CRITICAL THINKING IN NURSING PRACTICE, NURSING ASSESSMENT, NURSING DIAGNOSIS, PLANNING NURSING CARE
NURSING ASSESSMENT
Assessment is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals. The accompanying display presents the essential elements of the assessment process. Effective planning of client care depends on a complete database and accurate interpretation of information. Incomplete or inadequate assessment may result in inaccurate conclusions and incorrect nursing interventions. Proper collection of assessment data directs decision-making activities of professional nurses.
The goal of assessment is the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes and planning care, and developing nursing interventions. This chapter discusses the purpose of assessment, types of assessment, and the use of data in the assessment process.
PURPOSE OF ASSESSMENT
The purpose of assessment is to establish a database concerning a client’s physical, psychosocial, and emotional health in order to identify health promoting behaviors as well as actual and/or potential health problems. The American Nurses Association (ANA), in its Standards of Clinical Nursing Practice (1998), supports the use of the nursing process and outlines the essential components of assessment in this process (see the accompanying display). Through assessment, the nurse determines the client’s functional abilities and the absence or presence of dysfunction. The client’s normal routine for activities of daily living and lifestyle patterns are also assessed. Identification of the client’s strengths provides the nurse and other members of the treatment team information about the skills, abilities, and behaviors the client has available to promote the treatment and recovery process. Some examples of client strengths are family support, intelligence, spiritual beliefs, and coping skills (how previous problems have been solved). The assessment phase also offers an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. During assessment, the client is provided an opportunity to discuss health care concerns and goals with the nurse.
TYPES OF ASSESSMENT
The type and scope of informatioeeded for assessment are usually determined by the health care setting and needs of the client (see Figure 6-1).
Three types of assessment are comprehensive, focused, and ongoing. Although a comprehensive assessment is most desirable in initially determining a client’s need for nursing care, time limitations or special circumstances may dictate the need for abbreviated data collection, as represented by the focused assessment.
The assessment database can then be expanded after the initial focused assessment, and data should be updated through the ongoing assessment process.
COMPREHENSIVE ASSESSMENT
A comprehensive assessment is usually completed upon admission to a health care agency and includes a complete health history to determine current needs of the client. This database provides a baseline against which changes in the client’s health status can be measured and should include assessment of physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, and the client’s coping patterns.
FOCUSED ASSESSMENT
A focused assessment is an assessment that is limited in scope in order to focus on a particular need or health care problem or potential health care risks. Focused assessments are not as detailed as comprehensive assessments and are often used in health care agencies in which short stays are anticipated (e.g., outpatient surgery centers and emergency departments), in specialty areas such as labor and delivery, and in mental health settings or for purposes of screening for specific problems or risk factors (e.g., well-child clinics). See the accompanying display for sample questions used to assess a client experiencing labor.
ONGOING ASSESSMENT
Systematic follow-up is required when problems are identified during a comprehensive or focused assessment. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. This type of assessment allows the nurse to broaden the database or to confirm the validity of the data obtained during the initial assessment. Ongoing assessment is particularly important when problems have been identified and a plan of care has been implemented to address these problems.
Systematic monitoring and observations allow the nurse to determine the response to nursing interventions and to identify any emerging problems.
The nurse delivering care to a client at home uses ongoing assessment. In the home, the nurse often has to direct the client to provide information relevant to the current problem, as the client may have a tendency to spend a lot of time telling stories of past medical problems and treatment, as opposed to providing information relevant to the situation at hand (Humphrey, 1994). Use of specific questions will be most helpful in eliciting specific information (see the accompanying display).
DATA COLLECTION
The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. This process often begins prior to initial contact between the nurse and the client, primarily through the nurse’s review of biographical data and medical records. Upon meeting the client, the nurse continues data collection through interview, observation, and examination. A variety of sources and methods are used in compiling a comprehensive database.
TYPES OF DATA
Client data include information that the client communicates concerning perceptions of his or her own health status, as well as specific observations made by the nurse.
These two types of information are referred to as subjective and objective data.
Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data (also referred to as symptoms) are obtained through interviews with the client. They are called subjective because they rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another.
Objective data are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.
These data (also called signs) can be seen, heard, or felt by someone other than the person experiencing them. Assessments that are comprehensive and accurate include both subjective and objective data.
See Table 6-1 for examples of both types of data.
SOURCES OF DATA
A comprehensive database should include data from every possible source (see the accompanying display). The client should always be considered the primary source of information; however, other sources should not be overlooked.
The client’s family and significant others can also provide useful information, especially if the client is unable to verbalize or relate information. In addition, other health care professionals who have cared for the client may contribute valuable information. Medical records should also be reviewed, including the medical history and physical examination; results of laboratory and diagnostic tests and various health care professionals should also be consulted.
Pertinent literature should be investigated in order to pursue relevant information and plan appropriate nursing interventions. Written standards are valuable sources of data for comparison, for example, a standard table of infant growth to determine if an infant’s weight and height are withiormal growth range. Another valuable source of data is knowledge about the client’s normal parameters of functioning. The nurse’s knowledge based on experience is another important source of data.
METHODS OF DATA COLLECTION
The nurse collects information through the following methods: observation, interview, health history, symptom analysis, physical examination, and laboratory and diagnostic data. These approaches require systematic use of assessment skills that are discussed below.
OBSERVATION
The nurse uses the skill of observation to carefully and attentively note the general appearance and behavior of the client. These observations occur whenever there is contact with the client and include factors such as client mood, interactions with others, physical and emotional responses, and any safety considerations.
Observation helps the nurse determine the client’s status, both physical and mental. By carefully watching the client, the nurse can detect nonverbal cues that indicate a variety of feelings, including presence of pain, anxiety, and anger. Observational skills are essential in detecting the early warning signs of physical changes (e.g., pallor and sweating).
INTERVIEW
An interview is a therapeutic interaction that has a specific purpose The purpose of the assessment interview is to collect information about the client’s health history and current status in order to make determinations about the client’s health needs. Effective interviewing depends on the nurse’s knowledge and ability to skillfully elicit information from the client using appropriate techniques of communication. Observation of nonverbal behavior during the interview is also essential to effective’s data collection.
INTERVIEW PREPARATION
The interview is more productive if the nurse has an opportunity to prepare for the interaction. Such preparation includes review of the client’s medical records, conversations with other health care team members (e.g., personnel in emergency departments or long-term care facilities), and research of the presenting medical diagnosis. This information can be useful in obtaining the client’s relevant history and formulating a current needs assessment.
INTERVIEW STAGES
Since the assessment interview often occurs at the beginning of a nurse-client relationship, it is helpful to begin the process with an orientation phase. During this period introductions are made, rapport is established, and roles are defined. The nurse interviews for a variety of reasons throughout the nurse-client relationship, including data collection, teaching, exploration of the client’s feelings or concerns, and provision of support.
The first few minutes of the nurse-client meeting may give an indication of the type of interviewing needed, so it is important that the nurse exhibit good listening skills as the relationship leads into the interview process.
There are three phases to an interview: introduction, working, and closure.
INTRODUCTION
The introduction stage of the interview establishes the goals for the interaction. The primary goal of the assessment interview is the collection of data about the client. In this phase of the interview, the purpose and use of the data collection should be discussed. For example, the nurse might state, “I need to ask you a few questions and talk to you for a few minutes about your health so that we can better plan your care.”
Adequate time and privacy should be allowed for the interview so that the client feels free to share any information that may be relevant. The nurse should also inform the client about the approximate duration of the interview.
The client is more likely to respond freely if the interview environment provides comfort and privacy and if rapport exists between the client and the nurse. The nurse should sit (if possible), establish eye contact with the client, and listen attentively. It is the nurse’s responsibility to note nonverbal messages that can indicate that the client is uncomfortable, tired, or preoccupied with other matters. If this situation occurs, it might be necessary to complete the interview at a later time.
For example, if the client is guarding an incision and verbalizing discomfort or is extremely anxious about an impending procedure, only essential data are collected and the comprehensive interview is postponed until immediate needs have been met.
WORKING
The working stage of the interview focuses on the details of data collection. The scope of the assessment interview depends on the type of assessment to be conducted (e.g., comprehensive or focused). The interview may be structured and formal (used in situations when a large amount of informatioeeds to be obtained) or unstructured and informal (used in interactions that focus on a specific area of concern to the client). The nurse should be familiar with the specific assessment format used by the health care agency so that attentionn can be focused toward the client rather than the form itself. The interview generally begins with questions about biographical and other nonthreatening information.
The client’s reason for seeking health care is also addressed early in the working phase. The depth of the majority of questions that the nurse will ask the client depends on the data collection model used by the health care agency. Information is usually gathered from the general to the specific, with details about intimate or potentially embarrassing topics reserved until later in the interview.
The Nursing Checklist provides guidelines for interview preparation.
Techniques used during the interview will be determined by the setting and purpose of the interview. A comprehensive interview that seeks to identify problems and concerns is facilitated by open-ended questions, while an interview that focuses on specific details about a presenting problem will be facilitated by direct, closed questions. For example, an emergency setting would likely employ more direct, closed questions, while admission to a long-term care facility might require greater use of open-ended questions.
Closed questions are questions that can be answered briefly or with one-word responses. For example, the question “Have you been in the hospital before?” is a closed question that can easily be answered by a one-word response. Questions about the dates of and reasons for the hospitalizations are also closed questions that require brief answers.
