The concept of nursing process.
The first stage of nursing process.
THE NURSING PROCESS The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. “The nursing process provides the basis for critical thinking iursing” (Alfaro-LeFavre, 1998, p. 64).
HISTORICAL PERSPECTIVE Lydia Hall first referred to nursing as a “process” in a 1955 journal article, yet the term was not widely used until the late 1960s (Edelman & Mandle, 1997). Referring to the “nursing process” as a series of steps, Johnson (1959), Orlando (1961), and Wiedenbach (1963) further developed this description of nursing. At this time, the nursing process involved only three steps: assessment, planning, and evaluation. In their 1967 book The Nursing Process, Yura and Walsh identified four steps in the nursing process:
• Assessing
• Planning
• Implementing
• Evaluating
The Standards of Practice, first published in 1973 by the American Nurses Association (ANA), included eight standards. These standards identified each of the steps, including nursing diagnosis, that are now included in the nursing process.
Fry (1953) first used the term nursing diagnosis, but it was not until 1974, after the first meeting of the group now called the North American Nursing Diagnosis Association (NANDA), that Gebbie and Lavin added nursing diagnosis as a separate and distinct step in the nursing process. Prior to this, nursing diagnosis had been included as a natural conclusion to the first step, assessment.
Following publication of the ANA standards, the nurse practice acts of many states were revised to include the steps of the nursing process specifically. The ANA made revisions to the standards in 1991 to include outcome identification as a specific part of the planning phase. Currently, the steps in the nursing process are:
• Assessment
• Diagnosis
• Outcome identification and planning
• Implementation
• Evaluation
The American Nurses Association practice standards address each step of the nursing process.
OVERVIEW OF THE NURSING PROCESS A process is a series of steps or acts that lead to accomplishment of some goal or purpose. The purpose of the nursing process is to provide care for clients that is individualized, holistic, effective, and efficient. The steps of the nursing process build upon each other, but they are not linear. There is overlap of each step with the previous and subsequent steps (Figure 5-1).
The nursing process is dynamic and requires creativity for its application. The steps remain the same, but the application and results will be different in each client situation. The nursing process is designed to be used with clients throughout the life span and in any setting in which a nurse provides care for clients. It is also a basic organizing system for the National Council Licensure Examination for Registered Nurses (NCLEX-RN).
Assessment Assessment is the first step in the nursing process and includes collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of the information obtained during assessment are directly related to the accuracy of the steps that follow. Assessment involves several steps:
• Collecting data from a variety of sources
• Validating the data
• Organizing data
• Categorizing or identifying patterns in the data
• Making initial inferences or impressions
• Recording or reporting data
Data are collected from a variety of sources; however, the client should be considered the primary source of data (the major provider of information about self). As much information as possible should be gathered from the client, using both interview techniques and physical examination skills. Sources of data other than the client are considered secondary sources and include family members, other health care providers, and medical records.
Assessment provides information that will form the client database. Two types of information are collected through the assessment component: subjective and objective.
Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The method of collecting subjective information is primarily the interview. Using therapeutic interviewing techniques, the nurse collects data that will begin to build the client database. Examples of subjective information include such statements as:
• “I drink only coffee for breakfast.”
• “I have had pains in my legs for three days now.”
• “I go to sleep easily each night, but I wake up about two hours later and cannot go back to sleep until it is time to get up in the morning.”
Objective data are observable and measurable data that are obtained through both standard assessment techniques performed during the physical examination and diagnostic tests. The primary method of collecting objective information is the physical examination, which provides information about the function of body systems (Figure 5-2).
Examples of objective information include:
• T 98.6°F, P 100, R 12, B/P 130/76
• Bowel sounds auscultated in all four quadrants
• Gait slow, shuffling, and unsteady
This objective information may add to or validate subjective information. Validation is a critical step in data collection to avoid omissions, prevent misunderstandings, and avoid incorrect inferences and conclusions.
Data that are collected must be organized to be useful to the health care professional collecting the data as well as others involved with the client’s care. Clustering similar pieces of information assists the nurse in constructing a picture of the client’s problems and strengths. There are a number of organizing frameworks for collection of data—for example, Gordon’s Functional Health Patterns. Many health care agencies use an admission assessment format, which assists the nurse in collecting data in specific categories of functioning.
Critical thinking is used in determining the significance of data collected. Once data are organized into categories, the data are clustered into groups of related pieces. Placing data into clusters helps the nurse to recognize patterns of response or behavior. When data are placed into clusters, the nurse can:
• Distinguish between relevant and irrelevant data
• Determine if and where there are gaps in the data
• Identify patterns of cause and effect
With this information, the nurse, through critical thinking, can begin to develop impressions or inferences about what the data mean.
Assessment data must be recorded and reported. The nurse must make a judgment about which data are to be reported immediately and which data need only to be recorded at that time. Data that reflect a significant deviation from the normal (for example, rapid heart rate with irregular rhythm, severe difficulty in breathing, or high levels of anxiety) would need to be reported as well as recorded. Examples of data that need only to be recorded at the time include a report that prescribed medication has relieved a headache and a determination that an abdominal dressing is dry and intact.
Assessment does not end with the initial interview and physical examination. Assessment is dynamic and continues with each nurse-client interaction.
