Fundamentals - Practice & Skills, part 1: Nursing Process, Interdisciplinary Team, SBAR Report, and Continuity of Care
by Meris Shuwarger BSN, RN, CEN, TCRN July 22, 2021 Updated: December 07, 2022 11 min read
In this article, we will explain the nursing process. This is the systematic approach that guides the way you should think and that is the foundation for everything you need to know about learning to be a nurse. We will introduce your interdisciplinary team members — the providers, therapists, pathologists, social workers, and case managers with whom you'll work. We'll explain SBAR communication, a technique to help you communicate with your interdisciplinary team members. And we'll discuss continuity of care for your patient, from admission, to transfer, to discharge.
The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
The nursing process
The nursing process is the systematic approach nurses use to guide patient care. It guides the way nurses should think critically while performing nursing duties. Critical thinking in nursing is the way nurses solve the problems of patients; it is a combination of decision-making and creativity that allows nurses to arrive at the best solution.
The nursing process is a systematic approach because there is a specific sequence of steps to take in providing patient care. There are five steps in this system, and we remember the five steps with the acronym ADPIE. This stands for Assessment, nursing Diagnosis, Planning, Implementation, and Evaluation.
Let's take them in order.
The first step of the ADPIE sequence of the nursing process is assessment. Assessment means collecting data to understand what is going on with a patient. The gathered data can be objective or subjective.
Objective data are measurements or observations, things we use our five senses for when we seek information. Objective data can be things like vital signs (a patient's temperature or blood pressure) or lab results.
Subjective data are things you cannot verify with your five senses, for example, what a patient reports they are feeling (e.g., how much pain they are in). You cannot assess such a report objectively. Instead you must consider how your patient seems, how they are acting. Subjective data can provide clues to understanding how your patient is doing. Plus, listening to your patient and understanding how they feel establishes trust — an important part of the nurse-patient relationship.
For more information on nursing documentation and documenting objective vs. subjective findings, check out Fundamentals - Principles, Part 8: Patient Education and Nursing Documentation.
The next step of the ADPIE sequence of the nursing process is the nursing diagnosis. It's what you identify — after you have assessed the objective and subjective data — as the patient's primary actual or potential health problem that you need to help correct.
Remember, this is a nursing diagnosis, not a medical diagnosis.
What's the difference between a nursing diagnosis and a medical diagnosis?
A nursing diagnosis, according to the North American Nursing Diagnosis Association (NANDA), is a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.
A medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. A medical diagnosis can only be made by the provider.
The key resource at your disposal when you make a nursing diagnosis is a list provided by NANDA. This list is always being updated and will help you prioritize and plan care. It includes a hierarchy of needs, including the most basic physiological, safety, and emotional needs of a patient.
This hierarchy is based on Maslow's Hierarchy of Needs and lays the foundation for your patient's physical and emotional health. Maslow's Hierarchy is often shown in the form of a pyramid, indicating which needs are the most basic and important — the foundation that the other needs are built on. The key takeaway from Maslow's Hierarchy is that our psychosocial, higher-level needs can't be met until our basic and physiological needs are met.
The next step in the ADPIE sequence of the nursing process is planning. The planning stage is where we start to set goals and outcomes for our patient. The goals we want to set are SMART goals.
What is a SMART goal in nursing?
A SMART goal is an acronym for a goal that is Specific, Measurable, Attainable, Realistic, and Timely.
A specific goal is one in which the objective is clear and detailed. For example: What do you want to achieve with this patient and how are you going to go about achieving that goal? What are the steps you will take?
A measurable goal is one in which your patient's progress can be tracked or measured. Setting specific measurements for your patients (e.g., keeping their pain level under a certain number) means you can track their progress over time.
Sometimes called an "achievable" goal, an attainable goal means a goal you can actually meet. Setting attainable goals increases the likelihood of successfully meeting them. This can motivate a patient and boost their morale as they successfully attain goal after goal.
Set realistic, or relevant goals for your patient. This means setting goals that make sense for them, that apply to their long-term health. Goals that are realistic or relevant are more likely to inspire your patient to stick to the plan.
