Nursing process: definition, nobjectives, functions, steps. General characteristics. nPhases the first stage of nursing process. Examination and determination of health status as the phase of the nfirst stage of nursing process.
THE NURSING PROCESS nThe nursing process is the framework for providing nprofessional, quality nursing care. It ndirects nursing activities nfor health promotion, health protection, and disease prevention and is used by nurses in every npractice setting and specialty. “The nnursing process provides the nbasis for critical thinking iursing” (Alfaro-LeFavre, 1998, p. n64).
HISTORICAL PERSPECTIVE Lydia Hall first referred to nursing as a “process” in a 1955 journal article, yet the term was not nwidely used until the late 1960s n(Edelman & Mandle, 1997). Referring to the “nursing process” as a nseries of steps, nJohnson (1959), Orlando (1961), and Wiedenbach (1963) further developed this description of nnursing. At this ntime, the nursing process involved only three steps: assessment, planning, and evaluation. Itheir 1967 book nThe Nursing Process, Yura and Walsh identified nfour steps in the nursing process:
• Assessing n
• Planning n
• Implementing
• Evaluating n
The Standards of Practice, nfirst published in 1973 by the American Nurses Association (ANA), nincluded eight standards. These nstandards identified each of the steps, including nursing diagnosis, that are nnow included in the nursing nprocess.
Fry (1953) first used the term nursing ndiagnosis, but it was not until n1974, after the first meeting of the group nnow called the North American Nursing Diagnosis Association (NANDA), that Gebbie nand Lavin added nnursing diagnosis as a separate and distinct step in the nursing process. Prior to this, nursing ndiagnosis had been nincluded as a natural conclusion to the first step, assessment. n
Following publication of the ANA nstandards, the nurse npractice acts of many states were revised to ninclude the steps of the nursing process specifically. The ANA made nrevisions to the standards in 1991 to include noutcome identification as a specific part of the planning phase. Currently, the steps in the nursing nprocess are:
• Assessment
• Diagnosis
• Outcome identification and planning n
• Implementation
• Evaluation
The American Nurses Associatiopractice standards naddress each step of the nursing process.
OVERVIEW OF THE NURSING nPROCESS A nprocess is a series of steps or acts that lead to accomplishment of some goal or purpose. The purpose of the nursing process nis to provide care for clients that is individualized, holistic, effective, and efficient. The steps nof the nursing nprocess build upon each other, but they are nnot linear. There is overlap of each step with the previous and subsequent steps (Figure n5-1).
The nursing process is dynamic and nrequires creativity nfor its application. The steps remain the same, but the application and results will nbe different in each client situation. nThe nursing process is designed to be used with clients throughout the life nspan and in any setting in which a nurse nprovides care for clients. It is also a nbasic organizing system for the National Council Licensure Examination for nRegistered Nurses (NCLEX-RN).
Assessment Assessment is the first step in the nursing process and includes collection, verification, norganization, interpretation, and ndocumentation of data. The completeness and correctness of the informatioobtained during assessment are directly nrelated to the accuracy of the steps nthat 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 n
• Recording or reporting data
Data are collected from a variety of nsources; however, the nclient should be considered the primary source of data (the major provider of information about nself). As much ninformation as possible should be gathered from the client, using both interview techniques and nphysical examination skills. Sources of ndata other than the client are considered secondary sources and ninclude family members, other health ncare providers, and medical records.
Assessment provides information that nwill form the client ndatabase. Two types of information are collected through the assessment component: nsubjective and objective.
Subjective data are data from the client’s point of view and include feelings, nperceptions, and concerns. The method of ncollecting subjective information is primarily the interview. Using therapeutic interviewing techniques, nthe nurse collects data that will begin to nbuild 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 nuntil it is time to get up in the nmorning.”
Objective data are observable and measurable data that are obtained through both nstandard assessment techniques performed nduring the physical examination and ndiagnostic tests. The primary method of collecting objective information is the physical nexamination, which provides informatioabout the function of body systems n(Figure 5-2).
Examples of objective informatioinclude:
• T 98.6°F, P 100, R 12, B/P 130/76 n
• Bowel sounds auscultated in all four nquadrants
• Gait slow, shuffling, and unsteady n
This objective information may add to nor validate subjective ninformation. Validation is a critical step in data collection to avoid nomissions, prevent misunderstandings, nand avoid incorrect inferences and conclusions.
Data that are collected must be norganized to be useful nto the health care professional collecting the data as well as others involved with the client’s ncare. Clustering nsimilar pieces of information assists the nurse iconstructing a picture of the client’s nproblems and strengths. There are a nnumber of organizing frameworks for collection of data—for example, nGordon’s Functional Health Patterns. nMany health care agencies nuse an admission assessment format, which assists the nurse in collecting data in specific ncategories of functioning.
Critical thinking is used idetermining the significance nof data collected. Once data are organized into categories, the data are clustered ninto groups of related pieces. Placing ndata into clusters helps the nurse to recognize patterns of response or behavior. Whedata are placed ninto 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 n
With this information, the nurse, nthrough critical thinking, ncan begin to develop impressions or inferences about what the data mean.
Assessment data must be recorded and nreported. The nurse nmust make a judgment about which data are to be nreported immediately and which data need only to be recorded at that time. Data that reflect a nsignificant deviation nfrom the normal (for example, rapid heart rate with irregular rhythm, severe difficulty ibreathing, or high levels of anxiety) nwould need to be reported as well as nrecorded. Examples of data that need only to be recorded at the time include a report nthat prescribed medication has relieved na headache and a determination that aabdominal dressing is dry and intact.
Assessment does not end with the ninitial interview and nphysical examination. Assessment is dynamic and continues with each nurse-client ninteraction.
Diagnosis The second step in the nursing process involves further analysis (breaking the whole down into nparts that can be examined) and synthesis n(putting data together in a new way) nof the data that have been collected. nFormulation of the list of nursing diagnoses is the outcome of this process. According to nthe North American nNursing Diagnosis Association (NANDA) a nursing ndiagnosis is a clinical judgment nabout individual, family, or community nresponses to actual or potential health nproblems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for nwhich the nurse is accountable. n(Carroll-Johnson, 1990, np. 50)
The nursing diagnoses developed nduring this phase of nthe nursing process provide the basis for client care delivered through the remaining steps. Client problems are labeled by both medical and nursing ndiagnoses. Clients receive both medical and nursing diagnoses. Table 5-3 compares nthe two categories of ndiagnoses.
The nurse uses critical-thinking and ndecision-making skills nin developing nursing diagnoses. This process is facilitated by asking questions such nas:
• Are there problems here?