Diagnosis The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected. Formulation of the list of nursing diagnoses is the outcome of this process. According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990, p. 50)
The nursing diagnoses developed during this phase of the nursing process provide the basis for client care delivered through the remaining steps. Client problems are labeled by both medical and nursing diagnoses. Clients receive both medical and nursing diagnoses. Table 5-3 compares the two categories of diagnoses.
The nurse uses critical-thinking and decision-making skills in developing nursing diagnoses. This process is facilitated by asking questions such as:
• Are there problems here?
• If so, what are the specific problems?
• What are some possible causes for the problems?
• Is there a situation involving risk factors?
• What are the risk factors?
• Is there a situation in which a problem can develop if preventive measures are not taken?
• Has the client indicated a desire for a higher level of wellness in a particular area of function?
• What are the client’s strengths?
• What data are available to answer these questions?
• Are more data needed to answer the question?
• If so, what are some possible sources of the data that are needed?
See the accompanying display for a clinical example of applying critical thinking when determining nursing diagnoses.
Types of Nursing Diagnoses Analysis of the collected data leads the nurse to make a diagnosis in one of the following categories:
• Actual problems
• Potential problems (including those where risk factors exist and there are possible problems)
• Wellness conditions
• Collaborative problems
Examples of the various types of diagnoses are shown in Table 5-4.
An actual nursing diagnosis indicates that a problem exists, and is composed of the diagnostic label, related factors, and signs and symptoms. An example of an actual diagnosis is: Impaired Skin Integrity related to prolonged pressure on bony prominence as manifested by (AMB) Stage II pressure ulcer over coccyx,
A risk nursing diagnosis (potential problem) indicates that a problem does not yet exist, but special risk factors are present. A risk diagnosis is composed of the diagnostic label preceded by the phrase “risk for,” with the specific risk factors listed. An example of a risk diagnosis is: Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed.
A possible nursing diagnosis indicates a situation in which a problem could arise unless preventive action is taken. In addition, a possible diagnosis may state a “hunch” or intuition by the nurse that cannot be confirmed or eliminated until more data have been collected. A possible diagnosis is composed of the diagnostic label and related factors. An example of a possible diagnosis is: Possible Self-Esteem Disturbance related to recent retirement and relocation. The nurse may not yet have enough data to confirm this diagnosis or a more specific one. However, this diagnosis will alert other nurses to collect data that will either confirm this or another diagnosis, verify a risk diagnosis, or rule out the existence of a problem.
A wellness nursing diagnosis indicates the client’s expression of a desire to attain a higher level of wellness in some area of function. It is composed of the diagnostic label preceded by the phrase “potential for enhanced.” For example a client who is neither overweight nor underweight tells the nurse that she knows she could improve her diet in some ways. She states that she eats only a small number of vegetables and fruits and thinks that the fat content of her diet is probably high. She expresses a desire to know more about how to improve her diet. The nurse would make a wellness diagnosis of Potential for Enhanced Nutrition.
Carpenito introduced the bifocal clinical practice model that includes nursing diagnoses and collaborative problems. Collaborative problems are defined as physiologic complications monitored by nurses to assess changes in client status. Collaborative problems are managed through the use of interventions prescribed by other health care practitioners and/or nurses (Carpenito, 1999). Collaborative problems include those conditions in which the nurse seeks medical input for treatment of potential medical problems. Usually, collaborative problems involve alterations in organ and/or system function or structure (e.g., myocardial infarction, duodenal ulcer). Collaborative problems begin with the label Potential Complication (PC) followed by the situation—for example, Potential Complication: Hemorrhage.
Analysis of the data also assists the nurse in identifying strengths of the client. For example, the client’s strong family support system would be identified as a strength. These areas of positive functioning will be reinforced and used as a basis for planning care for those areas where functioning is less than optimal.
After it is formulated, the list of diagnoses is presented to the client for confirmation if possible. If that is not possible, family members may be able to confirm the diagnoses. Finally, the list of nursing diagnoses is recorded on the client’s record. Once this list is developed and recorded, the remainder of the client’s plan of care can be completed. The list of nursing diagnoses is not static. It is dynamic, changing as more data are collected and as client goals and client responses to interventions are evaluated.
Outcome Identification and Planning Planning is the third step of the nursing process and 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. Once the nursing diagnoses have been developed and client strengths have been identified, planning can begin. The planning phase involves several tasks:
• The list of nursing diagnoses is prioritized.
• Client-centered long- and short-term goals and outcomes are identified and written.
• Specific interventions are developed.
• The entire plan of care is recorded in the client’s record.
Once the list of nursing diagnoses has been developed from the data, decisions must be made about priority. Critical thinking enables the nurse to make decisions about which diagnoses are the most important and need attention first. There are a number of frameworks used to prioritize nursing diagnoses; however, those diagnoses involving life-threatening situations are given the highest priority. For example, the following nursing diagnoses would be stated in this order of priority:
• Ineffective Airway Clearance related to excessive and thick secretions and pain secondary to surgery and inability to cough effectively; respirations: 25, shallow, wheezing
• Risk for Injury (falls) related to unsteady gait
• Imbalanced Nutrition: Less Than Body Requirements related to nausea and vomiting
Client-centered goals are established in collaboration with the client whenever possible. A goal is an aim, intent, or end. Goals are broad statements that describe the intended or desired change in the client’s behavior. Goal statements refer to the diagnostic label (or problem statement) of the nursing diagnosis. If the client or significant others are unable to participate in goal development, the nurse assumes that responsibility until the client is able to participate. Client-centered goals assure that nursing care is individualized and focused on the client.