Timely as in "time-based" or "time-bound" — that is, goals with a deadline. Goals that have a deadline or finish line are more likely to be met than open-ended goals. For example, setting the goal that the patient loses one pound per week. Some goals might be achieved in a matter of weeks. Others may take years. Lay out your plan and track it over time.
Here is an example of what differentiates a SMART goal from a poorly written goal:
- Poorly written goal: “Patient’s blood pressure will decrease.”
- SMART goal: “The patient’s systolic blood pressure will decrease by 10 mmHg by (date).”
The poorly written goal is vague (unspecific), doesn't state the trackable measurement, may or may not be attainable or realistic, and does not have a deadline. The SMART goal includes all the necessary details.
Remember, too, that SMART goals are patient-centered, not nurse-centered. The nurse helps the patient to achieve the goal. Express a SMART goal starting with "The patient will..." not "The nurse will..."
The Implementation/Intervention step in the ADPIE sequence of the nursing process is the action stage, where the nurse carries out the intervention outlined in the plan. That is, you are doing something for the patient. For example, administering medication, applying oxygen, or tending to a wound.
The last step of the ADPIE sequence of the nursing process involves reassessing or evaluating your patient. Has the desired outcome been met? Did your interventions work? Has your patient's pain decreased? Is their oxygen intake improving? Do they tell you that they are feeling better? All of this information and feedback is important as you ascertain whether or not the care plan has been successful.
If the patient's condition has improved, you may decide to add new goals and interventions
If your patient is not doing better, then reassess — go back to the first step of the ADPIE sequence and make a new assessment. Start again.
Remember: these steps are sequential. Always start by assessing.
Interdisciplinary team members
As a nurse, you will likely have many members on your team. Here is a list of some of the most important ones. Please note that this list is not comprehensive; your team may have many more on it.
The provider is the person who examines, diagnoses, and treats a patient's illness or injury. This could be a physician, an MD (doctor of medicine), or a DO (doctor of osteopathic medicine). Osteopathy is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. The primary difference between an MD and a DO is that some osteopathic doctors provide manual medicine therapies, such as massage therapy, as part of their treatment.
Another provider might be a physician's associate/assistant, also known as a PA. A physician's associate could be a nurse practitioner (NP).
There are many different ways to be a provider, so when you are told to "report to the provider," you'll know that not every provider is an MD.
An occupational therapist (OT) helps patients regain or maintain their ability to perform activities of daily living (ADLs), for example, helping patients learn how to feed themselves again.
The physical therapist (PT) works with patients to improve their mobility, range of motion, and/or endurance. If you have ever been injured, you might have had to see a physical therapist. Your PT will have taught you exercises specific to helping you improve the strength, mobility, and flexibility of your injured joint or muscles so you can get back to moving about normally again.
What's the difference between a physical and occupational therapist?
OTs and PTs may work closely together, but their focus differs. A physical therapist focuses on improving the patient's ability to move their body. An occupational therapist focuses on improving the patient's ability to perform ADLs. A PT's medical foundation is physical rehabilitation, while the OT's is founded in mental healthcare and physical rehabilitation.
Speech Language Pathologist
A speech language pathologist assists a patient with speech, language, and swallowing issues. As their name suggests, helping patients overcome speech impediments is a key function of the speech language pathologist. But perhaps more important, they can also help when your patient has dysphagia.
Dysphagia means having difficulty swallowing, literally dys (bad) phagia (eating). A patient suffering from dysphagia has to take more time and effort to move food or liquid from their mouth to their stomach. Sometimes dysphagia is associated with pain. Risk factors include nervous system disorders (e.g., stroke, Parkinson’s, dementia, ALS, cerebral palsy), head/neck/esophageal injury, and GERD (gastroesophageal reflux disease).
Difficulty swallowing increases the risk of aspiration, which is when something enters the airway or lungs by accident. It's what we mean when we say something "went down the wrong pipe." This could be a piece of food, liquid, or some other material, and it can lead to serious health issues, potentially harming the lungs and increasing a patient's risk of pneumonia.
The speech language pathologist can perform swallowing studies and determine the best therapies for improving a patient's ability to swallow correctly.