• If so, what are the specific problems? n
• 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 ntaken?
• Has the client indicated a desire for a higher level of wellness in a particular area of nfunction?
• 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 nclinical example of napplying critical thinking when determining nursing diagnoses. n
Types of Nursing Diagnoses Analysis of the collected data leads the nurse to make a diagnosis in one of the following ncategories:
• Actual problems
• Potential problems (including those where risk factors exist and there are possible nproblems)
• Wellness conditions
• Collaborative problems
Examples of the various types of ndiagnoses are shown in nTable 5-4.
An actual nursing diagnosis indicates nthat a problem exists, nand is composed of the diagnostic label, related factors, and signs and symptoms. An example nof an actual ndiagnosis is: Impaired Skin Integrity related to prolonged pressure on bony prominence as manifested nby (AMB) Stage II pressure ulcer over ncoccyx, 3 cm nin diameter.
A risk nursing diagnosis (potential nproblem) indicates nthat a problem does not yet exist, but special risk factors are present. A risk diagnosis is ncomposed of the ndiagnostic label preceded by the phrase “risk for,” with the specific risk factors listed. An example nof a risk diagnosis is: nRisk for Impaired Skin Integrity related to inability to turn self from side to side in bed.
A possible nursing diagnosis indicates na situation in which na problem could arise unless preventive action is taken. In addition, a possible diagnosis may nstate a “hunch” nor intuition by the nurse that cannot be confirmed or eliminated until more data have beecollected. A possible diagnosis is ncomposed of the diagnostic nlabel and related factors. An example of a possible diagnosis is: Possible Self-Esteem nDisturbance related to recent nretirement and relocation. The nurse may not yet have enough data to confirm this ndiagnosis or a more specific one. nHowever, this diagnosis will alert other nurses to collect data that will neither confirm this or another ndiagnosis, verify a risk diagnosis, or rule out nthe existence of a problem.
A wellness nursing diagnosis indicates nthe client’s nexpression of a desire to attain a higher level of wellness in some area of function. It is composed of nthe diagnostic label npreceded by the phrase “potential for nenhanced.” For example a client who is neither overweight nor underweight tells the nurse that nshe knows she could improve her diet isome ways. She states that nshe eats only a small number of vegetables and fruits and thinks that the fat content of her diet nis probably high. She expresses a desire nto know more about how to nimprove her diet. The nurse would make a wellness diagnosis of Potential for Enhanced nNutrition.
Carpenito introduced the bifocal clinical practice model that includes nursing diagnoses nand collaborative problems. Collaborative nproblems are defined as nphysiologic complications monitored by nurses to assess changes in client status. Collaborative nproblems are managed nthrough the use of interventions prescribed by nother health care practitioners and/or nurses (Carpenito, 1999). nCollaborative problems include those conditions in which the nurse nseeks medical input for treatment of npotential medical problems. Usually, collaborative nproblems involve alterations in organ nand/or system function or structure (e.g., myocardial infarction, duodenal ulcer). Collaborative problems begin with nthe label Potential Complication (PC) followed by the situation—for example, Potential nComplication: Hemorrhage.
Analysis of the data also assists the nurse in identifying strengths nof the client. For example, the client’s strong family support system would be nidentified as a strength. These areas of npositive functioning will be nreinforced and used as a basis for planning care for those areas where functioning is less thaoptimal.
After it is formulated, the list of diagnoses is presented to the nclient for confirmation if possible. If that is not possible, family members may be nable to confirm the diagnoses. Finally, nthe list of nursing diagnoses nis recorded on the client’s record. Once this list is developed and recorded, the nremainder of the client’s plan of care ncan be completed. The list of nnursing diagnoses is not static. It is dynamic, changing as more data nare collected and as client goals and nclient responses to interventions are evaluated.
Outcome Identification and nPlanning Planning is the third step of the nursing process and includes the formulation of guidelines that nestablish the proposed course of nursing naction in the resolution of nursing ndiagnoses and the development of the client’s nplan of care. Once the nursing diagnoses have been developed and client strengths have nbeen identified, planning can begin. The nplanning phase involves several tasks: n
• The list of nursing diagnoses is prioritized.
• Client-centered long- and short-term goals and outcomes are identified and written.
• Specific interventions are developed. n
• The entire plan of care is recorded in the client’s record.
Once the list of nursing diagnoses nhas been developed nfrom the data, decisions must be made about priority. Critical thinking enables the nurse nto make decisions nabout which diagnoses are the most important nand need attention first. There are a number of frameworks used to prioritize nursing ndiagnoses; however, those diagnoses ninvolving life-threatening situations nare given the highest priority. For example, the following nursing diagnoses would be nstated in this order of priority:
• Ineffective Airway Clearance related nto excessive and thick nsecretions and pain secondary to surgery and ninability to cough effectively; respirations: 25, shallow, wheezing n
• Risk for Injury (falls) related to nunsteady gait
• Imbalanced Nutrition: Less Than Body Requirements related to nausea and vomiting
Client-centered goals are established nin collaboration with nthe client whenever possible. A goal is an aim, intent, or end. Goals are broad statements nthat describe the nintended or desired change in the client’s behavior. Goal statements refer nto the diagnostic label (or problem statement) nof the nursing diagnosis. If the client or significant others are unable to participate igoal development, the nurse assumes that nresponsibility until the client is able to nparticipate. Client-centered goals assure that nursing care is nindividualized and focused on the client. n
Expected outcomes are specific objectives related to the goals and are used to evaluate the nnursing interventions. They must be nmeasurable, have a time limit, and be realistic. Once goals and expected noutcomes have been nestablished, nursing interventions are planned nthat enable the client to reach the goals.
A nursing intervention is the nactivity that the nurse nwill execute for and with the client to enable naccomplishment of the goals. Nursing ninterventions refer ndirectly to the related factors in the actual nursing ndiagnoses and the risk factors in risk nnursing diagnoses. If nthe nursing interventions can remove or reduce the related factors and the risk factors, the nproblem can be resolved or prevented. nNursing interventions also refer to the diagnostic label for possible ndiagnoses and focus on data needed to nconfirm or eliminate the diagnosis.
For each nursing diagnosis there may nbe a number of nursing ninterventions. Nursing interventions are individualized and are stated in specific terms. nExamples of nursing ninterventions are:
• Turn, cough, and deep breathe q 2 h beginning at 0800, 2/10.
• Teach “nipple care when breastfeeding” at 1000, 2/11. n
• Weigh client at each visit.
