. If you find you've got any questions when you get home, feel free to call Captain Burns. If it's after normal duty hours, call here on the ward. Okay. Thanks a lot, Lieutenant Morgan. I've appreciated everything you've done. You're more than welcome. Why don't you finish packing and stop by the nurse's station before you leave? Okay. Captain Burnett's story is only one example of the nursing process in action. Through it, you've had the chance to review the four basic steps that comprise the nursing process. You've also seen how written documentation of the nursing process is carried out using the clinical nursing record forms developed for this purpose. If you are not currently using the nursing process in this manner, you should. You and your patient will benefit from it and you will be doing your part in contributing to our primary mission, conserving the fighting strength of the Army. The place? An Army drop zone. The day? Not as luckiest most for Sergeant John Rogers. This is ankle. You want to get split? We're going to give it a stretch. If you happen to be a nurse at the medical treatment facility Sergeant Rogers is headed for, this may be your chance to put the nursing process in action. It's up to you.