A respiratory therapist helps patients who are having trouble breathing, from premature infants with lungs that are not fully developed to elderly people with lung disease. The respiratory therapist may assist a patient by giving oxygen, managing a ventilator, or administering drugs to the lungs.
A social worker provides psychosocial support and appropriate referrals for patients and families, helping people solve and cope with problems in their everyday lives. These problems aren't always directly related to solving a patient's medical issue. Rather, a social worker might advise the patient's family or the patient, once their care is complete, and they have been discharged from care. A clinical social worker may diagnose and treat mental, behavioral, and emotional issues.
The case manager helps facilitate communication between clinical staff, loved ones, and community agencies to ensure continuity of care and address any questions or concerns. Case managers are responsible for discharge planning — they work closely with doctors, therapists, and nurses to ensure follow-up services are appropriate for each patient after the patient has been discharged, including arranging for medical equipment and services the patient may require once they are living at home again.
SBAR communication is the gold standard for communicating with other healthcare professionals. It is the technique whereby nurses organize and facilitate communication with interdisciplinary team members. SBAR communication helps ensure your report is organized and that you share all the relevant information that needs to be shared. It guides the flow of a patient's treatment.
SBAR is an abbreviation that stands for: Situation, Background, Assessment, Recommendation.
Understanding and utilizing SBAR communication is part of how a nurse's brain works. Click these links to learn more about the nurse's brain and explore our giving reports series — how to give reports to your CNA (Certified Nursing Assistant), doctor, and end-of-shift or oncoming nurse.
The “S” in SBAR stands for situation, which means stating what the problem is clearly and concisely. If you are communicating with someone else, introduce yourself, share the patient's name, and briefly describe the specific problem or concern.
The “B” in SBAR stands for background. Background is the reason the patient is there — their admitting diagnosis and relevant history.
The “A” in SBAR stands for assessment. Assessment is a review of the patient's current state, including relevant assessment data (e.g., vital signs, signs/symptoms, labs, or diagnostics).
The “R” in SBAR stands for recommendation. This is where you provide suggestions for next steps or you solicit advice as to what next steps to take.
Continuity of care
Continuity of care is how to provide care for a patient from the time they are first admitted, through any possible transfer (either within the same facility to a different facility), all the way through to their discharge from care. Continuity of care means maintaining a consistent quality of care through the duration of a patient's admittance.
When a patient is admitted, you'll confirm their advance directive status, cover specific safety concerns, assess them, and begin discharge planning
Advance directive status
When a patient is admitted, you need to first confirm their advance directive status. For example, is the patient “full code?” Full code is a type of code status where it is necessary to perform resuscitation procedures to keep the patient alive: the patient's heart has stopped beating or they have stopped breathing, for example.
Or perhaps the patient has a DNR ("do not resuscitate") order, which is the opposite of a full code — a patient with a DNR order does not want to be resuscitated.
Patient safety concerns
Upon patient admission, you must also assess for allergies to determine which medications should and should not be administered.
Determine their fall risk. Patients could injure themselves (further) if they should suffer a fall.
Examine the patient's ability to swallow. This must be done before allowing the patient to eat or drink anything. Remember, a patient with swallowing issues could aspirate when taking nutrients or medications orally.
Perform a head-to-toe assessment. This entails going through a checklist to review the patient's physical state functions. There are forms for the head-to-toe assessment that you can use to perform this assessment.
You can learn more about the flow and sequence of a head-to-toe patient assessment with our Health Assessment Flashcards for Nursing Students.
Begin discharge planning
Although you just admitted the patient, at this time you also want to begin planning for their discharge. From the moment the patient enters your care, you need to be considering what it will take to get them home again. Hospitals are not the best place for someone to be sick — people don't want to have to go to a hospital, hospitals have pathogens that might make a patient's condition worse, there are disruptions (which include regular check-ins by nurses that interrupt a patient's ability to get enough sleep). The best place for the patient is at home, where they can recuperate in a familiar, comfortable setting.
If a patient must be transferred to another room in the facility, or to an entirely different facility, communication among the care team is vital. When communicating with a nurse from your patient' transfer destination, use the SBAR communication technique to ensure all the relevant information is shared in an organized, clear and concise manner.