Once the interventions have been determined for each diagnosis, nthe interventions are recorded on the nclient’s plan of care. As is true with other steps in the nursing process, the list of ninterventions is not static. As the nurse interacts with the client, nassesses responses to interventions, and nevaluates those responses, interventions nmay change.
Implementation The fourth step nin the nursing process is implementation. nImplementation involves the execution of the nursing plan of care derived during the nplanning phase. It nconsists of performing nursing activities that have been planned to meet the goals set with the nclient. Nurses may ndelegate some of the nursing interventions to other persons assigned to care for the client—for nexample, the licensed practical nurses nand unlicensed assistive personnel.
Implementation involves many skills. The nurse must continue to nassess the client’s condition before, during, nand after the nursing intervention. Assessment prior to the intervention provides the nurse nwith baseline data. Assessment during nand after the intervention allows the nurse to detect positive or negative nresponses the client may have to the nintervention. If negative responses occur during the procedure, the nurse nmust take appropriate action. If npositive responses occur, the nurse adds this information to the database for use nin evaluating the efficacy of the nintervention. The nurse must also possess psychomotor skills, ninterpersonal skills, and critical nthinking skills to perform the nursing interventions that have been planned. The nurse uses psychomotor skills nwhen performing procedures such as giving injections, changing dressings, and helping the client nperform range-of-motion (ROM) exercises. nInterpersonal skills nare necessary as the nurse interacts with the client and the family to collect data, provide ninformation in teaching sessions, and noffer support in times of anxiety. nCritical thinking skills enable the nurse to think through the situation, ask the nappropriate questions, and make ndecisions about what needs to be done.
The implementation step also involves reporting and documentation. nData to be recorded include the client condition prior to the intervention, nthe specific intervention performed, the nclient response to the intervention, and nclient outcomes.
Evaluation Evaluation, nthe fifth step in the nursing process, involves ndetermining whether the client goals have been met, partially met, or not met. If the goal has nbeen met, the nurse nmust then decide whether nursing activities will cease or continue in order for status to be nmaintained. If the goal has beepartially met or not been met, the nurse must reassess the situation. nData are collected to ndetermine why the goal has not been achieved and what modifications to the plan of care are nnecessary. There are na number of possible reasons that goals are not met or are only partially met, including:
• The initial assessment data were nincomplete.
• The goals and expected outcomes were not nrealistic.
• The time nframe was too optimistic.
• The goals and/or the nursing interventions planned were not nappropriate for the client.
Evaluation is an ongoing process. Nurses continually evaluate ndata in order to make informed decisions during nother phases of the nursing process.
CRITICAL THINKING APPLIED IN NURSING Critical nthinking is a skill that can be learned just as nother skills are learned. The skill of critical thinking is important and nuseful in all aspects of a person’s life. nHowever, it is a vital tool for the nurse in using the nursing process. nCritical thinkers develop a questioning attitude and delve into situations in order to nseek possible explanations for what is nhappening. Examples of questions the nurse as a critical thinker might nask at each step in the nursing process nare listed in Table 5-5.
There are many similarities betweethe nursing process nand the problem solving process, as shown on nTable 5-6.
Nurses use critical thinking skills nin each step of the nnursing process. “Everything nurses do require highlevel thinking; no action is performed nwithout critical thinking” (Rubenfeld & Scheffer, 1999, np. 3).
Table 5-7 provides examples of how critical nthinking is used in each phase of the nnursing process. “Because the nconclusions and decisions we as nurses make affect people’s lives, our nthinking must be guided by sound nreasoning—precise, disciplined thinking that n
K E Y C ONCEPTS
• Critical-thinking, problem-solving, and decisionmaking skills are important for use in the nnursing process.
• Critical thinkers ask questions, evaluate evidence, identify assumptions, examine nalternatives, and seek to understand nvarious 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 nidentification and planning, nimplementation, and evaluation.
• Assessment is the first step in the nursing process and involves collecting, validating, norganizing, categorizing, and recording ndata.
• Both subjective data (information given by the client) and objective data (informatiocollected by the health care provider nusing the senses) are collected during nthe assessment process.
• The second step in the nursing process involves further analysis and synthesis of the data and nresults in a list of nursing ndiagnoses.
• Types of nursing diagnoses include: actual, potential (including risk and possible), and nwellness.
• Planning, the third step in the nursing process, involves prioritizing nursing ndiagnoses, identifying and writing goals nand client outcomes, developing nursing ninterventions, and recording the plan of care nin the client’s record.
• Implementation, the fourth step in the nursing process, involves performing or ndelegating nursing activities.
• The nurse uses psychomotor skills, interpersonal skills, and cognitive skills wheperforming nursing activities.
• Evaluation, the fifth step in the nursing process, involves deciding whether the client ngoals have been met, been partially met, nor not been met.
• The steps in the nursing process are similar to those in the problem-solving method in that nproblems are identified, information is ngathered, a specific problem is named, a nplan for solving the problem is developed, nthe 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 nT I V I T I E S
1. Think of all the ways you can use your senses when assessing clients. What type of ninformation can you ngather through vision, hearing, smell, and touch?
2. Mrs. Rose was admitted to your unit 2 hours ago. The following data are recorded on her nchart. Which data are objective? Which ndata are subjective? Use “S” and “O” to nindicate your response.
__ Temperature 102°F
__ Pulse 98, irregular
__ “My head hurts.”
__ Red maculopapular rash n
__ Nausea
__ Vomiting nfor 3 days
__ Grimaces when
__ Skin flushed, hot blinds open
4. Which of the nfollowing statements would not be used to describe the nursing nprocess?
a. It is a ncyclical dynamic process.
b. Creativity is nrequired for its application.
c. Cognitive, ncritical-thinking, and psychomotor skills are used.
d. It is a nlinear static procedure.
e. It is used nwith clients in any setting.
5. What do you nbelieve about how people react when they are in pain? How do you and the npeople you know nrespond when in pain? Your beliefs form the basis for assumptions about pairesponse. How could nthese assumptions influence your interpretation nof client responses to pain?
Asessment nis the first step in the nursing process and includes systematic collection, nverification, organization, interpretation, and documentation of data for use nby health care professionals. The accompanying display presents the essential nelements of the assessment process. Effective planning of client care depends non a complete database and accurate interpretation of information. Incomplete nor inadequate assessment may result in inaccurate conclusions and incorrect nnursing interventions. Proper collection of assessment data directs ndecision-making activities of professional nurses.
The goal of assessment is the collection and analysis nof data that are used in formulating nursing diagnoses, identifying outcomes nand planning care, and developing nursing interventions. This chapter discusses nthe purpose of assessment, types of assessment, and the use of data in the nassessment process.