Expected outcomes are specific objectives related to the goals and are used to evaluate the nursing interventions. They must be measurable, have a time limit, and be realistic. Once goals and expected outcomes have been established, nursing interventions are planned that enable the client to reach the goals.
A nursing intervention is the activity that the nurse will execute for and with the client to enable accomplishment of the goals. Nursing interventions refer directly to the related factors in the actual nursing diagnoses and the risk factors in risk nursing diagnoses. If the nursing interventions can remove or reduce the related factors and the risk factors, the problem can be resolved or prevented. Nursing interventions also refer to the diagnostic label for possible diagnoses and focus on data needed to confirm or eliminate the diagnosis.
For each nursing diagnosis there may be a number of nursing interventions. Nursing interventions are individualized and are stated in specific terms. Examples of nursing interventions are:
• Turn, cough, and deep breathe q 2 h beginning at 0800, 2/10.
• Teach “nipple care when breastfeeding” at 1000, 2/11.
• Weigh client at each visit.
Once the interventions have been determined for each diagnosis, the interventions are recorded on the client’s plan of care. As is true with other steps in the nursing process, the list of interventions is not static. As the nurse interacts with the client, assesses responses to interventions, and evaluates those responses, interventions may change.
Implementation The fourth step in the nursing process is implementation. Implementation involves the execution of the nursing plan of care derived during the planning phase. It consists of performing nursing activities that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing interventions to other persons assigned to care for the client—for example, the licensed practical nurses and unlicensed assistive personnel.
Implementation involves many skills. The nurse must continue to assess the client’s condition before, during, and after the nursing intervention. Assessment prior to the intervention provides the nurse with baseline data. Assessment during and after the intervention allows the nurse to detect positive or negative responses the client may have to the intervention. If negative responses occur during the procedure, the nurse must take appropriate action. If positive responses occur, the nurse adds this information to the database for use in evaluating the efficacy of the intervention. The nurse must also possess psychomotor skills, interpersonal skills, and critical thinking skills to perform the nursing interventions that have been planned. The nurse uses psychomotor skills when performing procedures such as giving injections, changing dressings, and helping the client perform range-of-motion (ROM) exercises. Interpersonal skills are necessary as the nurse interacts with the client and the family to collect data, provide information in teaching sessions, and offer support in times of anxiety. Critical thinking skills enable the nurse to think through the situation, ask the appropriate questions, and make decisions about what needs to be done.
The implementation step also involves reporting and documentation. Data to be recorded include the client condition prior to the intervention, the specific intervention performed, the client response to the intervention, and client outcomes.
Evaluation Evaluation, the fifth step in the nursing process, involves determining whether the client goals have been met, partially met, or not met. If the goal has been met, the nurse must then decide whether nursing activities will cease or continue in order for status to be maintained. If the goal has been partially met or not been met, the nurse must reassess the situation. Data are collected to determine why the goal has not been achieved and what modifications to the plan of care are necessary. There are a number of possible reasons that goals are not met or are only partially met, including:
• The initial assessment data were incomplete.
• The goals and expected outcomes were not realistic.
• The time frame was too optimistic.
• The goals and/or the nursing interventions planned were not appropriate for the client.
Evaluation is an ongoing process. Nurses continually evaluate data in order to make informed decisions during other phases of the nursing process.
CRITICAL THINKING APPLIED IN NURSING Critical thinking is a skill that can be learned just as other skills are learned. The skill of critical thinking is important and useful in all aspects of a person’s life. However, it is a vital tool for the nurse in using the nursing process. Critical thinkers develop a questioning attitude and delve into situations in order to seek possible explanations for what is happening. Examples of questions the nurse as a critical thinker might ask at each step in the nursing process are listed in Table 5-5.
There are many similarities between the nursing process and the problem solving process, as shown on Table 5-6.
Nurses use critical thinking skills in each step of the nursing process. “Everything nurses do require highlevel thinking; no action is performed without critical thinking” (Rubenfeld & Scheffer, 1999, p. 3).
Table 5-7 provides examples of how critical thinking is used in each phase of the nursing process. “Because the conclusions and decisions we as nurses make affect people’s lives, our thinking must be guided by sound reasoning—precise, disciplined thinking that
K E Y C ONCEPTS
• Critical-thinking, problem-solving, and decisionmaking skills are important for use in the nursing process.
• Critical thinkers ask questions, evaluate evidence, identify assumptions, examine alternatives, and seek to understand various points of view.
• The nursing process is an organized method of planning and delivering nursing care.
• The nursing process is composed of five steps: assessment, diagnosis, outcome identification and planning, implementation, and evaluation.
• Assessment is the first step in the nursing process and involves collecting, validating, organizing, categorizing, and recording data.
• Both subjective data (information given by the client) and objective data (information collected by the health care provider using the senses) are collected during the assessment process.
• The second step in the nursing process involves further analysis and synthesis of the data and results in a list of nursing diagnoses.
• Types of nursing diagnoses include: actual, potential (including risk and possible), and wellness.
• Planning, the third step in the nursing process, involves prioritizing nursing diagnoses, identifying and writing goals and client outcomes, developing nursing interventions, and recording the plan of care in the client’s record.