Open-ended questions are questions that encourage the client to elaborate about a particular concern or problem. For example, the question “What led to your coming here today?” is open-ended and allows the client flexibility in response. Both closed and open-ended questions can be effective in collecting information.
CLOSURE
Closure is established in the introduction phase when approximate time parameters are set. As the interview session is concluding, the nurse should indicate this fact by stating that almost all the information needed has been obtained or that the time for the interview is almost over. This action allows the client an opportunity to present any other relevant information and it avoids surprises when the interview terminates.
During the closure phase, the nurse summarizes what was covered or accomplished during the interview and requests validation of perceptions with the client. If the nurse or the client feels that additional time is needed for further exploration of specific points discussed during this session, plans can be made for future interviews.
HEALTH HISTORY
A primary focus of the data collection interview is the health history. The health history is a review of the client’s functional health patterns prior to the current contact with a health care agency. While the medical history concentrates on symptoms and the progression of disease, the nursing health history focuses on the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle. The health history is also used in developing the plan of care and formulating nursing interventions.
DEMOGRAPHIC INFORMATION
Personal data including name, address, date of birth, gender, religion, race/ethnic origin, occupation, and type of health plan/insurance should be included. This information may be useful in helping to foster understanding of a client’s perspective.
REASON FOR SEEKING HEALTH CARE
The client’s reason for seeking health care should be described in the client’s own words. For example, the statement “fell off four-foot ladder and landed on right shoulder; unable to move right arm” is the client’s actual report of the event that precipitated his or her need for health care. The client’s perspective is important because it explains what is significant about the event from the client’s point of view. It is also important to determine the time of the onset of symptoms as well as a complete symptom analysis.
PERCEPTION OF HEALTH STATUS
Perception of health status refers to the client’s opinion of his or her general health. It may be useful to ask clients to rate their health on a scale of 1 to 10 (with 10 being ideal and 1 being poor), together with the clients’ rationale for their rating score. For example, the nurse may record a statement such as the following to represent the client’s perception of health: “Rates health a 7 on a scale of 1 (poor) to 10 (ideal) because he must take medication regularly in order to maintain mobility, but the medication sometimes upsets his stomach.”
PREVIOUS ILLNESSES, HOSPITALIZATIONS, AND SURGERIES
The history and timing of any previous experiences with illness, surgery, or hospitalization are helpful in order to assess recurrent conditions and to anticipate responses to illness, since prior experiences often have an impact on current responses.
CLIENT/FAMILY MEDICAL HISTORY
The nurse needs to determine any family history of acute and chronic illnesses that tend to be familial. Health history forms will frequently include checklists of various illnesses that the nurse can use as the basis of the questions about this aspect. The client should be instructed that family history refers to blood relatives. It is also helpful to indicate who the relative is in relation to the client (e.g., mother, father, sister).
IMMUNIZATIONS/EXPOSURE TO COMMUNICABLE DISEASE
Any history of childhood or other communicable diseases should also be noted. In addition, a record of current immunizations should be obtained. This is particularly important with children; however, records of immunizations for tetanus, influenza, and hepatitis B can also be important for adults. If the client has traveled out of the country, the time frame should be indicated in order to determine incubation periods for relevant diseases. The client should also be asked about potential exposure to communicable diseases, such as tuberculosis, or to human immunodeficiency virus (HIV).
ALLERGIES
Any drug, food, or environmental allergies should be noted in the health history. In addition to the name of the allergen, the type of reaction to the substance should also be noted.
For example, a client may report that he or she developed a rash or became short of breath. This reaction should be recorded. Clients may report an “allergy” to a medication because they developed an upset stomach after ingesting it, which the nurse will recognize as a side effect that would not necessarily preclude administration of the drug in the future.
CURRENT MEDICATIONS
All medications currently taken, both prescription and over-the-counter, are to be recorded by name, frequency and dosage. Remind clients that this information should include medications such as birth control pills, laxatives, and nonprescription pain relief medications. Ask which, if any, herbal preparations the client uses. Patterns related to caffeine and alcohol intake and use of tobacco or recreational drugs should also be explored.
Use of alternative/complementary treatment methods, including herbals, is ofteot shared by health care consumers. Some clients fear rejection or ridicule when divulging such information with health care providers. The nurse uses a sensitive, nonjudgmental approach when assessing for the client’s use of all healing practices.
DEVELOPMENTAL LEVEL
Knowledge of developmental level is essential for considering appropriate norms of behavior and for appraising the achievement of relevant developmental tasks.
Any recognized theory of growth and development can be applied in order to determine if clients are functioning within the parameters expected for their age group.
For example, if the nurse uses Erikson’s stages of psychosocial development, validation of an adult client attaining the developmental task of generativity versus stagnation can be validated by the nurse’s statement, such as “client prefers to spend time with his family; very involved in children’s school activities.”
PSYCHOSOCIAL HISTORY
Psychosocial history refers to assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the client’s ability to cope.
Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should be explored.
SOCIOCULTURAL HISTORY
In exploring the client’s sociocultural history, it is important to inquire about the home environment, family situation, and client’s role in the family. For example, the client could be the parent of three children and the sole provider in a single-parent family.
The responsibilities of the client are important data through which the nurse can determine the impact of changes in health status and thus plan the most beneficial care for the client.
ACTIVITIES OF DAILY LIVING
The activities of daily living is a description of the client’s lifestyle and capacity for self-care and is useful both as baseline information and as a source of insight into usual health behaviors. This database should include the following areas:
Nutrition: Includes type of diet and foods eaten and fluids consumed regularly, food preparation, the size of portions, and the number of meals per day. Food preferences and dislikes, as well as the client’s need for assistance in food preparation or eating should also be determined.
Elimination: Includes both urinary and bowel elimination frequency and patterns. Any recent changes or problems in these patterns should be noted.
Rest/sleep: Includes the usual number of hours of sleep, number of hours of sleep needed to feel rested, sleep aids used, and the time within the day or night when sleep usually occurs. Any bedtime rituals (especially with children) should also be noted.
Activity/exercise: Includes types of exercise and patterns in a typical day or week. If assistance is needed with activities such as walking, standing, or meeting hygienic needs, this information should be noted.
REVIEW OF SYSTEMS
The review of systems (ROS) is a brief account from the client of any recent signs or symptoms associated with any of the body systems. This allows the client an opportunity to communicate any deviations from normal that have not been otherwise identified. The review of systems relies on subjective information provided by the client rather than on the nurse’s own physical examination.
When a symptom is encountered, either while eliciting the health history or during the physical examination of the client, the nurse should obtain as much information as possible about the symptom. Relevant data include:
• Location: The area of the body in which the symptom (such as pain) can either be pointed to or described in detail.
• Character: The quality of the feeling or sensation (e.g., sharp, dull, stabbing).
• Intensity: The severity or quantity of the feeling or sensation and its interference with functional abilities. The sensation can be rated on a scale of 1 (very little) to 10 (very intense).
• Timing: The onset, duration, frequency, and precipitating factors of the symptom.
• Aggravating/alleviating factors: The activities or actions that make the symptom worse or better.
PHYSICAL EXAMINATION
The purpose of the physical examination is to make direct observations of any deviations from normal and to validate subjective data gathered through the interview.
Baseline measurements are obtained, and physical examination techniques are used to gather objective data.
BASELINE DATA
Baseline data collection is the systematic organization of observations obtained during the physical examination that forms the basis for comparison and evaluation to establish the status of a client at a given point in time.
Measurement of height, weight, and vital signs (temperature, pulse, respirations, and blood pressure) is important for comparison with future measurements in order
to judge the significance of any changes (progress or regression) over time.
ASSESSMENT TECHNIQUES
The physical examination incorporates the use of visual, auditory, tactile, and olfactory senses and the use of systematic assessment techniques. The use of visual, auditory, and tactile senses will be described with each of the specific assessment techniques. In addition, olfaction (sense of smell) is helpful in detecting characteristic odors as well as those associated with altered health states.
For example, presence of infection is sometimes first detected by the change in the characteristic odor of body fluids or drainage. The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation.
INSPECTION
Inspection involves careful visual observation. The client is observed first from a general point of view and then with specific attention to detail. For example, the nurse first observes for patterns of skin lesions and then focuses on the specific characteristics of individual lesions. Instruments such as a penlight and otoscope are often used to enhance visualization.
Effective inspection requires adequate lighting and exposure of the body parts being observed. Beginning nurses often feel self-conscious or embarrassed using the technique of inspection; however, most become comfortable with the technique over time. Nurses must also be sensitive to the client’s feelings of embarrassment with the use of inspection and respond to this situation by discussing the technique with the client and using measures such as draping in order to increase the client’s comfort level.
PALPATION
Palpation uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.
The technique of palpation uses the hands and fingers in different ways for assessment of:
• Temperature: Best detected using the dorsal (back) surface of the hand
• Texture, pulses, and swelling: Best detected using fingertips
• Vibration: Best detected with the base of the fingers
• Shape and consistency of organs or masses: Best detected by grasping organ or mass between fingertips
PERCUSSION
Percussion uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body. Structures with relatively more air (such as the lungs) produce louder, deeper, and longer sounds with ercussion than more dense, solid structures (such as the liver), which produce softer, higher, and shorter sounds.