PURPOSE nOF ASSESSMENT
The purpose of assessment is to establish a ndatabase concerning a client’s physical, psychosocial, and emotional health iorder to identify health promoting behaviors as well as actual and/or potential nhealth problems. The American Nurses Association (ANA), in its Standards of nClinical Nursing Practice (1998), supports the use of the nursing process and noutlines the essential components of assessment in this process (see the naccompanying display). Through assessment, the nurse determines the client’s nfunctional abilities and the absence or presence of dysfunction. The client’s nnormal routine for activities of daily living and lifestyle patterns are also nassessed. Identification of the client’s strengths provides the nurse and other nmembers of the treatment team information about the skills, abilities, and nbehaviors the client has available to promote the treatment and recovery nprocess. Some examples of client strengths are family support, intelligence, nspiritual beliefs, and coping skills (how previous problems have been solved). nThe assessment phase also offers an opportunity for the nurse to form a ntherapeutic interpersonal relationship with the client. During assessment, the nclient is provided an opportunity to discuss health care concerns and goals nwith the nurse.
TYPES nOF ASSESSMENT
The type and scope of informatioeeded for nassessment are usually determined by the health care setting and needs of the nclient (see Figure 6-1).
Three types of assessment are comprehensive, focused, nand ongoing. Although a comprehensive assessment is most desirable in initially ndetermining a client’s need for nursing care, time limitations or special ncircumstances may dictate the need for abbreviated data collection, as nrepresented by the focused assessment.
The nassessment database can then be expanded after the initial focused assessment, nand data should be updated through the ongoing assessment process.
COMPREHENSIVE nASSESSMENT
A comprehensive assessment is usually completed nupon admission to a health care agency and includes a complete health history nto determine current needs of the client. This database provides a baseline nagainst which changes in the client’s health status can be measured and should ninclude assessment of physical and psychosocial aspects of the client’s health, nthe client’s perception of health, the presence of health risk factors, and the nclient’s coping patterns.
FOCUSED nASSESSMENT
A focused assessment is an assessment that is nlimited in scope in order to focus on a particular need or health care problem nor potential health care risks. Focused assessments are not as detailed as ncomprehensive assessments and are often used in health care agencies in which nshort stays are anticipated (e.g., outpatient surgery centers and emergency ndepartments), in specialty areas such as labor and delivery, and in mental nhealth settings or for purposes of screening for specific problems or risk nfactors (e.g., well-child clinics). See the accompanying display for sample nquestions used to assess a client experiencing labor.
ONGOING nASSESSMENT
Systematic follow-up is required when problems nare identified during a comprehensive or focused assessment. An ongoing nassessment is an assessment that includes systematic monitoring and observatiorelated to specific problems. This type of assessment allows the nurse to nbroaden the database or to confirm the validity of the data obtained during the ninitial assessment. Ongoing assessment is particularly important when problems nhave been identified and a plan of care has been implemented to address these nproblems.
Systematic monitoring and observations allow the nnurse to determine the response to nursing interventions and to identify any nemerging problems.
The nurse delivering care to a client at home uses nongoing assessment. In the home, the nurse often has to direct the client to nprovide information relevant to the current problem, as the client may have a ntendency to spend a lot of time telling stories of past medical problems and ntreatment, as opposed to providing information relevant to the situation at nhand (Humphrey, 1994). Use of specific questions will be most helpful ieliciting specific information (see the accompanying display).
DATA nCOLLECTION
The nurse must possess strong cognitive, interpersonal, nand technical skills in order to elicit appropriate information and make nrelevant observations during the data collection process. This process oftebegins prior to initial contact between the nurse and the client, primarily nthrough the nurse’s review of biographical data and medical records. Upomeeting the client, the nurse continues data collection through interview, nobservation, and examination. A variety of sources and methods are used icompiling a comprehensive database.
TYPES nOF DATA
Client data include information that the client ncommunicates concerning perceptions of his or her own health status, as well as nspecific observations made by the nurse.
These two types of information are referred to as nsubjective and objective data.
Subjective ndata are data from the client’s point of view and include nfeelings, perceptions, and concerns. The data (also referred to as symptoms) nare obtained through interviews with the client. They are called subjective nbecause they rely on the feelings or opinions of the person experiencing them nand cannot be readily observed by another.
Objective ndata are observable and measurable (quantitative) data nthat are obtained through observation, standard assessment techniques performed nduring the physical examination, and laboratory and diagnostic testing.
These data (also called signs) can be seen, nheard, or felt by someone other than the person experiencing them. Assessments nthat are comprehensive and accurate include both subjective and objective data.
See nTable 6-1 for examples of both types of data.
SOURCES nOF DATA
A comprehensive database should include data from nevery possible source (see the accompanying display). The client should always nbe considered the primary source of information; however, other sources should nnot be overlooked.
The nclient’s family and significant others can also provide useful information, nespecially if the client is unable to verbalize or relate information. Iaddition, other health care professionals who have cared for the client may ncontribute valuable information. Medical records should also be reviewed, nincluding the medical history and physical examination; results of laboratory nand diagnostic tests and various health care professionals should also be nconsulted.
Pertinent literature should be investigated iorder to pursue relevant information and plan appropriate nursing ninterventions. Written standards are valuable sources of data for comparison, nfor example, a standard table of infant growth to determine if an infant’s weight nand height are withiormal growth range. Another valuable source of data is nknowledge about the client’s normal parameters of functioning. The nurse’s nknowledge based on experience is another important source of data.
METHODS nOF DATA COLLECTION
The nurse collects information through the nfollowing methods: observation, interview, health history, symptom analysis, nphysical examination, and laboratory and diagnostic data. These approaches nrequire systematic use of assessment skills that are discussed below.
OBSERVATION
The nurse uses the skill of observation to ncarefully and attentively note the general appearance and behavior of the nclient. These observations occur whenever there is contact with the client and ninclude factors such as client mood, interactions with others, physical and nemotional responses, and any safety considerations.
Observatiohelps the nurse determine the client’s status, both physical and mental. By ncarefully watching the client, the nurse can detect nonverbal cues that nindicate a variety of feelings, including presence of pain, anxiety, and anger. nObservational skills are essential in detecting the early warning signs of nphysical changes (e.g., pallor and sweating).
INTERVIEW
An interview is a therapeutic interaction that nhas a specific purpose The purpose of the assessment ninterview is to collect information about the client’s health history and ncurrent status in order to make determinations about the client’s health needs. nEffective interviewing depends on the nurse’s knowledge and ability to nskillfully elicit information from the client using appropriate techniques of ncommunication. Observation of nonverbal behavior during the interview is also nessential to effectivem data collection.