• Implementation, the fourth step in the nursing process, involves performing or delegating nursing activities.
• The nurse uses psychomotor skills, interpersonal skills, and cognitive skills when performing nursing activities.
• Evaluation, the fifth step in the nursing process, involves deciding whether the client goals have been met, been partially met, or not been met.
• The steps in the nursing process are similar to those in the problem-solving method in that problems are identified, information is gathered, a specific problem is named, a plan for solving the problem is developed, the plan is put into action, and the results of the plan are evaluated.
C R I T I C A L T H I N K I N G AC T I V I T I E S
1. Think of all the ways you can use your senses when assessing clients. What type of information can you gather through vision, hearing, smell, and touch?
2. Mrs. Rose was admitted to your unit 2 hours ago. The following data are recorded on her chart. Which data are objective? Which data are subjective? Use “S” and “O” to indicate your response.
__ Temperature
__ Pulse 98, irregular
__ “My head hurts.”
__ Red maculopapular rash
__ Nausea
__ Vomiting for 3 days
__ Grimaces when
__ Skin flushed, hot blinds open
4. Which of the following statements would not be used to describe the nursing process?
a. It is a cyclical dynamic process.
b. Creativity is required for its application.
c. Cognitive, critical-thinking, and psychomotor skills are used.
d. It is a linear static procedure.
e. It is used with clients in any setting.
5. What do you believe about how people react when they are in pain? How do you and the people you know respond when in pain? Your beliefs form the basis for assumptions about pain response. How could these assumptions influence your interpretation of client responses to pain?
Asessment 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 effectivem 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 informatioeeded 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)
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.
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)
Physical assessment, an essential nursing function, is performed on every client. The measurement of vital signs and the execution of the physical examination as part of the assessment process are done to gather information regarding the physiological functioning of the body. This chapter discusses the normal physiological functioning of the body and the common deviations from normal, measurement and evaluation of these functions, preparation of the client for the physical examination, and the techniques used to perform a physical examination.
VITAL SIGNS
The “taking of vital signs” refers to measurement of the client’s body temperature (T), pulse (P) and respiratory (R) rates, and blood pressure (BP). Vital signs are fundamental to physical assessment (the first step in the physical examination) to establish baseline values of the client’s cardiorespiratory integrity. Baseline values establish the norm against which subsequent measurements can be compared. Variations from normal findings may indicate potential problems with the client’s health status. Nurses should confirm “normal” measurements with clients because the perception of what is normal may vary among clients.
Vital signs are taken whenever the client is admitted to a health care facility or service, for example, home health care, clinic, or other ambulatory setting, and on a routine basis in the hospital. The frequency of vital sign measurements for the hospitalized client is determined by the client’s health status, physician orders, and the established standards of care for the particular clinical setting or service. Whenever a change is suspected in the client’s status, the nurse should measure
the vital signs, regardless of the setting.
The sequence for recording vital signs measurement in the nurses’ notes is T-P-R and BP. Agencies usually have special graphic forms used to record vital signs findings. These forms facilitate data comparison at a glance because the data are plotted on a graph.
THERMOREGULATION
Thermoregulation is the body’s physiological function of heat regulation to maintain a constant internal body temperature. The heat of the body is measured in units called degrees. The “core” internal temperature of 98.6° Fahrenheit (F) (37° centigrade [C]) does not vary more than
RESPIRATION
Respiration is the act of breathing. Respiration is defined by physiological functioning as:
• External respiration—the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood system
• Internal respiration—the interchange of oxygen and carbon dioxide between the circulating blood and cells throughout the body
• Inspiration (inhalation)—the intake of air into the lungs
• Expiration (exhalation)—the movement of gases from the lungs to the atmosphere
• Vital capacity—the amount of air exhaled from the lungs after a minimal full inspiration
The following five major physiological pulmonary functions provide oxygen to the tissues and remove carbon dioxide:
1. Ventilation—the inflow and outflow of air between the atmosphere and the lung alveoli.
2. Circulation—the quantity of blood flowing through the lungs is approximately 4 to 6 L/min.
3. Diffusion—the exchange of oxygen and carbon dioxide between the alveoli and the blood.
4. Transport—the carrying of oxygen and carbon dioxide in the blood and body fluids to and from the cells.
5. Regulation—the neurogenic system that adjusts the rate of alveolar ventilation to meet the demands of the body. The arterial blood oxygen pressure (Po2) and arterial blood carbon dioxide pressure (Pco2) may be altered during times of strenuous exercise and other types of respiratory stress.
The mechanics of pulmonary ventilation depend on abdominal recti and internal intercostal muscles that cause lung expansion and contraction. Normal breathing is accomplished by:
1. The downward and upward movement of the diaphragm to lengthen or shorten the chest cavity
2. The elevation and depression of the ribs to increase and decrease the anteroposterior diameter of the chest cavity
Children and meormally breathe with their diaphragm muscles; adult women generally breathe with their upper chest muscles (Firth & Watanabe, 1996).
PULSE
The pulse is the bounding of blood flow in an artery that is palpable at various points on the body. The pulse is caused by the stroke volume ejection and distension of the walls of the aorta, which creates a pulse wave as it travels rapidly toward the distal ends of the arteries. As the pulse wave reaches a superficial peripheral artery and travels over an underlying bone or muscle, the pulse can be palpated by applying gentle pressure over a pulse point (a specific area where the peripheral pulses can be palpated).