AUSCULTATION
Auscultation involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultated include the lungs, heart, abdomen, and blood vessels. Although direct auscultation is sometimes possible, a stethoscope is usually employed in order to channel the sound.
LABORATORY AND DIAGNOSTIC DATA
Results of laboratory and diagnostic tests can be useful objective data as these values often serve as defining characteristics for various altered health states; these can also be helpful in ruling out certain suspected problems.
For example, diabetic clients who are poorly controlled on diet and/or medication will usually have an elevated blood glucose level. The pattern of these types of variations is useful in determining a plan of care. In addition, the effectiveness of nursing and medical interventions and progress toward health restoration are often monitored through laboratory and diagnostic test data.
DATA VERIFICATION
Data verification is the process through which data are validated as being complete and accurate. Once the nurse completes the initial data collection, the data are reviewed for inconsistencies or omissions. This process is particularly important if data sources are considered unreliable. For example, if a client is confused or unable to communicate, or if two sources provide conflicting data, it is necessary for the nurse to seek further information or clarification. Data verification is done by examining the congruence between subjective and objective data.
For example, a client might exhibit nonverbal expressions of pain (e.g., guarding a part of the body, facial grimacing) but verbally deny feeling pain. The nurse would need to consider possible reasons for this discrepancy in findings and collect more information before formulating conclusions or planning care.
Findings should also be compared with norms. Any grossly abnormal findings should be rechecked and confirmed.
DATA ORGANIZATION
After data collection is completed and information is validated, the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. How data are organized depends on the assessment model used.
ASSESSMENT MODELS
An assessment model is a framework that provides a systematic method for organizing data. The use of a model helps to ensure comprehensive and organized data collection. A guiding framework also provides direction for decision making about nursing diagnoses. A number of nursing and nonnursing models are used to assist with organization of data. This section describes only a few of the many assessment models available to nurses.
NURSING MODELS
Nursing models have been developed to focus on a wide range of human responses to alterations in health status. These models typically include psychosocial, sociocultural, and behavioral data as well as biophysical data.
Nursing models may offer the advantage of organizing information in a mode that more easily allows transition from data collection to nursing diagnoses.
NONNURSING MODELS
Nursing, of course, neither exists nor functions in a vacuum. Nursing uses related health concepts from other disciplines, some of which are discussed next.
BODY SYSTEMS MODEL
Approaching data collection by examining body systems is sometimes referred to as the “medical model,” since it is frequently used by physicians to investigate presence or absence of disease. This method organizes data collection according to the organ and tissue function in various body systems (e.g., cardiovascular, respiratory, gastrointestinal). Although nurses often use this method as well, the body systems model does not facilitate the formulation of nursing diagnoses. In addition, psychosocial aspects of the client’s status are ofteeglected with resultant fragmentation of care.
HIERARCHY OF NEEDS
Abraham Maslow’s hierarchy of needs proposes that an individual’s basic needs (physiological) must be met before progressing to higher-level needs. Maslow’s framework can be used to prioritize needs. Use of a hierarchy of needs model requires initial assessment of all physiological needs, followed by assessment of higher-level needs.
Using Maslow’s theory, a person’s needs should be addressed in the following order:
First: Physiologic needs—the basic survival needs, such as food, water, and oxygen.
Second: Safety and security needs—both physical (e.g., protection from bodily harm) and psychological (e.g., security and stability) needs.
Third: Need for love and belonging—humans have an innate need to be a part of a group, and to feel accepted by others.
Fourth: Self-esteem needs—individuals need to feel they are valued and worthwhile.
Fifth: Self-actualizatioeeds—the need to function at one’s optimal level, and to be personally fulfilled.
DATA INTERPRETATION
Data clustering facilitates recognition of patterns, and determination of further data that are needed. Data interpretation is necessary for identification of nursing diagnoses.
DATA DOCUMENTATION
Accurate and complete recording of assessment data are essential for communicating information to other health care team members. In addition, documentation is the basis for determining quality of care and should include appropriate data to support identified problems.
TYPES OF ASSESSMENT FORMATS
Health care agencies may choose from a variety of assessment forms for documentation depending on the type of agency, the population served by the facility, and the primary reasons for documentation. For example, clients seeking health care in a clinic or physician’s office might be asked to complete a brief self-questionnaire, while a client admitted to an acute-care facility for labor and delivery might be asked to provide only information directly related to pregnancy and child care needs. Four types of documentation formats include open ended,
checklist, combination, and specialty.
See Figure 6-2 for an example of a form used in occupational nursing.
OPEN-ENDED FORMATS
The open-ended format for documentation allows the nurse to write a narrative description of observations (see Figure 6-3).
This format is more time-consuming for the nurse, but allows flexibility in recording findings.
CHECKLIST FORMATS
Formats that include checklists facilitate documentation by summarizing findings in an abbreviated form (see Figure 6-4)
They also provide more consistency in the recording of information and reduce the likelihood of omitting relevant information. However, checklists may discourage nurses in obtaining elaboration about observations from clients that require further explanation. For example, if a checklist indicates that mobility is impaired, further explanation is required in order to determine the extent of the impairment and thus plan the necessary interventions.
COMBINATION FORMATS
Combination formats often allow the convenience of a checklist together with space to document a complete narrative description of any significant or abnormal
findings (see Figure 6-5).
Some agencies provide cues on the form to alert personnel when further informa tion is needed. This format provides for some consistency in recording data while allowing flexibility for documenting specific information.
SPECIALTY FORMATS
Specialty areas such as outpatient surgery, labor and delivery, and psychiatric facilities may use abbreviated formats focused directly on assessment needs for the particular service provided. In addition, specialty assessment forms may be included together with comprehensive assessment forms for clients at particular risk for various conditions (e.g., falls, impaired skin integrity).
Documentation of assessment data is essential as a means of communication among health care team members to assure accurate problem identification, determination of appropriate client outcomes, and continuity of care.
THE MINIMUM DATA SET (MDS)
The Minimum Data Set (MDS) was developed by the Health Care Financing Administration (HCFA) to promote the development of a comprehensive care plan for every resident of Medicare/Medicaid certified nursing homes. As such, the MDS is a standardized assessment instrument used in all long-term care facilities that are funded by HCFA. The MDS is a comprehensive assessment tool designed to collect data on the following resident characteristics:
• Activities of daily living (ADLs)
• Medical needs
• Mental status
• Therapy use (American Nurses Association, 2000)
MDS is a comprehensive assessment tool designed to collect data on the following resident characteristics:
• Activities of daily living (ADLs)
• Medical needs
• Mental status
• Therapy use (American Nurses Association, 2000)
NURSING DIAGNOSTIC OF HUMAN RESPOND.
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he nursing diagnosis is the second step in the nuring process and is the clinical judgment about individual, family, or community (aggregate) responses to actual or risk health problems, wellness states, or syndromes. This judgment is based on a critical analysis of the assessment data. The purpose of a nursing diagnosis is to effectively communicate the health care needs of individuals and aggregates among members of the health care team and within the health care delivery system. Society tends to interpret nursing through the use of nursing language.
When a nursing diagnosis is a part of the client’s plan of care, the nurse is able to communicate the client’s needs to other professionals involved in that care. These needs encompass physiologic, role function, self-concept, interdependence, and spiritual dimensions. In order to determine individualized therapeutic nursing interventions, the nurse must first collect and organize assessment data before developing appropriate nursing diagnoses.
This lecture describes the nature of a nursing diagnosis, its purposes, and the components of a nursing diagnostic statement. It also discusses the process involved in developing a nursing diagnosis and methods through which nurses can avoid errors in the formulation of nursing diagnoses. This chapter concludes with strategies for overcoming barriers to the use of a nursing diagnosis in the clinical setting.
WHAT IS A NURSING DIAGNOSIS?
Diagnosis is the science and art of identifying problems or conditions. Although this process has been linked primarily with physicians, it is also used by members of other professions, such as nurses, lawyers, social workers, mechanics, psychologists, and teachers. Though the term nursing diagnosis may convey multiple meanings, “in effect, nursing diagnosis defines nursing practice” (Sparks & Taylor, 1994, p. 32H).
There are many definitions of nursing diagnosis that have evolved over the past decades. At the ninth North American Nursing Diagnosis Association (NANDA) conference, the following definition of nursing diagnosis was approved:
Additional definitions of nursing diagnosis abound in the nursing literature. It is clear that although all definitions are not exactly alike, there are similar attributes
among them, such as a focus on client-centered problems; the promotion of nursing accountability; an awareness of the human response to health problems; the formation of clinical judgments about individuals, families, or communities; and the development of nursing interventions that a nurse is licensed to enact.
COMPARISON OF NURSING AND MEDICAL DIAGNOSES
It is important to have a clear understanding of the nature of a nursing diagnosis as compared to a medical diagnosis. Clarification of this point is necessary to distinguish between the nursing and medical professions and the potential legal ramifications.
Delineation of “What is the nature of nursing?” versus “What is the nature of medicine?” is critical. In order to practice nursing, nurses need to know what it is that they do. Nursing diagnoses assist nurses in defining their scope of practice just as medical diagnoses assist physicians in defining their scope of practice. In addition, the use of diagnoses iursing and medicine enables clarification of the legal boundaries for practice.