INTERVIEW nPREPARATION
The interview is more productive if the nurse has nan opportunity to prepare for the interaction. Such preparation includes review nof the client’s medical records, conversations with other health care team nmembers (e.g., personnel in emergency departments or long-term care nfacilities), and research of the presenting medical diagnosis. This informatiocan be useful in obtaining the client’s relevant history and formulating a ncurrent needs assessment.
INTERVIEW nSTAGES
Since the assessment interview often occurs at nthe beginning of a nurse-client relationship, it is helpful to begin the nprocess with an orientation phase. During this period introductions are made, nrapport is established, and roles are defined. The nurse ninterviews for a variety of reasons throughout the nurse-client relationship, nincluding data collection, teaching, exploration of the client’s feelings or nconcerns, and provision of support.
The first few minutes of the nurse-client meeting nmay give an indication of the type of interviewing needed, so it is important nthat the nurse exhibit good listening skills as the relationship leads into the ninterview process.
There are three phases to an interview: nintroduction, working, and closure.
INTRODUCTION
The introduction stage of the interview establishes nthe goals for the interaction. The primary goal of the assessment interview is nthe collection of data about the client. In this phase of the interview, the npurpose and use of the data collection should be discussed. For example, the nnurse might state, “I need to ask you a few questions and talk to you for a few nminutes about your health so that we can better plan your care.”
Adequate time and privacy should be allowed for nthe interview so that the client feels free to share any information that may nbe relevant. The nurse should also inform the client about the approximate nduration of the interview.
The nclient is more likely to respond freely if the interview environment provides ncomfort and privacy and if rapport exists between the client and the nurse. The nnurse should sit (if possible), establish eye contact with the client, and nlisten attentively. It is the nurse’s responsibility to note nonverbal messages nthat can indicate that the client is uncomfortable, tired, or preoccupied with nother matters. If this situation occurs, it might be necessary to complete the ninterview at a later time.
For example, if the client is guarding aincision and verbalizing discomfort or is extremely anxious about an impending nprocedure, only essential data are collected and the comprehensive interview is npostponed until immediate needs have been met.
WORKING
The working stage of the interview focuses on the ndetails of data collection. The scope of the assessment interview depends othe type of assessment to be conducted (e.g., comprehensive or focused). The ninterview may be structured and formal (used in situations when a large amount nof informatioeeds to be obtained) or unstructured and informal (used iinteractions that focus on a specific area of concern to the client). The nurse nshould be familiar with the specific assessment format used by the health care nagency so that attentionn can be focused toward the nclient rather than the form itself. The interview generally begins with nquestions about biographical and other nonthreatening ninformation.
The client’s reason for seeking health care is nalso addressed early in the working phase. The depth of the majority of nquestions that the nurse will ask the client depends on the data collectiomodel used by the health care agency. Information is usually gathered from the ngeneral to the specific, with details about intimate or potentially nembarrassing topics reserved until later in the interview.
The Nursing Checklist provides guidelines for ninterview preparation.
Techniques used during the interview will be ndetermined by the setting and purpose of the interview. A comprehensive ninterview that seeks to identify problems and concerns is facilitated by nopen-ended questions, while an interview that focuses on specific details about na presenting problem will be facilitated by direct, closed questions. For nexample, an emergency setting would likely employ more direct, closed nquestions, while admission to a long-term care facility might require greater nuse of open-ended questions.
Closed nquestions are questions that can be answered briefly or with none-word responses. For example, the question “Have you been in the hospital nbefore?” is a closed question that can easily be answered by a one-word nresponse. Questions about the dates of and reasons for the hospitalizations are nalso closed questions that require brief answers.
Open-ended nquestions are questions that encourage the client to elaborate nabout a particular concern or problem. For example, the question “What led to nyour coming here today?” is open-ended and allows the client flexibility iresponse. Both closed and open-ended questions can be effective in collecting ninformation.
CLOSURE
Closure is established in the introduction phase wheapproximate time parameters are set. As the interview session is concluding, nthe nurse should indicate this fact by stating that almost all the informationeeded has been obtained or that the time for the interview is almost over. nThis action allows the client an opportunity to present any other relevant ninformation and it avoids surprises when the interview terminates.
During the closure phase, the nurse summarizes nwhat was covered or accomplished during the interview and requests validatioof perceptions with the client. If the nurse or the client feels that nadditional time is needed for further exploration of specific points discussed nduring this session, plans can be made for future interviews.
HEALTH nHISTORY
A primary focus of the data collection interview nis the health history. The nhealth history is a review of the client’s functional health npatterns prior to the current contact with a health care agency. While the nmedical history concentrates on symptoms and the progression of disease, the nnursing health history focuses on the client’s functional health patterns, nresponses to changes in health status, and alterations in lifestyle. The health nhistory is also used in developing the plan of care and formulating nursing ninterventions.
DEMOGRAPHIC nINFORMATION
Personal ndata including name, address, date of birth, gender, religion, race/ethnic norigin, occupation, and type of health plan/insurance should be included. This ninformation may be useful in helping to foster understanding of a client’s nperspective.
REASON nFOR SEEKING HEALTH CARE
The nclient’s reason for seeking health care should be described in the client’s owwords. For example, the statement “fell off four-foot ladder and landed oright shoulder; unable to move right arm” is the client’s actual report of the nevent that precipitated his or her need for health care. The client’s nperspective is important because it explains what is significant about the nevent from the client’s point of view. It is also important to determine the ntime of the onset of symptoms as well as a complete symptom analysis.
PERCEPTION nOF HEALTH STATUS
Perceptioof health status refers to the client’s opinion of his or her general health. nIt may be useful to ask clients to rate their health on a scale of 1 to 10 n(with 10 being ideal and 1 being poor), together with the clients’ rationale nfor their rating score. For example, the nurse may record a statement such as nthe following to represent the client’s perception of health: “Rates health a 7 non a scale of 1 (poor) to 10 (ideal) because he must take medication regularly nin order to maintain mobility, but the medication sometimes upsets his nstomach.”
PREVIOUS nILLNESSES, HOSPITALIZATIONS, AND SURGERIES
The nhistory and timing of any previous experiences with illness, surgery, or nhospitalization are helpful in order to assess recurrent conditions and to nanticipate responses to illness, since prior experiences often have an impact non current responses.
CLIENT/FAMILY nMEDICAL HISTORY
The nnurse needs to determine any family history of acute and chronic illnesses that ntend to be familial. Health history forms will nfrequently include checklists of various illnesses that the nurse can use as nthe basis of the questions about this aspect. The client should be instructed nthat family history refers to blood relatives. It is also helpful to indicate nwho the relative is in relation to the client (e.g., mother, father, sister).