Figure 27–1 shows the location of pulse points throughout the body.
BLOOD PRESSURE
Both the blood pressure and pulse are measurements that determine the volume of ejected blood into the arterial system with each ventricular contraction. Blood pressure is the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole. It is measured in terms of millimeters of mercury (mm Hg). In a healthy young adult, the pressure at the height of each pulse (the systolic pressure) is approximately
The body has four hemodynamic regulators for blood pressure control:
1. Blood volume—the volume of blood in the circulatory system. Blood pressure is proportional to the blood volume. Hemorrhage causes a loss in blood volume that, in turn, lowers the blood pressure. Rapid infusion of intravenous fluids causes an increase in volume and subsequent rise in pressure.
2. Cardiac output—the major factor that influences systolic pressure.
3. Peripheral vascular resistance—the size and distensibility of the arteries, which is the most important determinant of diastolic pressure. Arterial resistance (decreased distensibility) is encountered when the left ventricle pumps blood from the heart under pressure during the systolic phase. The arteries contain smooth muscles that allow them to contract, which decreases their compliance (tone) and causes resistance. The varying degrees of tone allow some of the arterioles to remain constricted while others dilate to protect the body’s circulatory system from accommodating a greater blood capacity than the actual blood volume.
If all of the arterioles were to dilate at one time, there would not be enough blood to fill them.
4. Viscosity—the thickness of the blood based on the ratio of proteins and cells to the liquid portion of blood. The greater the viscosity, the harder the heart must work to pump blood, with a resultant increase in blood pressure.
These regulators work in unison to create a constant blood pressure. For instance, when the blood volume decreases, the body compensates with an increased heart rate and vasoconstriction that increases peripheral resistance to maintaiormal pressure and functions of the vital organs.
Blood pressure is a result of the cardiac output and peripheral vascular resistance. Normal arteries expand during systole and contract during diastole, creating two distinct pressure phases:
• Systolic blood pressure is a measurement of the maximal pressure exerted against arterial walls during systole (when myocardial fibers contract and tighten to eject blood from the ventricles), primarily a reflection of cardiac output.
• Diastolic blood pressure is a measurement of pressure remaining in the arterial system during diastole (period of relaxation that reflects the pressure remaining in the blood vessels after the heart has pumped), primarily a reflection of peripheral vascular resistance.
Serial blood pressure readings provide significant clinical data relative to the client’s cardiovascular and fluid volume status.
FACTORS INFLUENCING VITAL SIGNS
Several factors can cause changes in one or more of the vital signs: age, gender, heredity, race, lifestyle, environment, medications, pain, and other factors such as exercise and metabolism, anxiety and stress, postural changes, diurnal variations, and hormones.
BODY TEMPERATURE
Body temperature is measured during the routine physical examination by using one of the instruments described in Table 27–3. Frequent monitoring is required for clients who have or are at risk for infection; for example, postoperative clients or those with suppressed white blood cell count. Accuracy of temperature measurement is essential because it guides nursing and medical decision making and interventions.
TEMPERATURE SCALES
The nurse should consistently measure and record the temperature using either the centigrade or Fahrenheit scale as defined in specific health care agency policies. A centigradecalibrated scale ranges from 34° to
SITES
Although the physician may order a specific site to measure the temperature, nursing judgment usually determines the best site based on the client’s age and physical and mental condition. Traditional sites for measuring the body’s internal (core) temperature are oral (OT), rectal (RT), and axillary (AT), using either glass or electronic thermometers.
Advances in clinical thermometry provide other devices and sites, such as thermistors for pulmonary artery temperature (PAT) and infrared thermometers for ear canal temperature (ET). ET is the most common site used for temperature measurements in adults because it is a safe and efficient method; however, it is less sensitive in detecting fever in infants and young children. ET should not be used in infected or draining ears or if adjacent lesions or incisions exist. The most reliable measure of core temperature is PAT. Since PAT requires placement of a thermodilution pulmonary artery catheter, it is impractical for routine care.
Oral and rectal temperature measurements are higher than axillary because the measuring device is in contact with the mucous membrane. Rectal measurements are higher than oral because of the seal created by the anal sphincter, which decreases contact with environmental air.
With the availability of electronic measuring devices, a glass thermometer should never be used for oral readingsif there is danger that the client will bite and break the thermometer. The axilla is commonly used as a site for infants and children with disabilities because it is the safest, even though least accurate, method. Axillary or rectal sites are used for clients who are uncooperative, comatose, or who have a nasogastric or feeding tube in place.
ASSESSING BODY TEMPERATURE
Assess the client for the most appropriate site and gather the necessary equipment. When checking the client’s oral temperature, the nurse should confirm that the client has neither consumed hot or cold food or beverage nor smoked for 15 to 30 minutes before the measurement. Mouth breathing and tachypnea may also cause an inaccurate oral reading. The nurse should wear nonsterile gloves when assessing oral temperature in clients with herpetic lesions (Crow, 1997). Herpes viruses are extremely contagious and require implementation of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others.
When using a glass thermometer stored in a disinfectant solution, the nurse should rinse it under cold water to remove the solution. Hot water should not be used on the thermometer because it will cause the mercury to expand and could break the thermometer.
Procedure 27–1 describes the actions involved in measuring body temperature according to site.