Medicine uses the term medical diagnosis and nursing uses the term nursing diagnosis to identify problems relating to a client’s health status:
• Medical diagnosis is the terminology used for a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathologic state.
• Nursing diagnosis is the terminology used for a clinical judgment by the professional nurse that identifies the client’s or aggregate’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.
See the accompanying display for a comparison of nursing and medical diagnoses.
It is important to emphasize that the term nursing diagnosis has been used in three contexts: “the process of diagnosis, the product of diagnosis or individual diagnoses, and the taxonomy of diagnoses” (Wooldridge, Brown, & Herman, 1993, p. 51). The process of diagnosis is identified as the second step of the nursing process. In this step, the nurse collects data, validates and critically analyzes the data, clusters the data into groups, and identifies the client, family, or community health problems or conditions. The product of diagnosis is the diagnostic label that is assigned to the identified problem.
The taxonomy of diagnosis is a classification system in which nursing diagnoses are organized according to client responses to specific conditions.
There are both similarities and differences between medical and nursing diagnoses. The similarities include
(1) using the diagnostic process, with “process” imply ing purpose, organization, and creativity (Bevis, 1978);
(2) using cognitive, interpersonal, and psychomotor skills;
(3) collecting and critically analyzing assessment data;
(4) evaluating outcomes to ascertain continuation, resolution, or change of identified diagnosis;
(5) performing within legal dimensions and standards of the respective profession.
An example of these similarities can be illustrated by considering Alan Brown, a client who has a medical diagnosis of asthma. The physician and nurse would both collect assessment data on respiratory status. The physician would use this information to treat the disease of asthma and the nurse would use this information to focus on Mr. Brown’s response to the disease, which would result in a nursing diagnosis of Ineffective Breathing Pattern.
Nursing diagnoses are different from medical diagnoses in (1) purpose, (2) goals, and (3) therapeutic interventions. The purpose of a nursing diagnosis is to focus on the human response or responses of the individual family or community to identified problems or conditions. Medical diagnoses center on the disease state or pathological condition. For example, if the medical diagnosis for Sheila Barrington is breast cancer, appropriate nursing diagnoses may include Fear, Deficient Knowledge related to treatment measures, Anticipatory Grieving, Body Image Disturbance, Powerlessness, and Ineffective Coping. In addition, the goals (aims, intent, or ends) that accompany these nursing diagnoses differ, as do the specific, individualized therapeutic nursing interventions (nursing actions to promote or restore health and enhance general well-being).
HISTORICAL PERSPECTIVE
The term nursing diagnosis has been in the literature since the early 1950s. Fry (1953) identified that nursing diagnosis is integral to the plan of nursing care and is an important tool for individualizing client care. However, these ideas were slow to gain momentum despite the interests of several nurse theorists and the focus on client-centered problems in the 1960s and the 1970s. In 1973, the First National Conference for the Classification of Nursing Diagnoses convened in
Additional endorsement for nursing diagnosis came from the American Nurses Association (ANA) in
At the 13th conference in 1998, NANDA developed 21 new nursing diagnoses and revised 37 nursing diagnoses by clarifying existing diagnoses and their definitions, defining their characteristics, and related factors.
Following the biennial conference in April 1994, the Taxonomy Committee identified the need to revise the structure of Taxonomy I. During the 14th biennial conference in April 2000, NANDA adopted the taxonomy, Taxonomy II. “Taxonomy II was designed to be multiaxial in its form, thereby substantially improving the flexibility of the nomenclature and allowing for easy additions and modifications” (NANDA, 2001, p. 212). With the publication of these standards, the nurse has both a professional and legal obligation to practice as defined by the professional organization for nurses.
RESEARCH
With the inception of the first conference oursing diagnoses, NANDA supported research endeavors on the development of a nursing diagnosis classification system. The first type of research conducted was identification studies, where the clinician repeatedly observed a condition in order to label a nursing diagnoses. At the sixth conference in 1986, Fehring identified the need for two standardized research methodologies for data collection: (1) diagnostic content validity (DCV), retrospective evidence from experts on the characteristics of a given label; and (2) clinical diagnostic validity (CDV), prospective evidence on the characteristics from a clinical perspective (Whitley, 1999). In 1989, NANDA sponsored an invitational conference on research methodologies for generating and validating existing diagnoses and to develop new methodologies to direct future studies.
Although there is an abundance of DCV studies, only a few clinical studies have been conducted because the CDV model is more complicated to execute. Nursing Diagnosis: The Journal of Nursing Language & Classification is the official publication of NANDA. The journal was first published in 1989 to promote the development, refinement, and utilization of nursing language and classification.
Roberts, Madigan, Anthony, and Pabst (1996) conducted a secondary analysis study to examine the congruence betweeursing diagnoses and clinically relevant data of clients being transferred from intensive care to medical-surgical units. The results of this study showed that diagnoses were not made or were made less frequently than indicated by the supporting clinical evidence (see the Research Focus). One of the findings indicated that a system still needs to be developed for determining that clients being observed have the diagnosis being studied and that nurses accurately identify all relevant diagnoses in the clinical setting.
Whitley (1999) suggests the development of a “research agenda” to promote research in a coordinated fashion since interest about nursing diagnoses has spread in the international community, at a time when a commoursing language is needed to strengthen nursing’s bases for practice. In 1998, the NANDA Board instituted an ad hoc research committee to coordinate nursing diagnosis research and funding and to develop a “research agenda.”
PURPOSES OF NURSING DIAGNOSIS
Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered. Although these characteristics have always been in existence withiursing, they were unidentified prior to the mid-20th century. One of the requisites of a profession is a unique body of knowledge or frame of reference (
Nursing diagnosis also provides a means for effective communication. It is generally agreed among nurses, health care practitioners, and other health care professionals that there is a need for a common language within the health care sector. A mutual vocabulary that can be used for describing practice, research, and education benefits both the profession and the consumer. With this language, collaboration and international exchanges regarding nursing and health care are possible and benefit from “common definitions of the phenomena of concern within the discipline” (Fitzpatrick & Zanotti, 1995, p. 42). In addition, communication about nursing diagnoses is possible through computer search.
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) has listed the term nursing diagnosis since 1983 (Dougherty, Jankin, Lunney, & Whitley, 1993).
Holistic client, family, and community-focused care are facilitated with the use of nursing diagnosis. The list of NANDA-approved nursing diagnoses (NANDA, 2001) for clinical use provides assistance for the nurse in individualizing care and developing comprehensive therapeutic nursing interventions. Quality care and continuity of care are enhanced with identified nursing diagnoses as part of the client’s plan of nursing care. The accompanying display illustrates the value of applying nursing diagnosis to a home health care situation.
Nursing diagnoses also have the potential of providing an avenue for theory development and nursing research. Dougherty, Jankin, Lunney, and Whitley (1993) published a listing of theory and research-based articles on accepted nursing diagnoses from 1950 to 1993.
Nursing diagnosis has an important impact on the health care delivery system: “Nursing diagnoses provide a method for synthesizing and communicating nurses’ observations and judgements” and “the ability to communicate the health needs of clients can influence funding of preventive and comprehensive health care services” (Gordon, 1994, p. 12).
In summary, nursing diagnosis allows for empowerment of the profession of nursing, facilitates effective communication, and provides a means to individualize nursing care. Nursing diagnosis is essential to clinical practice and education and pivotal for theory development and research.
NURSING DIAGNOSES AND DIAGNOSTIC-RELATED GROUPS
Diagnostic-related groups (DRGs) were developed and implemented in the health care industry in 1983 as a response to escalating health care costs in
Diagnostic-related groups were developed on the basis of the medical model of identifying signs and symptoms that then result in the formulation of medical diagnoses.
Therefore, this reimbursement system is centered on medical diagnoses, not nursing diagnoses. As a result, this federally regulated system lacks a mechanism for direct financial reimbursement based oursing diagnoses.
Over the years, in light of the fact that the nursing process is more than just a response to medical diagnosis (Caterinicchio, 1984), there have been attempts to identify nursing’s contribution to the over 400 different DRGs. In these studies, efforts have mostly been directed at attempting to isolate nursing care delivered to the client (McKibbin, Brimmer, Clinton, & Galliher, 1985; Wolf, Lesic, & Leak, 1986). Through the use of elaborate formulas, nursing care costs have been derived for many of the DRGs. However, few studies have evaluated the relationship betweeursing diagnoses and DRGs.
One of the best attempts to identify nursing costs has been described by
According to Fitzpatrick (1995), if the nursing profession does not have and use a common language, nurses will be unable to assign a monetary status to their services for reimbursement. At present, consensus still needs to be established by the profession for use of nursing diagnosis language. With agreement on what nurses define as client problems or conditions, the profession will be able to establish a system that reimburses nurses for what they contribute to the health care industry.
COMPONENTS OF A NURSING DIAGNOSIS
There are several formats that have been used to structure nursing diagnosis statements. Two formats that are frequently seen in the nursing literature are the two- and three-part statements. The two-part statement is NANDA approved and is used by most nurses, in large part because of its brief and precise format. The three-part statement is preferred by those nurses desiring to strengthen the diagnostic statement by including specific manifestations, an attribute that is not possible through the use of the two-part format.
THE TWO-PART STATEMENT
The components of a nursing diagnosis typically consist of two parts. Hence, the nursing diagnosis is often described as a “two-part statement.” The first component is a problem statement or diagnostic label that describes the client’s response to an actual, possible, and risk health problem or a wellness condition.