IMMUNIZATIONS/EXPOSURE nTO COMMUNICABLE DISEASE
Any history of childhood or other communicable ndiseases should also be noted. In addition, a record of current immunizations nshould be obtained. This is particularly important with children; however, nrecords of immunizations for tetanus, influenza, and hepatitis B can also be nimportant for adults. If the client has traveled out of the country, the time nframe should be indicated in order to determine incubation periods for relevant ndiseases. The client should also be asked about potential exposure to ncommunicable diseases, such as tuberculosis, or to human immunodeficiency virus n(HIV).
ALLERGIES
Any drug, food, or environmental allergies should nbe noted in the health history. In addition to the name of the allergen, the ntype of reaction to the substance should also be noted.
For example, a client may report that he or she developed na rash or became short of breath. This reaction should be recorded. Clients may nreport an “allergy” to a medication because they developed an upset stomach nafter ingesting it, which the nurse will recognize as a side effect that would nnot necessarily preclude administration of the drug in the future.
CURRENT nMEDICATIONS
All medications currently ntaken, both prescription and over-the-counter, are to be recorded by name, nfrequency and dosage. Remind clients that this informatioshould include medications such as birth control pills, laxatives, and nnonprescription pain relief medications. Ask which, if any, herbal preparations nthe client uses. Patterns related to caffeine and alcohol intake and use of ntobacco or recreational drugs should also be explored.
Use of alternative/complementary treatment nmethods, including herbals, is ofteot shared by health care consumers. Some nclients fear rejection or ridicule when divulging such information with health care nproviders. The nurse uses a sensitive, nonjudgmental approach when assessing nfor the client’s use of all healing practices.
DEVELOPMENTAL nLEVEL
Knowledge of developmental level is essential for nconsidering appropriate norms of behavior and for appraising the achievement of nrelevant developmental tasks.
Any recognized theory of growth and development ncan be applied in order to determine if clients are functioning within the nparameters expected for their age group.
For example, if the nurse uses Erikson’s stages of psychosocial development, validation of nan adult client attaining the developmental task of generativity nversus stagnation can be validated by the nurse’s statement, such as “client nprefers to spend time with his family; very involved in children’s school nactivities.”
PSYCHOSOCIAL nHISTORY
Psychosocial history refers to assessment of ndimensions such as self-concept and self-esteem as well as usual sources of nstress and the client’s ability to cope.
Sources of support for clients in crisis, such as nfamily, significant others, religion, or support groups, should be explored.
SOCIOCULTURAL nHISTORY
In exploring the client’s sociocultural nhistory, it is important to inquire about the home environment, family nsituation, and client’s role in the family. For example, the client could be nthe parent of three children and the sole provider in a single-parent family.
The responsibilities of the client are important ndata through which the nurse can determine the impact of changes in health nstatus and thus plan the most beneficial care for the client.
ACTIVITIES nOF DAILY LIVING
The activities of daily living nis a description of the client’s lifestyle and capacity for self-care nand is useful both as baseline information and as a source of insight into nusual health behaviors. This database should include the following areas:
Nutrition: nIncludes type of diet and foods eaten and fluids consumed regularly, food npreparation, the size of portions, and the number of meals per day. Food
preferences and ndislikes, as well as the client’s need for assistance in food preparation or neating should also be determined.
Elimination: nIncludes both urinary and bowel elimination frequency and patterns. Any recent nchanges or problems in these patterns should be noted.
Rest/sleep: nIncludes the usual number of hours of sleep, number of hours of sleep needed to nfeel rested, sleep aids used, and the time within the day or night when sleep nusually occurs. Any bedtime rituals (especially with children) should also be nnoted.
Activity/exercise: nIncludes types of exercise and patterns in a typical day or week. If assistance nis needed with activities such as walking, standing, or meeting hygienic needs, nthis information should be noted.
REVIEW OF SYSTEMS
The review of systems (ROS) is a brief account nfrom the client of any recent signs or symptoms associated with any of the body nsystems. This allows the client an opportunity to communicate any deviations nfrom normal that have not been otherwise identified. The review of systems nrelies on subjective information provided by the client rather than on the nnurse’s own physical examination.
When a symptom is encountered, either while neliciting the health history or during the physical examination of the client, nthe nurse should obtain as much information as possible about the symptom. nRelevant data include:
• nLocation: The area of the body in which the symptom (such nas pain) can either be pointed to or described in detail.
• Character: nThe quality of the feeling or sensation (e.g., sharp, dull, stabbing).
• Intensity: nThe severity or quantity of the feeling or sensation and its interference with nfunctional abilities. The sensation can be rated on a scale of 1 (very little) nto 10 (very intense).
• Timing: nThe onset, duration, frequency, and precipitating factors of the symptom.
• Aggravating/alleviating nfactors: The activities or actions that make the symptom worse or nbetter.
PHYSICAL nEXAMINATION
The purpose of the physical examination is to make ndirect observations of any deviations from normal and to validate subjective ndata gathered through the interview.
Baseline measurements are obtained, and physical nexamination techniques are used to gather objective data.
BASELINE nDATA
Baseline ndata collection is the systematic organization of observations obtained during nthe physical examination that forms the basis for comparison and evaluation to nestablish the status of a client at a given point in time.
Measurement of height, weight, and vital signs n(temperature, pulse, respirations, and blood pressure) is important for ncomparison with future measurements in order
to judge the significance of any nchanges (progress or regression) over time.
ASSESSMENT nTECHNIQUES
The physical examination incorporates the use of nvisual, auditory, tactile, and olfactory senses and the use of systematic nassessment techniques. The use of visual, auditory, and tactile senses will be ndescribed with each of the specific assessment techniques. In addition, nolfaction (sense of smell) is helpful in detecting characteristic odors as well nas those associated with altered health states.
For nexample, presence of infection is sometimes first detected by the change in the ncharacteristic odor of body fluids or drainage. The four assessment techniques nused in physical examination are inspection, palpation, percussion, and nauscultation.
INSPECTION
Inspection involves careful visual observation. nThe client is observed first from a general point of view and then with nspecific attention to detail. For example, the nurse first observes for npatterns of skin lesions and then focuses on the specific characteristics of nindividual lesions. Instruments such as a penlight and otoscope nare often used to enhance visualization.
Effective inspection requires adequate lighting nand exposure of the body parts being observed. Beginning nurses often feel nself-conscious or embarrassed using the technique of inspection; however, most nbecome comfortable with the technique over time. Nurses must also be sensitive nto the client’s feelings of embarrassment with the use of inspection and nrespond to this situation by discussing the technique with the client and using nmeasures such as draping in order to increase the client’s comfort level.