Alterations in Thermoregulation
When heat production exceeds heat loss and body temperature rises above the normal range pyrexia occurs. This condition is caused by an elevation of the body’s set-point in the hypothalamus. When the body’s temperature rises above
NURSING CONSIDERATIONS
The nurse should place the client experiencing heat exhaustion in a cool environment. The goal of nursing care is to stop diaphoresis by administering fluid and electrolytes as prescribed by a physician.
Victims of heat stroke do not perspire because of severe electrolyte loss and impaired hypothalamic function as discussed in Table 27–4.
Heat stroke victims are usually discovered outdoors, with emergency measures instituted to lower the temperature during transport to an emergency center. Nursing’s primary role relative to heat stroke is prevention. The nurse is usually involved in teaching preventive measures, such as drinking liquids before, during, and after exercise; avoiding strenuous exercise in humid, hot weather; and wearing light-colored, loose-fitting clothing and covering the head when working outdoors in hot climates.
Hypothermia and frostbite victims found injured in cold weather or who were immersed in cold water are treated while in transit to an emergency center with heating blankets and instillation of warm fluids into the stomach. Nursing’s role is to teach preventive measures to groups at risk, such as the homeless, and to parents or guardians of mentally ill or handicapped clients who live in cold environments.
DOCUMENTATION
Record the temperature measurement and the site on the designated medical record form. Schmitz and colleagues (1995) identify the importance of both consistency in the measurement process for the purpose of establishing a client’s temperature trend and awareness of the method used when interpreting clinical data.
Temperature measurements are usually plotted on a graph to identify alteration patterns, such as sharp elevations and declines in temperature (a condition known as spiking).
PULSE
Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. Assessment of pulse characteristics provides clinical data regarding the heart’s pumping action and the adequacy of peripheral artery blood flow.
SITES
There are multiple pulse points. The most accessible peripheral pulses are the radial and carotid sites.
Because the body shunts blood to the brain whenever a cardiac emergency such as hemorrhage occurs, the carotid site should always be used to assess the pulse in these situations.
Variances exist among health care agencies regarding which pulse sites to assess. The common sites for each type of assessment are:
• Complete physical assessment—apical and all bilateral peripheral pulses
• Initial assessment—apical and bilateral peripheral radial and dorsalis pedis pulses
• Routine vital sign assessment—apical and radial pulses in adults and apical and temporal pulses in infants and children Disorders that alter the client’s cardiovascular status require different pulse point assessments (Table 27–5).
Whenever circulation is compromised, the corresponding pulse point should be assessed.
ASSESSING PULSE RATE
The nurse should begin the assessment by speaking with the client about the normal pulse rate. The client’s medical record should be reviewed for baseline data, if available, and any medications that could affect the heart rate should be noted. Because physical activity increases the heart rate, ensure that the client rests 5 to 10 minutes before the pulse is assessed.
Clinical data regarding the efficacy of blood circulation to an extremity are obtained by assessing the characteristics (quality, rate, rhythm, and volume) of the peripheral pulses. These attributes are described in the section entitled
PULSE CHARACTERISTICS.
Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate pressure. A firm pressure will obliterate the pulse; if the pressure is too light, the pulse cannot be felt.
A Doppler ultrasound stethoscope (DUS) is used on superficial pulse points to detect and magnify heart sounds and pulse waves when the peripheral pulse cannot be palpated. The DUS, which has an earpiece similar to that of a stethoscope, is connected by a cord to volume-control audio unit with an ultrasound transducer.
Normal radial and apical pulses are identical in rate.The stethoscope is used to auscultate the heart’s rate and rhythm. The stethoscope should be placed on the fifth intercostal space at the midclavicular line, as described in Procedure 27–2.
COUNT THE RATE FOR A FULL MINUTE, NOTING THE REGULARITY (RHYTHM).
When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit (condition in which the apical pulse rate is greater than the radial pulse rate). A pulse deficit results from the ejection of a volume of blood that is too small to initiate a peripheral pulse wave. When a discrepancy exists between the apical and radial pulses, the deficit is assessed by simultaneously measuring the apical and radial pulses for a minute. This procedure is usually performed by two nurses; however, it can be performed by one nurse if necessary.
PULSE CHARACTERISTICS
***A normal pulse has defined characteristics: quality, rate, rhythm, and volume (strength or amplitude)***
Pulse quality refers to the “feel” of the pulse, its rhythm and forcefulness.
Pulse rate is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point. A normal pulse rate for adults is between 60 and 100 beats per minute.
Bradycardia is a heart rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult.
Pulse rhythm is the regularity of the heartbeat. It describes how evenly the heart is beating: regular (the beats are evenly spaced) or irregular (the beats are not evenly spaced).
Dysrhythmia (arrhythmia) is an irregular rhythm caused by an early, late, or missed heartbeat.
Pulse volume is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction. It is described as normal (full, easily palpable), weak (thready and usually rapid), or strong (bounding). To facilitate data comparison of this measurement, a standard pulse volume scale should be used in documenting findings (see the accompanying display). Procedure 27-2 describes the actions involved in assessing the pulse rate.
Clients on certain cardiac medications, such as cardiovascular agents and cardiac glycosides, need to monitor their pulse rate. Clients receiving cardiovascular agents (verapamil hydrochloride) and cardiac glycosides (digoxin) may experience an irregular pulse or pulse rate change that should be reported to their physician. In addition, clients who follow an exercise regimen should assess their pulse rate to measure their heart’s response to the exercise. Routine or regular exercise lowers the resting and activity pulses. When teaching clients how to monitor their own heart rate, nurses should show them the procedure in assessing the radial or carotid pulse points.