When a patient is discharged, it is important to educate them about any restrictions to their diet and/or activities. This is called “patient teaching.” Among the things your discharged patient should know: Are there changes to their medications and the way they should be taking them? Do they have follow-up appointments, and when and where and with whom will these be — give them the relevant information about the follow-up provider; and consider the possibility that the patient has never seen this provider before. Patients need to know who they must contact for follow-ups.
Specific patient teaching will be a large part of your nursing education and clinical practice. Our Medical-Surgical Nursing Flashcards cover specific patient teaching for each disease/disorder, and our Pharmacology Flashcards cover specific patient teaching for each medication!
One of the most important things to do before a patient is discharged or transferred (internally or to another facility) is the medication reconciliation. This is when you and the patient review the full list of their medications — which medications should be stopped, and any that are new. Provide your patient with a list of their medications at discharge, so they have an updated version they can take home with them.
If you'd like an in-depth look at medication reconciliation, check out Pharmacology Basics, part 1: Introduction, Drug Names, Medication Regulation and Reconciliation, which is covered in our Pharmacology Basics and Safe Medication Administration Flashcards.
Hi. I'm Meris. And in this video, I'm going to be talking about the nursing process. The interdisciplinary team members, SBAR communication, and how to protect your patient's continuity of care during admission, transfer, and discharge.
I will be following along using our Fundamentals of Nursing flashcards. As you can see, we are finally in the Practice and Skills section of this deck.
These cards are available on LevelUpRN.com if you don't already have your own. And if you do, and you're following along with me, we are on card number 42. So let's get started.
So up first is the nursing process. And I cannot stress to you how important this is for you to know for all of nursing school. It is going to help you to guide your thinking. It's going to help you in test-taking scenarios. It's going to help you in clinical. You've got to be comfortable with the nursing process. So what is it?
Well, we remember the steps with the acronym ADPIE which stands for Assessment, Diagnosis (Nursing Diagnosis), Planning, Intervention, and Evaluation.
So we talk about this on this card. There's a lot of information here. It's bold and red. You're going to want to know it. I promise.
But Assessment is what we start with first. This is data gathering, so looking at my patients, their lab results, their vitals, how do they seem, how are they acting. All of that is assessment.
Then we move on to Diagnosis. This is a nursing diagnosis, not a medical diagnosis. So this is going to be what I identify as being their primary problem that I as the nurse need to help correct. So this is very important. And if you are not used to writing nursing diagnoses, I would definitely recommend that you get a nursing diagnosis handbook to help you learn how to formulate those.
Then we move on to the Planning stage. And in the planning stage, this is where we start setting goals for our patients. But these aren't just any goals. These are SMART goals. SMART standing for Specific, Measurable, Attainable, Realistic, and Timely. And when you write a goal, you need to make sure that it is all of those things.
Remember this is also patient-centered. So, "The patient will blah, blah, blah." Not, "The nurse will." This is the patient's goal. The nurse may be able to help them. But they are not the focus of the goal. So we're focusing on the patient.
We have here a poorly-written goal, and then a SMART goal. I would very much recommend you look at this to see the difference there.
And then we move on to Implementation. You may have heard this called intervention, as well. This is the doing stage.
At this point, I'm doing something. Maybe I'm giving a medication. Maybe I'm applying oxygen. Perhaps there's some sort of wound care going on. All of these things are happening in the implementation stage. This is where we are actually doing something to our patient.
Pay attention that this comes way down the line, after we've done those first steps. Very important to know what order we follow.
And then at the very end, I'm going to Evaluate. Did my interventions work? Is my patient's pain better? Is their oxygen better? Do they say they're feeling better? All of that is good information.
And if not, if they're not doing better, then we need to go back to assessment and reassess and start over. Just make sure you understand, we go in order and we always start by assessing.
Moving on to card number 43. Here we are talking about the interdisciplinary team members. There are a lot listed here. I'm not going to go over all of them. But a few key members I want to highlight for you to know.
The provider is the person who examines, diagnoses, and treats the patient. So this could be a physician, an MD, a DO. This could be a physician's associate, a PA. This could be a nurse practitioner, an NP, right. There's lots of different ways to be a provider.