PALPATION
Palpation uses the sense of touch to assess ntexture, temperature, moisture, organ location and size, vibrations and npulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle napproach and is used systematically, with light palpation preceding deep palpatioand palpation of tender areas performed last.
The technique of palpation uses the hands and nfingers in different ways for assessment of:
• nTemperature: Best detected using the dorsal (back) surface of the hand
• nTexture, pulses, and swelling: Best detected using fingertips
• nVibration: Best detected with the base of the fingers
• nShape and consistency of organs or masses: Best detected by grasping organ or nmass between fingertips
PERCUSSION
Percussion uses short, tapping strokes on the nsurface of the skin to create vibrations of underlying organs. It is used for nassessing the density of structures or determining the location and the size of norgans in the body. Structures with relatively more air (such as the lungs) nproduce louder, deeper, and longer sounds with ercussion nthan more dense, solid structures (such as the liver), which produce softer, nhigher, and shorter sounds.
AUSCULTATION
Auscultation involves listening to sounds in the body nthat are created by movement of air or fluid. Areas most often auscultated include the lungs, heart, abdomen, and blood nvessels. Although direct auscultation is sometimes possible, a stethoscope is nusually employed in order to channel the sound.
LABORATORY nAND DIAGNOSTIC DATA
Results of laboratory and diagnostic tests can be nuseful objective data as these values often serve as defining characteristics nfor various altered health states; these can also be helpful in ruling out ncertain suspected problems.
For example, diabetic clients who are poorly ncontrolled on diet and/or medication will usually have an elevated blood nglucose level. The pattern of these types of variations is useful idetermining a plan of care. In addition, the effectiveness of nursing and nmedical interventions and progress toward health restoration are oftemonitored through laboratory and diagnostic test data.
DATA nVERIFICATION
Data verification is the process through which ndata are validated as being complete and accurate. Once the nurse completes the ninitial data collection, the data are reviewed for inconsistencies or nomissions. This process is particularly important if data sources are nconsidered unreliable. For example, if a client is confused or unable to ncommunicate, or if two sources provide conflicting data, it is necessary for nthe nurse to seek further information or clarification. Data verification is ndone by examining the congruence between subjective and objective data.
For example, a client might exhibit nonverbal nexpressions of pain (e.g., guarding a part of the body, facial grimacing) but nverbally deny feeling pain. The nurse would need to consider possible reasons nfor this discrepancy in findings and collect more information before nformulating conclusions or planning care.
Findings nshould also be compared with norms. Any grossly abnormal findings should be nrechecked and confirmed.
DATA nORGANIZATION
After data collection is completed and ninformation is validated, the nurse organizes, or clusters, the informatiotogether in order to identify areas of strengths and weaknesses. This process nis known as data clustering. How data are organized depends on the assessment nmodel used.
ASSESSMENT nMODELS
An assessment model is a framework that provides na systematic method for organizing data. The use of a model helps to ensure ncomprehensive and organized data collection. A guiding framework also provides ndirection for decision making about nursing diagnoses. A number of nursing and nonnursing models are used to assist with organization of ndata. This section describes only a few of the many assessment models available nto nurses.
NURSING nMODELS
Nursing models have been developed to focus on a nwide range of human responses to alterations in health status. These models ntypically include psychosocial, sociocultural, and nbehavioral data as well as biophysical data.
Nursing nmodels may offer the advantage of organizing information in a mode that more neasily allows transition from data collection to nursing diagnoses.
NONNURSING nMODELS
Nursing, of course, neither exists nor functions nin a vacuum. Nursing uses related health concepts from other disciplines, some nof which are discussed next.
BODY nSYSTEMS MODEL
Approaching data collection by examining body nsystems is sometimes referred to as the “medical model,” since it is frequently nused by physicians to investigate presence or absence of disease. This method norganizes data collection according to the organ and tissue function in various nbody systems (e.g., cardiovascular, respiratory, gastrointestinal). Although nnurses often use this method as well, the body systems model does not nfacilitate the formulation of nursing diagnoses. In addition, psychosocial naspects of the client’s status are ofteeglected with resultant fragmentatioof care.
HIERARCHY nOF NEEDS
Abraham Maslow’s nhierarchy of needs proposes that an individual’s basic needs (physiological) nmust be met before progressing to higher-level needs. Maslow’s nframework can be used to prioritize needs. Use of a hierarchy of needs model nrequires initial assessment of all physiological needs, followed by assessment nof higher-level needs.
Using Maslow’s theory, na person’s needs should be addressed in the following order:
First: Physiologic nneeds—the basic survival needs, such as food, water, and oxygen.
Second: Safety and nsecurity needs—both physical (e.g., protection from bodily harm) and npsychological (e.g., security and stability) needs.
Third: Need for nlove and belonging—humans have an innate need to be a part of a group, and to nfeel accepted by others.
Fourth: Self-esteem nneeds—individuals need to feel they are valued and worthwhile.
Fifth: nSelf-actualizatioeeds—the need to function at one’s optimal level, and to be npersonally fulfilled.
DATA INTERPRETATION
Data nclustering facilitates recognition of patterns, and determination of further ndata that are needed. Data interpretation is necessary for identification of nnursing diagnoses.
DATA DOCUMENTATION
Accurate nand complete recording of assessment data are essential for communicating ninformation to other health care team members. In addition, documentation is nthe basis for determining quality of care and should include appropriate data nto support identified problems.
TYPES OF ASSESSMENT FORMATS
Health ncare agencies may choose from a variety of assessment forms for documentatiodepending on the type of agency, the population served by the facility, and the nprimary reasons for documentation. For example, clients seeking health care ia clinic or physician’s office might be asked to complete a brief nself-questionnaire, while a client admitted to an acute-care facility for labor nand delivery might be asked to provide only information directly related to npregnancy and child care needs. Four types of documentation formats include nopen ended,
checklist, ncombination, and specialty.
See nFigure 6-2 for an example of a form used in occupational nursing.
OPEN-ENDED FORMATS
The nopen-ended format for documentation allows the nurse to write a narrative ndescription of observations (see Figure 6-3).
This nformat is more time-consuming for the nurse, but allows flexibility irecording findings.
CHECKLIST FORMATS
Formats nthat include checklists facilitate documentation by summarizing findings in aabbreviated form (see Figure 6-4)
They nalso provide more consistency in the recording of information and reduce the nlikelihood of omitting relevant information. However, checklists may discourage nnurses in obtaining elaboration about observations from clients that require further nexplanation. For example, if a checklist indicates that mobility is impaired, nfurther explanation is required in order to determine the extent of the nimpairment and thus plan the necessary interventions.
