TCCN and the Nursing Process

The “nursing process” as commonly thought of is a set of activities done by the nurse centering on the patient. These activities include the following:

Assessment
Diagnosis
Planning
Intervention/Implementation
Evaluation

Note that although Dr. Locsin does not in any way undervalue the biomedical nursing process i.e., ADPIE, he did mention in his work and interview that this is not the only process in nursing. It is even quite misleading to think this. He discussed the history on how this biomedical nursing process came to be. It was lifted out of the medical process used by physicians.

For Dr. Locsin and TCCN, this biomedical approach in nursing is predictive and prescriptive. It does not highly promote the autonomy of the nurse. This is because the nurse may become too dependent on the physician or a list of cues, a diagnosis, a set of nursing tasks, and expected outcomes. The use of this biomedical nursing process encourages the idea that human nurses can be replaced by robots which can be commanded with codes of algorithmic processes and outcomes.

Nonetheless, that hypothetical future of human nurses is conditional. Depending on how we perceive and perform nursing now, our future can be bright or bleak. If we go beyond merely “doing” nursing and enter the world of the other, knowing the person, and caring for him/her, then nursing has a future – not only to survive as a discipline or profession but to pave the way in healthcare.

Clinical Scenario

To deepen our understanding of TCCN practically, let us use it in a clinical scenario. Although we have considered how Dr. Locsin views the biomedical nursing process, we shall still use it as an outline to walk us through this scenario.

Suppose you are an ICU nurse. Your patient is ABC, a 6 y/o boy, admitted to your unit postoperatively. He underwent craniectomy of his left parietal skull and evacuation of blood clots due to a subdural bleed. He has hemophilia. Currently, he is awake, coherent, and calm. He can follow commands and verbalize pain or discomfort. He is on room air. Hooked to him is a cardiac monitor with a thermometer and a pulse oximeter. He is supposed to be transfused with packed RBCs at 9 pm.

At 6 pm, he verbalized that he experiences headaches and abdominal pain. His blood pressure on the monitor is 136/78, his heart rate is at 60s – 70s and labile, and his respiration ranges from 9 – 12cpm. He then vomited greenish gastric output. Gradually, you notice that he is being more combative and shows behavioral changes yet he is still able to verbalize, “ate” and “mama”. You deem that he is having an increased intracranial pressure and suspects that he has another bleeding episode.

How can TCCN be applied in this situation?

Assessment

The nurse must be knowledgeable enough of what the monitors tell. Systolic hypertension (widened pulse pressure), bradycardia, and bradypnea consist the Cushing’s triad. This is a classic sign of increased intracranial pressure. Knowing the disease process of the patient, the nurse was quick to judge the cause of what the vital signs tell. Vomiting and behavioral changes are also pertinent signs in assessing for increased ICP.

TCCN states that technological competency is caring. It is not just a portion of nursing but the actual means of nursing a patient. A nurse unable to interpret the vital signs on the monitor is not only lacking competence but also a caring attitude. The use of the monitors in this case makes the nurse’s work efficient and that makes them “technology”. We must emphasize also that the goal in TCCN is to know the person and to enter the world of the other to care. Correct interpretation and correlation of the patient’s vital signs and other symptoms allows the nurse to know the patient a little deeper, enabling her to care further in that moment.

Diagnosis/Planning

The nurse has correctly diagnosed that the patient is having increased ICP. S/he might use the nursing diagnosis Risk for Complications of Increased ICP secondary to intracranial bleeding. Part of the planning is to direct herself on what interventions are to be prioritized. Since this is considered an emergency, the nurse must plan and intervene simultaneously.

Interventions and Evaluation

Independent interventions include positioning the patient. To lessen ICP, the nurse should raise the head of the bed for the patient to assume a moderate-high back rest position. The head must be kept at midline to prevent further injury. Since the patient started to vomit, placing a dental suction hooked to continuous low negative pressure can help prevent aspiration. Restraining the patient may also be necessary if his combative actions can injure him. A consent for restraining must be taken from his parents or guardian depending on hospital protocols. The nurse can hold the patient’s hand to assure him of his/her presence amidst the crisis. Children need to feel that they are not alone while being treated.

Collaborative interventions include immediate referral to the doctor-in-charge, clearly stating the problem, a background of the situation, relevant observations, and the recommendation of the nurse.

Dependent interventions include the administration of decompressive medications such as Mannitol. The doctor may also order a stat dose of sedation or pain medication to calm the patient. A stat imaging of the patient’s brain might also be needful (i.e., via cranial CT scan or MRI) so the nurse must prepare the needs for transport.

TCCN defines technology as anything that can increase the efficiency of the nurse’s work. Contrary to mainstream definition, technology is not exclusive to devices and equipment in the hospital such as cardiac monitors and pulse oximeters. Medications, hospital beds, syringes, and even linen restraints can be considered “technology” because they make nursing efficient.

As abovementioned, the goal in TCCN is to know the person in that moment to care for him/her. In our present case, the nurse can intervene with the use of technology towards the goal of knowing the patient. What does the patient feel while the nurse administers medications? Does he feel pain or even fear? These can be known once the patient allows the nurse to enter his world in that moment. Even when the kid became combative, the nurse should adjust to the changes he presented and still be able to care for him. TCCN asserts that a person is not static or predictable and the nurse should be aware of this to be able to care for the person moment to moment.