DOCUMENTATION
All pulse measurements are documented by recording in the client’s medical record on the appropriate forms (e.g., the vital sign flow sheet). The nurse should report and document an irregular pulse.
RESPIRATIONS
Respiratory assessment is the measurement of the breathing pattern. Assessment of respirations provides clinical data regarding the pH of arterial blood.
SITES
Normal breathing is slightly observable, effortless, quiet, automatic, and regular. It can be assessed by observing chest wall expansion and bilateral symmetrical movement of the thorax. Another method the nurse can use to assess breathing is to place the back of the hand next to the client’s nose and mouth to feel the expired air.
ASSESSING RESPIRATIONS
When assessing respirations ascertain the rate, depth, and rhythm of ventilatory movement. The nurse should assess the rate by counting the number of breaths taken per minute. Note the depth and rhythm of ventilatory movements by observing for the normal thoracic and abdominal movements and symmetry in chest wall movement.
Normal respirations are characterized by a rate ranging from 12 to 20 breaths per minute. Procedure 27-3 describes the actions involved in assessing resiprations.
One inspiration and expiration cycle is counted as one breath. The nurse should observe the rise and fall of the chest wall and count the rate by placing the hand lightly on the chest to feel its rise and fall. Count the number of respirations as explained in Procedure 27-3.
MOVEMENT OF THE DIAPHRAGM
When the chest wall moves, so do the lungs, because the lungs are attached to the inner wall of the thoracic cavity by the outer layer of the pleura (lining of the chest cavity). The movement of the chest wall should be even and regular, without noise and effort. On inspiration the chest changes shape and expands as the rib cage is raised and the diaphragm is lowered. Before inspiration, the pressure inside the chest cavity is negative (–4.5 to –9.0 mm Hg below atmospheric pressure). Air flows along the concentration gradient from a higher atmospheric pressure to the lower intrathoracic pressure.
The opposite action occurs with expiration. The muscles relax, causing the rib cage to lower, and the diaphragm to rise, compressing the chest. Intrathoracic pressure decreases to –3 to –6 mm Hg to allow the air to escape into the atmosphere.
Characteristics of
Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific.
Bradypnea is a respiratory rate of 10 or fewer breaths per minute.
Hypoventilation is characterized by shallow respirations.
Tachypnea is a respiratory rate greater than 24 breaths per minute.
Hyperventilation is characterized by deep, rapid respirations.
The nurse can also observe alterations in the movement of the chest wall:
1. costal (thoracic) breathing occurs when the external intercostal muscles and the other accessory muscles are used to move the chest upward and outward;
2. diaphragmatic (abdominal) breathing occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen.
Dyspnea refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe. Dyspneic clients are acutely aware of their respirations and complain of shortness of breath.
NURSING CONSIDERATIONS
Respiratory alterations may cause changes in skin color as observed by a bluish appearance in the nail beds, lips, and skin. The bluish color (cyanosis) results from reduced oxygen levels in the arterial blood.
Changes in the level ofconsciousness may also occur with decreased oxygen levels. Dyspneic clients will assume a forward-leaning position to increase the expansion capacity of the lungs.
Clients with respiratory alterations require additional nursing assessment. Noninvasive oxygen assessment can be performed with an oximeter (a machine that measures the oxygen saturation of the blood through a probe clipped to the fingernail or earlobe) or an apnea monitor (a machine with chest leads that monitors the movement of the chest).
Both noninvasive machines have alarm features that are set to specific parameters. For example, if the client’s respirations fall below 6 breaths per minute, the apnea monitor alarm will sound. The apnea monitor is used in the home environment for apneic clients; when the alarm sounds, it wakes the person and causes him to breathe.
DOCUMENTATION
Document the assessment findings for the respiratory rate, depth, rhythm, and character on the appropriate form (e.g., the vital sign flow sheet). Report a respiratory rate outside the normal age range, an irregular rhythm, inadequate depth, or any abnormal characteristics such as dyspnea.
BLOOD PRESSURE
Blood pressure measurement is performed during a physical examination, at initial assessment, and as part of routine vital signs assessment. Depending on the client’s condition, the blood pressure is measured by either a direct or an indirect technique. The direct method requires an invasive procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. The indirect method requires use of the sphygmomanometer and stethoscope for auscultation and palpation as needed.
SITES
The most common site for indirect blood pressure measurement is the client’s arm over the brachial artery. When the client’s condition prevents auscultation of the brachial artery, the nurse should assess the blood pressure in the forearm or leg sites (see the accompanying display).
When pressure measurements in the upper extremities are not accessible, the popliteal artery, located behind the knee, becomes the site of choice. The nurse can also assess the blood pressure in other sites, such as the radial artery in the forearm and the posterior tibial or dorsalis pedis artery in the lower leg. Because it is difficult to auscultate sounds over the radial, tibial, and dorsalis pedis arteries, these sites are usually palpated to obtain a systolic reading.
ASSESSING BLOOD PRESSURE
Selecting the proper equipment and following procedural technique are basic to ensuring an accurate reading. Psychomotor skills, acquired with practice, are needed to manipulate the blood pressure equipment.