Table 7-1 presents the list of NANDA-approved nursing diagnoses.
The second component of a two-part nursing diagnosis is the etiology. The etiology is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells. Descriptive words or terms may be added to clarify specific nursing diagnoses. These descriptive words are called qualifiers and include Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. These terms specify a degree of qualification for the identified nursing diagnosis and are placed (used) before the problem statement.
THE THREE-PART STATEMENT
The nursing diagnosis can also be expressed as a threepart statement. As in the two-part statement, the first two components are the diagnostic label and the etiology.
The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations).
In the three-part nursing diagnosis format, the third part is joined to the first two components with the connecting phrase “as evidenced by” (AEB). Defining characteristics list the relevant clinical manifestations, such as signs or symptoms for the identified client problem and the related etiology. Defining characteristics are identified for each NANDA-approved diagnosis. These characteristics continue to evolve as they are reviewed and updated at the biennial conference. It is important to emphasize that defining characteristics may assist the nurse in identifying client goals, measurable client outcome criteria, and relevant nursing interventions.
Some nurses believe that the three-part statement strengthens the diagnostic process. However, other nurses prefer the two-part statement and refer to the defining characteristics as part of the original database.
Table 7-2 depicts the components and relationship of the one-, two-, and three-part statements. Although the most commonly used format is the two-part statement, it is beneficial for the nurse to be knowledgeable about the use of the threepart statement for development of a nursing diagnosis.
Table 7-3 for a comparison of selected approved NANDA diagnoses in the two- and three-part statements.
CATEGORIES OF NURSING DIAGNOSES
Nursing diagnoses may be classified into three categories: actual, risk, and wellness. The most commoursing diagnoses used are actual and risk diagnoses.
Wellness diagnoses were adopted by NANDA 1996, and Carpenito (1995) described possible nursing diagnoses.
• Actual diagnoses are those problems identified by the nurse that are already in existence. Actual diagnoses may include Excess Fluid Volume related to (RT) intravenous infusion therapy overload and Anxiety RT unknown results of breast biopsy.
• Risk diagnoses are identified by the nurse in situations in which problems might occur but are not currently in existence. Examples of risk diagnoses may include Risk for Poisoning RT increased mobility of infant and failure to have house childproofed and Risk for Deficient Fluid Volume RT excessive number of stools.
• Wellness diagnoses identify the individual or aggregate condition or state that may be enhanced by healthpromoting activities. These consist of a one-part statement (no “related to” phrase) that uses the label “Potential for Enhanced” followed by the state the nurse desires to enhance. Examples of wellness diagnoses may include Readiness for Enhanced Community Coping and Readiness for Enhanced Spiritual Well-Being.
TAXONOMY OF NURSING DIAGNOSIS
The taxonomy of nursing diagnoses is the type of classification under which the diagnostic label is grouped based on which human response the client is demonstrating to the actual or perceived stressor. Rather than consult the alphabetical listing of NANDA diagnoses, some nurses might find it more helpful to review the NANDA listing by pattern of human response. This listing is called the NANDA Taxonomy II and organizes the NANDA-approved nursing diagnoses under the corresponding human response category.
The NANDA nursing diagnosis taxonomy is composed of nine patterns of human response:
• Exchanging
• Valuing
• Perceiving
• Communicating
• Choosing
• Knowing
• Relating
• Moving
• Feeling
Although the word taxonomy may be somewhat overwhelming for the beginning practitioner, remember it is only an organizational framework and one should not be intimidated by it. Rather, view this approach as another way to find appropriate nursing diagnoses for clients on the basis of the classification of human response.
DEVELOPING A NURSING DIAGNOSIS
The development of a nursing diagnosis is a systematic process in which certain activities need to be executed.
The accompanying display illustrates the steps in the development of nursing diagnoses.
ASSESSING DATABASE
In the assessment phase, the nurse collects data cues from the client. Cues are small amounts of data that are applied to the decision-making process. Nurses should be attentive to the cues gathered from the interview, health history, symptom analysis, physical examination, and laboratory and diagnostic data since they increase the index of suspicion and stimulate further observation of additional sets of cues. Examples of cues might be poor skin turgor, parched lips, dry skin, decreased urine output, and complaint of thirst. The expert nurse immediately processes these cues and determines a nursing diagnosis, plans client outcomes, and implements therapeutic nursing interventions. The novice nurse must proceed more cautiously and use additional time to process these data cues.
VALIDATING CUES
After reviewing the data cues, the nurse validates that information and examines it carefully. Verification can be done by interviewing Mr. Zachary again and reassessing data cues, for example, weighing him and measuring abdominal girth.
INTERPRETING CUES
Through interpretation of data cues and use of critical-thinking strategies, the nurse assigns a meaning to the data cues. In order to interpret Mr. Zachary’s subjective and objective data cues, the nurse should ask the following questions:
• What is this information telling me?
• Is there a pattern?
• Can this information be put together?
• Is the information falling into a logical arrangement?
• Is the information forming natural groupings?
Critical Thinking in Nursing Diagnosis
Contemporary nursing practice, with its focus oursing diagnoses, interventions, and outcomes, requires critical thinking (Pesut & Herman, 1999). Interpreting data cues is one example of critical thinking that the nurse must do on a daily basis when working with clients. Specifically, the synthesis of information that takes place when interpreting data cues demonstrates how essential it is for the nurse to think critically. Interpreting Mr. Zachary’s cues is pivotal for correctly diagnosing his actual, or at-risk problem, or wellness state. The accompanying display provides questions that are helpful in developing appropriate diagnoses.
CLUSTERING CUES
Once the cues have been collected, validated, and interpreted, the data are then grouped into clusters. A cluster is a set of data cues in which relationships between and among cues are established to identify a specific health state or condition. Related pieces of information about the client are grouped together. Conclusions are drawn from the data cues. One piece of information by itself can be misleading.
This idea is analogous to the assembly of a jigsaw puzzle.
One puzzle piece by itself does not give an accurate idea of the picture. In the same way, one data cue (or piece of assessment data) does not have much relevance by itself. When more pieces of the puzzle are put together or when more data assessment cues are put together, the nurse may have a beginning idea of what the puzzle picture or the client’s health looks like.
In Mr. Zachary’s situation, data cues that can be clustered together include: Subjective: “I always seem to be hungry and I eat five or six times a day” and “I’ve gained
Consulting NANDA List of Nursing Diagnoses
After the data have been organized into clusters, the nurse needs to consult the NANDA list to ascertain similarities and differences between the clusters and NANDA diagnoses. The clustered data are then matched with a particular NANDA diagnosis. In Mr. Zachary’s case, the NANDA-approved diagnosis is Imbalanced Nutrition: More Than Body Requirements.
WRITING THE NURSING DIAGNOSIS STATEMENT
The nursing diagnosis selected from the NANDA list becomes the diagnostic label, the first part of the diagnosis statement. Etiologies are also identified from the NANDA list. The appropriate etiology is selected and joined to the first part of the statement with the “related to” phrase. Because the NANDA list of nursing diagnoses is constantly evolving, there may be times wheo etiology is provided. In such cases, the nurse should attempt to describe likely contributing factors to the client’s condition.
In a two-part statement, the nursing diagnosis for Mr. Zachary would be Imbalanced Nutrition: More Than Body Requirements RT excessive food intake. The threepart statement would be Imbalanced Nutrition: More Than Body Requirements AEB weight gain, increased appetite, excess adipose tissue, and increased abdominal girth.
AVOIDING ERRORS IN DEVELOPING A NURSING DIAGNOSIS
Following is a discussion of common errors that may occur in the process of developing nursing diagnoses.
PROBLEM WITH ASSESSMENT DATA
There is an underlying assumption that nurses have adequate assessment skills and are knowledgeable about what data need to be collected. However, this is not always the case. The novice nurse may have only rudimentary assessment skills and limited clinical experience. Experienced nurses are challenged to keep current and sometimes are ill-equipped to collect appropriate assessment data.
Because of the potential for these deficits, there may be errors made when writing a nursing diagnosis related to an incomplete database or inappropriately collected assessment data. When assessment data are missing, regardless of the cause, the end result is either an omission of nursing diagnoses, inaccurate diagnoses, or incorrect qualifying statements about the diagnoses.
INCOMPLETE COLLECTION OF ASSESSMENT DATA
Incomplete collection can occur when the nurse has neither had nor taken the time to appropriately address all subjective and objective data. For example, during admission of a new client to a health care facility, a nurse is interrupted during the data collection and fails to return to finish the admission process at the end of the shift.
RESTRICTED DATA COLLECTION
Restricted data collection occurs when a client is unable or unwilling to provide the necessary data. An example would be a newly admitted client with a cerebrovascular accident who has impaired speech and can only provide limited assessment data.
FAILURE TO VALIDATE DATA
Failure to validate occurs when the nurse does not confirm previously collected data. An example would be failure by the nurse to recheck an admission blood pressure that was elevated. A follow-up blood pressure may have revealed a transient elevation due to the stress of the admission process.
MISINTERPRETATION OF DATA
Misinterpretation can occur when the meaning attached to the data is incorrect. An example would be a client who comes to the ambulatory care clinic and presents with several signs and symptoms, including a reported 4-pound weight gain that month. Further investigation indicates this finding is not related to increased adipose tissue but, rather, is associated with fluid retention that accompanies an edematous state.