So you will hear this in your nursing exams, to report to the provider. Because not every provider is a physician.
Then we have occupational therapy and physical therapy.
Now occupational therapy is going to help your patients with their activities of daily living. So learning how to feed themselves again, for instance, would be the job of the OT.
The physical therapist, the PT, is going to help with things like muscle strengthening, improving mobility, range of motion, that sort of stuff. They work very closely together. But they have a different job.
And then one that I really want to point out here, and you'll notice it is bold and red on this card, is speech-language pathologist. So an SLP can help your patients with things like speech impediments.
But they can also help when your patient has dysphagia -- GIA -- dysphaGIA, difficulty swallowing. So they can perform swallow studies. And they can help with therapies for your patient to improve their swallowing ability. So if your patient has dysphagia, you want to be working with SLP.
Okay. So next up on card number 44, we are talking about SBAR communication. This is going to be kind of the gold standard for communicating with other healthcare professionals, be that other nurses or a provider.
This is going to help us to organize what we have to say and to make sure that we get all the information across that we need to.
So SBAR stands for situation, background, assessment, and recommendations.
So it's going to be, "Here's the situation. I've got this patient. They're here for this diagnosis."
And I'm moving on to the background. Now here's why they came in. This is the relevant history.
And now I'm moving on to the assessment. "When I went in there, I saw that he was having a really hard time breathing. His sats are in the high 80s right now. He just doesn't look very good." I'm going to give them whatever my assessment data is, right, ABGs, that sort of thing. And then we move on to recommendation, "I'd like an order to give him 15 L per minute by non-rebreather. Is that acceptable, or do you have something else that you'd like to recommend?" So either I can provide a recommendation, "This is what I would like," or I can say, "Do you have a recommendation for how to proceed?" Either way, SBAR helps to guide that flow and make sure that we are providing all relevant data.
Okay. So card 45, we're talking about continuity of care. This is how we can provide the best care for our patient from their admission, any time they are transferred, either within the same facility to different facilities, and discharge. So you'll see here we have a lot of stuff to go over. There's key points and everything like that, so pay attention to this part. It's pretty important.
At admission, I need to confirm my patient's advanced directive status. "Are you a full code? Are you DNR?" Gotta know it. Right? I need to need to assess their allergies.
I need to determine their fall risk.
I should also do a swallow examination to make sure that my patient is able to swallow before they ever have anything to eat or drink.
And I'm going to do my head-to-toe assessment at this point. Very important to know, discharge planning begins at admission. From the time my patient walks into that hospital, we need to be thinking, how do we get this patient home? Because the hospital is no place for a sick person, right? Nobody wants to be in the hospital. There's pathogens. There's disruptions. There's poor sleep. The best place for my patient is going to be at home or wherever they reside, so we need to start thinking about their discharge planning at admission.
Now when we do a transfer, we're going to provide a report to the nurse who will be accepting the patient using that SBAR communication.
And also, at discharge, this is going to be very important that we educate our patients when they are being discharged from the hospital about any sort of diet and activity restrictions, any changes to their medications and how they should be taking them, what their follow-up appointments are, when and where and with whom, and give them the contact information for their provider. Maybe they didn't see this provider before being in the hospital. It's important that they know who to be able to call.
Now there is a key point here that I really want to make sure that you pay attention to.
A key point is a medication reconciliation, meaning going over the patient's full list of medications, what should be stopped, what is new, what's continuing, should be done at admission, transfer in the same unit or to another unit, and upon discharge.
We also want to provide our patient with that full medication reconciliation information at discharge so that they have it updated for their own use.
Alright. So that is it for the nursing process, the interdisciplinary team, SBAR communication, and continuity of care. I know that was a lot, but it's all super, super important information. So if you liked that review, please go ahead and like this video, and if there's anything that you want to leave me in the comments about how you remember things or a funny story, I always want to hear that, so please do!
My next video is going to be covering hospital-acquired infections and proper hand hygiene. So you don't want to miss that-- very important for fundamentals. So be sure you subscribe to the channel so you're the first to know. Thanks so much, and happy studying!
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