Procedure 27-4 describes the actions involved in assessing blood pressure.
As shown in Table 27-
The sphygmomanometer wears with usage. If there is a defect in any part of the system, the blood pressure reading will be inaccurate. The aneroid gauge needle or mercury in the manometer column should be at a zero reading when the cuff is deflated and should rise evenly when pressure is applied to the bulb. The valve should turn freely and all tubing should be intact, with secured connections to prevent air from leaking out of the system.
An accurate reading also requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity. The bladder cuff must encircle the width and length of the site. According to the American Heart Association (1987), the bladder width should be approximately 40% of the circumference or 20% wider than the diameter of the midpoint of the extremity. To measure the width of the bladder, the nurse should place the cuff lengthwise on the client’s extremity and extend the width to cover 40% of the extremity’s circumference (Figure 27-14).
The length of the sphygmomanometer bladder should be twice the width.
Table 27-6 recommends bladder sizes based on different arm circumferences. A falsely elevated reading will result if the bladder is too narrow, and a falsely low reading will result if it is too wide.
Electronic sphygmomanometers are used by clients for self-measurements. A stethoscope is not required because the device electronically inflates and deflates the cuff while simultaneously reading and displaying the systolic and diastolic pressures. The electronic device is useful for clients who must monitor their own pressure at home. However, it must be recalibrated routinely to ensure an accurate reading.
KEY CONCEPTS FOR NURSING ASSESSMENT
• Assessment includes collection, verification, organization, interpretation, and documentation of data.
• The nurse uses the process of assessment to establish a database about the client, to form an interpersonal relationship with the client, and to provide the client with an opportunity to discuss health care concerns.
• Assessment can be comprehensive, focused, or ongoing, depending on the health care setting and needs of the client.
• The two types of data collected during the assessment process are subjective (data from the client’s point of view) and objective (observable and measurable data that are obtained through both the physical examination and laboratory and diagnostic tests).
• Although a variety of sources should be used in data collection, the client is the primary source of information.
• Assessment models such as Gordon’s Functional Health Patterns, NANDA’s Human Response Patterns, Orem’s Theory of Self-Care Model, Roy’s Adaptation Model, the body systems model, and Maslow’s hierarchy of needs model ensure comprehensive data collection and organization.
• Data are collected through the interview, health history, symptom analysis, physical examination, and laboratory and diagnostic tests.
• The three stages of assessment interview are the introduction, working, and closure phases.
• A comprehensive health history is useful in determining the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle.
• The elements of the health history are demographic information; reason for seeking health care; perception of health status; previous illnesses, hospitalizations, and surgeries; client/family medical history; immunizations/exposure to communicable disease; allergies; current medications; developmental level; psychosocial history; sociocultural history; activities of daily living; and review of systems.
• The purposes of the physical examination are to gather baseline data, confirm data obtained in the interview and health history, and evaluate progress toward established goals. The examination includes the techniques of inspection, palpation, percussion, and auscultation. • Accurate and complete documentation of assessment findings is essential for communication to other health care team members and may be recorded on a variety of assessment tools, such as open-ended, checklist, combination, and specialty formats.
KEY CONCEPTS DIAGNOSTIC OF HUMAN RESPOND.
• Nursing diagnosis is the second step in the nursing process and is the clinical judgment about individual, family, or community (aggregates) responses to actual or risk problems, wellness states, or syndromes.
• Through the efforts of NANDA and ANA, the identification and validation of nursing diagnosis as the second step of the nursing process has been substantiated and forms the basis for professional accountability.
• Nursing diagnosis contributes to a clearer conceptualization of knowledge unique to nursing, improved communication among nurses and other health care professionals, promotion of individualized client care, and support for theory development and nursing research.
• Nursing diagnoses can be written as either two-part statements (diagnostic label and etiology) or threepart statements (diagnostic label, etiology, and defining characteristics).
• The NANDA nursing diagnosis taxonomy is composed of nine human response patterns: exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling.
• The process of developing a nursing diagnosis includes analysis of assessment cues, validation of cues, interpretation of cues, clustering of data, consulting NANDA’s list of approved nursing diagnoses, and writing the nursing diagnosis statement.
• When the nurse is knowledgeable about the components of the nursing diagnosis process and is equipped to develop the diagnostic statement, the nurse is able to make appropriate decisions regarding therapeutic nursing interventions.
• To avoid committing errors in the nursing diagnostic process, nurses should ensure that the data collection is complete, that the interpretation of the data is accurate and based upon the nursing and not the medical diagnosis, and that the client’s response to a health problem is amenable to therapeutic nursing interventions.
• The barriers that have been identified as preventing the use of nursing diagnosis in a more universal manner are the constraints on the time nurses can devote to client care; the continuing organization of health care according to medical diagnosis; the misunderstanding and ridicule that nurses can encounter when using nursing diagnoses; the nonapplicability of the list of nursing diagnoses to every client situation; the constantly evolving refinement of the nursing diagnosis language; and the availability of numerous approaches for formulation and application of nursing diagnoses.
• Although barriers to the use of nursing diagnosis may be present, they may be overcome by employing specific strategies such as agreeing on a common language; supporting colleagues’ attempts to use nursing diagnoses; adopting a nonjudgmental attitude; and continuing to communicate with other nurses at national and international levels.