INAPPROPRIATE DATA CLUSTERING ASSOCIATED WITH LACK OF CLINICAL KNOWLEDGE
Inappropriate data clustering may occur when the nurse lacks sufficient theoretical and clinical expertise and knowledge to appropriately cluster data cues. An example would be the client who visits an industrial clinic with complaints of flulike symptoms, stomach cramps, and vomiting. The nurse attributes the vomiting to the influenza, but further analysis indicates that, in addition to this condition, this client is actually manifesting symptoms of a toxic reaction to prescribed drug therapy that is causing the vomiting.
INCORRECT WRITING OF THE NURSING DIAGNOSIS STATEMENT
Incorrect writing of the statement can occur when the nurse does not follow the guidelines for formulating a two- or three-part statement. An example would be in the two-part statement Imbalanced Nutrition: Less Than Body Requirements RT renal disease. Renal disease is a medical diagnosis, and, according to the guidelines, the etiology must be a human response that the nurse is licensed and competent to treat. This diagnosis would be better stated as Imbalanced Nutrition: Less Than Body Requirements RT inadequate intake of an appropriate renal diet.
In conclusion, when the nurse makes premature conclusions without allowing sufficient time for analysis and interpretation of data, the subsequent care plan may be inappropriate for the client (Dobrzyn, 1995).
The Nursing Checklist provides selected questions that nurses can ask themselves in order to avoid making mistakes when developing nursing diagnoses.
Values play an important role in interpretation of data, clustering of data, and ultimately the development of the diagnosis. Nurses must be cognizant of personal biases, being careful not to impose their value systems on clients. Personal prejudices should be avoided in the diagnostic statement.
Nurses must also remember to focus on the client when developing a nursing diagnosis. The problem statement is client centered, not nurse centered. Kim (1985) stated that the diagnosis plays a pivotal role in the nursing process by directing nursing actions and providing the focus for evaluating outcomes.
LIMITATIONS OF NURSING DIAGNOSIS
There are a number of limitations and professional concerns associated with nursing diagnosis. The primary concern is directed toward the lack of consensus among nurses regarding the NANDA-approved nursing diagnosis list. Criticisms about the list include disagreement over specific labels in the classification system and the perception that the list is confining, incomplete, medically oriented, and confusing. Many nurses are not familiar with the NANDA list and do not know how to use it or feel “it doesn’t have the diagnosis” they need. It should be noted that this list is not meant to be inclusive.
Development and refinement of diagnoses continue to be a focus of NANDA conferences. In addition, nurses may disagree with or refuse to use diagnoses such as noncompliance or knowledge deficit (Carpenito, 1995). In this instance, the nurse then has the choice and the right to not use these specific diagnoses.
Novice nurses need to know nursing diagnosis and nursing process in order to understand how the discipline of nursing intersects with the other health care providers. NANDA (1999) recognizes that health care is moving into an interdisciplinary, client-focused care environment that requires standardization of languages across disciplines. Many acute care facilities use an interdisciplinary care plan such as care maps and/or critical pathways to monitor client outcomes. All health care providers use the same care plan to document the client’s response to specific interventions. Common “client problems” listed on a critical pathway are written as nursing diagnoses such as risk for infection or risk for injury.
There are also legal considerations concerning the use of nursing diagnoses. Nurses are accountable for their actions and must document their interventions. If a nursing diagnosis is inappropriate or a nursing diagnosis list is incomplete and, as a result, the interventions are inappropriate or lacking, the nurse is liable for these errors in clinical judgment. These errors can be avoided by collecting comprehensive assessment data and by critically analyzing these data.
OVERCOMING BARRIERS TO NURSING DIAGNOSIS
According to Iyer, Taptich, and Bernocchi-Losey (1994), objections to using nursing diagnoses include: (1) nurses are more overworked than ever and have less time to spend with clients; (2) care is still organized around the medical diagnosis and nurses are involved in the completion of tasks based on this focus; (3) nurses are afraid they may be ridiculed for using nursing diagnoses; and (4) the nursing diagnosis list does not always fit the client situation. Carlson-Catalano (1993) asserted that health care agency administrators and health care practitioners dominate nursing’s focus and activities. This domination may contribute to the devaluation of the nursing diagnosis language and promote the use of the medical diagnosis.
NANDA’s language is still relatively new (approximately 25 years) compared to modern medical language that has existed for several hundred years. Some nurses would rather wait until the NANDA listing is complete before they use it. However, it is unrealistic to think that a system such as NANDA should not be used until it is completed. The ever-changing health care scene dictates that nurses participate in evolving methods to communicate within the health care industry.
Another barrier to the use of nursing diagnoses is the numerous approaches for application that are found in the nursing literature. Due to these various methods, it may be difficult for nurses to choose “one” method that they feel comfortable with. Nurses may also be unable and unwilling to use nursing diagnoses because of incomplete knowledge about the process and disagreements about wording. As a result, they elect not to participate at all.
After identifying the existence of barriers to the use of nursing diagnoses, it is possible to design strategies to overcome them. According to Carlson-Catalano (1993), the only way society will understand professional nursing is through the language used by nurses. Nursing diagnoses serve as a language that can be shared among the entire community of nurses (Carlson-Catalano, 1993). Familiarity with this language empowers the nurse to communicate more effectively with other nurses and health care team members. Effective communication, in turn, improves the accuracy iursing diagnoses.
Ultimately, the quality of care should improve and the costs associated with that care should decrease.
Due to the fact that many acute-care facilities are asking nurses to do more with fewer resources, nurses are challenged to learn more efficient ways of performing their duties. Nurses’ time is spent more efficiently if less time is spent deciphering meanings of words.
Health care agency administrators and medical staffs need to be more supportive of the use of nursing diagnoses in their respective settings. In a survey by Thomas and Newsome (1992), findings suggested that institutional support makes a difference in the nurses’ use of nursing diagnoses. As the nursing profession becomes more confident in the use of the language, nurses will speak more sincerely and enthusiastically about nursing diagnoses. Increased professional confidence will then empower nurses to become more supportive of each other and less subject to ridicule.
When a nurse encounters client situations that do not readily fit the nursing diagnosis language, every attempt should be made to describe the phenomena.
The nurse may be on the threshold of documenting the need for a new, as-yet-undiscovered nursing diagnosis.
As nurses collaborate on the refinement of nursing diagnoses, it may be possible to agree on certain aspects of the language. The achievement of this goal will end the use of multiple approaches and will make choices less complicated. Enhanced communication among nurses in everyday settings and among professionals who convene nationally and internationally to exchange ideas about nursing diagnoses is essential.
Most nursing educational programs now offer standardized content related to nursing diagnoses. In addition, experienced nurses need opportunities to review principles of nursing diagnoses, especially since so many are working in settings that tend to favor medical diagnoses and focus on achievement of tasks by the nurse (Brackstone, 1993). See the Nursing Checklist for a list of strategies that are helpful in overcoming barriers to the use of nursing diagnoses.
PLANNING NURSING CARE. NURSING CARE PLAN.
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lanning, the third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Preceding this step is the collection of assessment data and the formulation of nursing diagnoses.
After a nurse thoroughly assesses a client and determines the client’s unique nursing diagnoses (or problems), a plan of action is developed with specific goals to resolve the nursing diagnoses or health problems of the client. Following the planning component, the nursing process continues with implementation of nursing interventions and evaluation of the client’s plan of care.
The four critical elements of planning include:
• Establishing priorities
• Setting goals and developing expected outcomes (outcome identification)
• Planning nursing interventions (with collaboration and consultation as needed)
• Documenting
The purpose, as well as the entire process, of the planning concept is illustrated with theory and examples. Strategies for effective planning of quality nursing care are described together with problems frequently encountered in this stage of the nursing process. The role of critical thinking in planning and outcome identification is emphasized.
PURPOSES OF OUTCOME IDENTIFICATION AND PLANNING
The American Nurses Association (1998), in its Standards of Clinical Nursing Practice, identifies outcome identification and planning as essential principles for ensuring the delivery of competent nursing care and outlines these components in terms of their significance within the nursing process. Although the overall purpose of a client’s plan of care should be to maintain or improve health at an optimal level, planning is a framework on which to base scientific nursing practice.
Therefore, the purposes of the planning component of the nursing process are to provide adequate direction to ensure quality nursing care for individual clients, to present a vehicle to improve staff communication, and to provide continuity in the delivery of individualized, quality nursing care to all clients.
The five steps of the nursing process are at the very core in using scientific reasoning for the delivery of individualized, quality nursing care in any setting (Doenges, Moorhouse, & Geissler, 1997). The ability to make appropriate decisions based on a strong knowledge base and problem-solving strategies is an expected behavior of the professional nurse.
CRITICAL THINKING
More specifically, professional nurses are expected to think critically to process data and to make convincing, intelligent decisions concerning the planning, management, and evaluation of health care for their clients (Prechter, 1993). By combining the critical-thinking skills inherent in the nursing process with the client’s identified nursing diagnoses, the nurse can focus on resolving the client’s nursing diagnoses with greater proficiency.
The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care.
Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Because of progressively shorter lengths of hospitalization, initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems.
Ongoing planning entails continuous updating of the client’s plan of care.
Every nurse who cares for the client is involved in ongoing planning. As new information about the client is gathered and evaluated, revisions may be formulated and the initial plan of care becomes further individualized to the client.
Discharge planning involves critical anticipation and planning for the client’s needs after discharge. Planning is sequential, dynamic, and future-oriented.
Planning includes establishing priorities, identifying goals and expected outcomes, developing nursing interventions, and documenting the client’s plan of care.
Appropriate guidelines are used to prioritize urgent needs. The client’s nursing diagnoses are determined and then ranked by mutual agreement of the nurse and client or significant others. The planning component continues with thorough examination of this prioritized list of nursing diagnoses and determination of the client’s goals and desired expected outcomes. After a clear picture is obtained regarding the diagnoses and goals, the nursing interventions can be planned to achieve the desired outcomes.
In the planning phase, the nurse organizes “thought processes for clinical decision making” (Doenges et al., 1997). To think critically is to examine an issue purposefully from a goal-directed perspective. Critical thinking “is based on principles of science and scientific method” (Alfaro-LeFevre, 1998). Therefore, critical thinking is a useful procedure in the development of objectives and in the formulation of a blueprint to achieve those objectives. The formulation of objectives is accomplished by using valid and reliable data previously gathered during the assessment component of the nursing process.
ESTABLISHING PRIORITIES
The establishment of priorities is the first element of planning. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance. This method organizes a client’s nursing diagnoses into an operational format for the planning of nursing care. These diagnoses should be mutually ranked by the nurse and client or family and significant others. Involving the client in shared decision-making power helps motivate the client and gives the client a feeling of control, which inspires successful achievement of each goal (Doenges et al., 1997).
When an individual client has more than one diagnosis, the nurse and client need to establish priorities to identify which nursing diagnosis will be addressed initially in the plan of care (Carpenito, 1999). By communicating this decision-making process to other members of the health care team, the nurse encourages an orderly approach to the achievement of optimal health for each client.
Various guidelines are used in the establishment of priorities for determining which nursing diagnosis will be addressed initially. The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non–life threatening diagnosis. Once the basic physiological needs (e.g., respiration, nutrition, hydration, elimination) are met to some degree, the nurse may consider needs on the next level of the hierarchy (e.g., safe environment, stable living condition) and so on up the hierarchy until all the client’s nursing diagnoses have been prioritized.
Following table illustrates this process
A useful guide for the beginning nursing student would be to examine each nursing diagnosis, determine its level of need, and rank the need in order of priority.
Another consideration in the designation of priorities is client preferences. If at all possible, the client should always be involved in the decision-making process of establishing priorities. If the nurse and the client do not mutually set priorities, there may be a contradictory course of direction and motivation, which may lead to noncompliance and nonresolution of the client’s nursing diagnoses. The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.
An additional point regarding the establishment of priorities is the anticipation of future diagnoses. Nursing diagnoses of low and moderate priorities often involve the prevention of anticipated potential or risk diagnoses. Although potential nursing diagnoses may not be a current threat to the client, their seriousness may require that the nurse consider the development of nursing interventions directed toward prevention of the problem. For example, a client in the Postanesthesia Care Unit may have a high-priority nursing diagnosis of Ineffective Breathing Pattern related to the anesthesia and sedative drugs. Despite the fact that the client currently has no problem in this area, this diagnosis is indeed the basis for the Postanesthesia Care Unit protocol of monitoring the client closely.
Establishing priorities does not mean that one diagnosis must be totally resolved before giving attention to another diagnosis. Nursing interventions for several diagnoses may be carried out simultaneously. However, at times, it is crucial that the nurse and client correctly identify the order of priority of the client’s nursing diagnoses so that maximum effort can be directed toward resolution of the most urgent diagnosis.
Following table illustrates this process:
ESTABLISHING GOALS AND EXPECTED OUTCOMES
After assessing the client, formulating nursing diagnoses, and establishing priorities, the nurse sets goals and identifies and establishes expected outcomes for each nursing diagnosis. The purposes of setting goals and expected outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan.
A goal is an aim, an intent, or an end. A goal is a broad or globally written statement describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved. It includes aspects such as direct nursing care and client teaching.
WRITING GOALS
Written goals need to be constructed clearly. Clear, precise terminology improves the chances that goals will be achieved. When goals are clearly written, their establishment provides direction for the nursing plan of care and for determination of effectiveness in the evaluation of nursing interventions. A guideline is provided for the desired change in the client, and the client has a clear idea of the direction to be taken for achieving resolution of each nursing diagnosis. Goals establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions for the resolution of the client’s individual nursing diagnoses.
Goals should be established to meet the immediate, as well as long-term prevention and rehabilitation, needs of the client.
A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days.
A long-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months (Alfaro-LeFevre, 1997). See the accompanying display for examples of short-term and long-term goals.
Another consideration is the accuracy in identifying the etiology of the problem. If the etiology of the problem is incorrectly identified, the client may meet the short-term goal but the problem will not be resolved. Thus, it is important to correctly identify the etiology of the problem.
Setting long-term goals is important in successful discharge planning. It assists in coordinating all health care team members to accomplish the same overall purpose, that is, client discharge. Coordination promotes continuity of care into settings such as restorative care or home health (see the accompanying display).
EXPECTED OUTCOMES
After the goal is established, the expected outcomes can be identified based on the goal. Given the client’s unique situation and resources, expected outcomes are constructed to be:
• Realistic
• Mutually desired by the client and nurse
• Attainable within a defined time period
These desired outcomes are the measurable steps toward achieving the previously established goals (Doenges et al., 1997). Because nursing care is based on a holistic approach, expected outcomes may be written in the spiritual, emotional, physiological, developmental, and social dimensions. An expected outcome depicts measurable behavioral change or evidence of change in the client when the goal has been met. Several expected outcomes may be required for each goal. Expected outcomes are used in the evaluation process by providing a standard for comparison to determine if the client successfully accomplished the goals.
In the construction of both goals and expected outcome objectives, essential components include: subject, task statement, criteria, the conditions (if necessary), and time frame (Doenges et al., 1997). When goals and outcomes are written clearly, the nurse can select nursing interventions to ensure that the client’s baseline data are thoroughly assessed, individual client needs are identified, and appropriate approaches are used in the plan of care. Usually, each nursing diagnosis has one global goal and several expected outcomes. In writing the goal statement, the nurse considers the nursing diagnosis for the formulation of a suitable client behavior that illustrates reduction or alleviation of the nursing diagnosis.
These concepts are demonstrated in the Nursing Process Highlight.
Each component of an appropriately written goal is discussed in the following paragraphs. For clarity of each concept, examples are provided with related discussion. The examples are designed with the intent of developing skills in the construction of goals.
SUBJECT
The component to be considered initially in writing a goal is the subject. The subject identifies the person who will perform the desired behavior or meet the goal. In a client-centered plan of nursing care, the client is the person who needs to achieve a desired change in behavior. See the accompanying display for an application of the subject component.
TASK STATEMENT
The next component in writing goals is the task statement or the action verb. This component describes what the client (or subject) will do to obtain an expected change in behavior. The task statement enables the evaluator to determine achievement of observable behavior. When the actual behavior is stated as a task statement that can be clearly and directly measured, the nurse can determine whether the client is demonstrating achievement of the goal.
Only one task statement should be used for each goal. It is clearer to write separate goals than to try to accurately measure a combination of tasks.
See the accompanying display for an application of the task statement.
CRITERIA
The next essential component is the criteria of a goal.
Criteria are standards used to evaluate whether the behavior demonstrated indicates accomplishment of the goal. Criteria may be written in a variety of ways.
Criteria may include:
• A time limit
• Amount of activity
• Important characteristics of accurate performance
• Description of the performance to be followed
The nurse should specify the precise performance to be considered acceptable in accomplishment of the goal. It is not always possible to specify a criterion with as much detail as one would like; however, the nurse should continue to communicate precise criteria as explicitly as possible. To provide better direction to the client, the nurse considers how well the client, family member, or significant other should perform the task.
See the accompanying display for an application of criteria.
CONDITIONS
The next component to be included in writing proper goals is the conditions under which the client should perform or demonstrate mastery of the task. Although this component is optional in terms of writing goals, conditions may provide clarity and assist the client in demonstrating the expected behavior. The conditions may include the experiences that the client is expected to have before performing the task.
See the accompanying display for an application of conditions.
TIME FRAME
The last component to be included in writing goals appropriately is the time frame in which the client should perform or demonstrate mastery of the task.
PROBLEMS FREQUENTLY ENCOUNTERED IN PLANNING
Nursing students, as beginners in the use of the nursing process, often fall into some common pitfalls when applying the steps to practice. These pitfalls are described with the intent of providing a clear direction for the use of this process and proposing suggestions for avoiding these common errors.
In regard to writing goals, the errors frequently observed in this component involve improper format.
Format errors include goals that are nurse-centered instead of client-centered, unrealistic, negative rather than positive, generically copied from a reference and not individualized to the client, unmeasurable, nonspecific, nonbehavioral, vague, wordy, and without a time frame.
Another challenge in the development of goals and expected outcomes is the establishment of appropriate time frames for accomplishment of the intended results.
Although this component may be difficult at first to master, nursing students should practice writing goals that are realistic and include appropriate time frames using available literature and resources to gain expertise. It is preferable for a goal to include an excessively short, rather than an excessively long, time frame, because the goal is brought to attention in the evaluation process more frequently. By inserting the time frame “daily” for specific goals, the expected outcome will be brought up frequently for evaluation. Through a process of building on continued professional growth and experience, students and beginning nurses will become more adept and realistic in applying the nursing process to client situations.
Finally, novices as well as experienced nurses tend to make decisions for clients in a paternalistic fashion by deciding what is best for the client without input from the client. To correct this problem, the nurse must establish a trusting nurse-client relationship that promotes mutual understanding and caring. The nurse should encourage clients to make their own decisions regarding health care.
PLANNING NURSING INTERVENTIONS
Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions.
A nursing intervention is an action performed by a nurse that helps the client to achieve the results specified by the goals and expected outcome. These terms are based on scientific principles and knowledge from behavioral and physical sciences. Usually, several nursing interventions are developed for each of the goals identified for the client (Sparks & Taylor, 1993). It is important to identify as many nursing interventions as possible so that if one proves to be unsuitable, others are readily available.
The interventions are prioritized according to the order in which they will be implemented. With the inclusion of scientific problem solving and critical thinking, the delivery of quality, individualized nursing care is greatly enhanced. Through critical thinking, sound conclusions are reached in the selection of nursing interventions to prevent, reduce, or eliminate the nursing diagnoses or problems. The nurse studies the entire issue thoroughly in the planning component of the nursing process by examining the assessment data and nursing diagnoses, analyzing the client’s goals and expected outcomes, and selecting which nursing interventions should be used from a multitude of possibilities to ensure the delivery of quality nursing care for each client.
Several factors can assist the nurse in selecting nursing interventions. Just as the client’s goals can be derived from the nursing diagnosis, the nursing interventions can be developed from the etiology of each nursing diagnosis. The effective nurse plans interventions that are directed toward the cause of the client’s nursing diagnosis or problem. For example, for a client with angina who may have the nursing diagnosis of Pain related to myocardial ischemia, an appropriate nursing intervention would be to help the client conserve energy (i.e., bedrest).
The nurse may use various guidelines in selecting appropriate nursing interventions. These guidelines include the individual nurse practice acts, state boards of nursing standards, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for nursing care. Other determining factors of appropriate nursing interventions include whether an action is realistic in terms of the abilities of the client and nurse, and if it is compatible with available resources, the client’s values and beliefs, and other therapies planned for the client.
In determining which nursing interventions to use, the nurse should critically consider the consequences and the risks of each intervention. After considering these factors, the nurse selects those that are most likely to be effective with the minimum of risk.
This table applies the guidelines for selection of appropriate nursing interventions for a specific nursing diagnosis.
After setting the goals and planning the appropriate nursing interventions, the nurse writes nursing orders to communicate the exact nursing interventions that are to be implemented for the client. A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. These statements specify direction and individualize the client’s plan of care. For example, a health care practitioner’s order to force fluids must be specified in the nursing order as the number of milliliters per hour or per shift (e.g., 100 ml/h or Day shift = 800 ml; Evening shift = 800 ml; Night shift = 400 ml).
Ensuring that nursing orders are well written requires several essential elements. These elements include: the nursing order date, action verb, detailed description, time frame, and signature (Wilkinson, 1998).
See the accompanying display for a summary of the elements of a nursing order.
The type of nursing order written is determined by the client problem. The nurse is responsible for writing nursing orders that involve health promotion, observation, prevention, and treatment (Wilkinson, 1998).
This table gives examples of types of nursing orders.
CATEGORIES OF NURSING INTERVENTIONS
Nursing interventions are classified according to three categories: independent, interdependent, and dependent.
Independent nursing interventions are nursing actions initiated by the nurse that do not require direction or an order from another health care professional.These interventions are sanctioned by professional nurse practice acts derived from licensure laws. In many states, the nurse practice acts allow independent nursing interventions regarding activities of daily living, health education, health promotion, and counseling. An example of an independent nursing intervention is the nurse’s action to elevate a client’s edematous extremity.
Interdependent nursing interventions are those actions that are implemented in a collaborative manner by the nurse with other health care professionals.
Collaboration is a partnership in which all parties are valued for their contribution. Collaboration is used to gather data, plan, implement, evaluate, and gain objectivity by examining another’s viewpoint. Interdependent nursing interventions allow the client’s nursing diagnoses to be resolved on the basis of recommendations of an interdisciplinary health care team approach. For example, a client care conference or a discharge planning committee uses an interdisciplinary approach that includes health care members such as a nursing supervisor, a home health care nurse, a dietitian, a social worker, a physical therapist, and occasionally a physician.
The nurse assumes the responsibility of being both the primary coordinator of the client’s plan of nursing care and intermediary of interdepartmental collaboration (Doenges et al., 1997).
In addition to collaboration, the planning of interdependent nursing interventions may also include consultation.
Consultation is a method of soliciting help from a specialist in order to resolve nursing diagnoses. The need for consultation arises when an individual nurse identifies a problem that cannot be solved using own knowledge, skills, or resources. In the management of the client’s plan of care, nurses may consult with other health care personnel including health care practitioners, clinical nurse specialists, nutritionists, physical therapists, and social workers. Nurses frequently consult to verify assessment data or to obtain clinical advice: for example, discussing the effects of chemotherapy on a client’s self-esteem with an oncology clinical nurse specialist.
Consultation can be informal or formal. An informal consultation may simply involve another health care practitioner’s ideas regarding a nursing problem. Some agencies have a formal protocol for the consultation of a health professional and may require that certain forms be completed. Steps in formal consultation reflect a logical sequence. and include:
• Identifying the problem
• Collecting all relevant data
• Selecting a suitable consultant
• Communicating unbiased data regarding the problem
• Discussing recommendations with the consultant
• Incorporating the recommendations into the client’s plan of care
The consultation process often generates new approaches to the client’s individualized plan of care.
Acquiring supplementary knowledge may help in ensuring that the best conceivable plan of care is being developed. In addition, nurses who have sought the help of a consultant are presented with an opportunity to learn from the recommendations for future situations.
Dependent nursing interventions are those actions that require an order from another health care professional.
An example of a dependent intervention is administration of a medication. Although this intervention requires specific nursing knowledge and responsibilities, it is not within the realm of legal nursing practice in many states to prescribe medications. The nurse may not order medications but, when administering them, the nurse is responsible for knowing the classification, the pharmacologic action, normal dosage, adverse effects, contraindications, and nursing implications of the drugs. Therefore, dependent nursing interventions must always be guided by appropriate knowledge and judgment. It should be noted that many state nurse practice acts sanction advanced practice registered nurses to prescribe medications. In those states, prescriptive authority is an independent intervention for nurses in advanced practice.
Figure 8-1 illustrates the three categories of nursing interventions.
All nursing interventions require critical thinking in making appropriate nursing judgments. Alfaro-LeFevre (1998) states that the development of critical reasoning skills by nurses is a progressive process that requires a dedication to examine common health problems, participate in diverse clinical experiences, and prepare for delivery of care in clinical settings. Given the emphasis on critical thinking in the planning step of the nursing process, the nurse does not automatically carry out a health care practitioner’s order without due consideration. All requested orders are given consideration for their appropriateness.
An in-depth knowledge base is necessary to recognize an error and seek clarification. The use of rationales helps the nurse practice decision making and substantiate judgments. The rationales should accompany the nursing intervention or nursing order statement on the written plan of nursing care. A rationale is an explanation based on theories and scientific principles of natural and behavioral sciences and the humanities.
EVALUATING CARE
Evaluating care involves determining the client’s progress toward achievement of expected outcomes.
Effective planning is essential if evaluation is to be effective. In other words, the planned outcomes are the yardsticks by which effectiveness of therapies are evaluated. If there is no stated expectation of care (i.e., client outcome), how can progress be measured?
NURSING OUTCOMES CLASSIFICATION (NOC)
Measuring outcomes iursing began with Nightingale, who relied on mortality statistics as an indicator of quality of care for British soldiers in the Crimean War. Nightingale proved that the mortality rate for soldiers declined as a result of improved sanitation (Oermann & Huber, 1999). Recently, there has been increased emphasis by the nursing community on evaluating outcomes. Nurse researchers (Mass & Johnson, 1997) at the
An outcome classification system can be used to enhance decision-making in clinical practice and research.
Linking nursing interventions to improved client outcomes through scientific research is important. Nurse researchers who are observing, measuring, and studying client outcomes believe that outcomes indicate the quality or effectiveness of the nursing interventions provided.
Porter-O’Grady (1999) states that nurses need to provide empirical evidence of the “insights and intuition of their practice. Strengthening the links betweeursing interventions and client outcomes will benefit not only clients, but nursing as well. Having solid research evidence that documents the effectiveness of nursing care on client outcomes will influence political and financial decisions relative to nursing. “By measuring patient outcomes, nurses can answer two pivotal questions; Do our patients benefit from our care? And if so, how?” (Oermann & Huber, 1999, p. 41). The NOC taxonomy focuses on function, physiology, psychosocial aspects, health knowledge and behavior, and perceived self-health and family health. The NOC system, which defines over 190 client outcomes that are sensitive to nursing interventions, allows nurses to evaluate client status over time.