COMBINATION FORMATS
Combinatioformats often allow the convenience of a checklist together with space to ndocument a complete narrative description of any significant or abnormal
findings (see Figure n6-5).
Some nagencies provide cues on the form to alert personnel when further informa tion is needed. This nformat provides for some consistency in recording data while allowing nflexibility for documenting specific information.
SPECIALTY FORMATS
Specialty nareas such as outpatient surgery, labor and delivery, and psychiatric nfacilities may use abbreviated formats focused directly on assessment needs for nthe particular service provided. In addition, specialty assessment forms may be nincluded together with comprehensive assessment forms for clients at particular nrisk for various conditions (e.g., falls, impaired skin integrity).
Documentatioof assessment data is essential as a means of communication among health care nteam members to assure accurate problem identification, determination of nappropriate client outcomes, and continuity of care.
THE MINIMUM DATA SET (MDS)
The nMinimum Data Set (MDS) was developed by the Health Care Financing nAdministration (HCFA) to promote the development of a comprehensive care plafor every resident of Medicare/Medicaid certified nursing homes. As such, the nMDS is a standardized assessment instrument used in all long-term care nfacilities that are funded by HCFA. The MDS is a comprehensive assessment tool ndesigned to collect data on the following resident characteristics:
• nActivities of daily living (ADLs)
• nMedical needs
• nMental status
• nTherapy use (American Nurses Association, 2000)
MDS nis a comprehensive assessment tool designed to collect data on the following nresident characteristics:
• nActivities of daily living (ADLs)
• nMedical needs
• nMental status
• nTherapy use (American Nurses Association, 2000)
DIAGNOSTIC nOF HUMAN RESPOND.
|
T |
he nnursing diagnosis is the second step in the nuring nprocess and is the clinical judgment about individual, family, or community n(aggregate) responses to actual or risk health problems, wellness states, or nsyndromes. This judgment is based on a critical analysis of the assessment ndata. The purpose of a nursing diagnosis is to effectively communicate the nhealth care needs of individuals and aggregates among members of the health ncare team and within the health care delivery system. Society tends to ninterpret nursing through the use of nursing language.
When a nursing diagnosis is a part of the nclient’s plan of care, the nurse is able to communicate the client’s needs to nother professionals involved in that care. These needs encompass physiologic, nrole function, self-concept, interdependence, and spiritual dimensions. Iorder to determine individualized therapeutic nursing interventions, the nurse nmust first collect and organize assessment data before developing appropriate nnursing diagnoses.
This lecture describes the nature of a nursing ndiagnosis, its purposes, and the components of a nursing diagnostic statement. nIt also discusses the process involved in developing a nursing diagnosis and nmethods through which nurses can avoid errors in the formulation of nursing ndiagnoses. This chapter concludes with strategies for overcoming barriers to nthe use of a nursing diagnosis in the clinical setting.
WHAT IS A NURSING DIAGNOSIS?
Diagnosis nis the science and art of identifying problems or conditions. Although this nprocess has been linked primarily with physicians, it is also used by members nof other professions, such as nurses, lawyers, social workers, mechanics, npsychologists, and teachers. Though the term nursing diagnosis may convey multiple nmeanings, “in effect, nursing diagnosis defines nursing practice” (Sparks & nTaylor, 1994, p. 32H).
There nare many definitions of nursing diagnosis that have evolved over the past decades. nAt the ninth North American Nursing Diagnosis Association (NANDA) conference, nthe following definition of nursing diagnosis was approved:
Additional ndefinitions of nursing diagnosis abound in the nursing literature. It is clear nthat although all definitions are not exactly alike, there are similar nattributes
among nthem, such as a focus on client-centered problems; the promotion of nursing naccountability; an awareness of the human response to health problems; the nformation of clinical judgments about individuals, families, or communities; nand the development of nursing interventions that a nurse is licensed to enact.
COMPARISON OF NURSING AND MEDICAL nDIAGNOSES
It nis important to have a clear understanding of the nature of a nursing diagnosis nas compared to a medical diagnosis. Clarification of this point is necessary to ndistinguish between the nursing and medical professions and the potential legal nramifications.
Delineatioof “What is the nature of nursing?” versus “What is the nature of medicine?” is ncritical. In order to practice nursing, nurses need to know what it is that nthey do. Nursing diagnoses assist nurses in defining their scope of practice njust as medical diagnoses assist physicians in defining their scope of npractice. In addition, the use of diagnoses iursing and medicine enables nclarification of the legal boundaries for practice.
Medicine nuses the term medical diagnosis and nursing uses the term nursing diagnosis to identify problems nrelating to a client’s health status:
• Medical diagnosis is the terminology nused for a clinical judgment by the physician that identifies or determines a nspecific disease, condition, or pathologic state.
• Nursing diagnosis is the terminology nused for a clinical judgment by the professional nurse that identifies the nclient’s or aggregate’s actual, risk, wellness, or nsyndrome responses to a health state, problem, or condition.
See nthe accompanying display for a comparison of nursing and medical diagnoses.
It nis important to emphasize that the term nursing diagnosis has been used ithree contexts: “the process of diagnosis, the product of diagnosis or nindividual diagnoses, and the taxonomy of diagnoses” (Wooldridge, Brown, & nHerman, 1993, p. 51). The process of diagnosis is identified as the second step nof the nursing process. In this step, the nurse collects data, validates and ncritically analyzes the data, clusters the data into groups, and identifies the nclient, family, or community health problems or conditions. The product of ndiagnosis is the diagnostic label that is assigned to the identified problem.
The ntaxonomy of diagnosis is a classification system in which nnursing diagnoses are organized according to client responses to specific nconditions.
There are both similarities and differences nbetween 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, ninterpersonal, and psychomotor skills;
(3) collecting and ncritically analyzing assessment data;
(4) evaluating outcomes nto ascertain continuation, resolution, or change of identified diagnosis;
(5) performing withilegal dimensions and standards of the respective profession.
An example of these similarities can be nillustrated by considering Alan Brown, a client who has a medical diagnosis of nasthma. The physician and nurse would both collect assessment data orespiratory status. The physician would use this information to treat the ndisease of asthma and the nurse would use this information to focus on Mr. nBrown’s response to the disease, which would result in a nursing diagnosis of nIneffective Breathing Pattern.
Nursing ndiagnoses are different from medical diagnoses in (1) purpose, n(2) goals, and (3) therapeutic interventions. The purpose of a nursing ndiagnosis is to focus on the human response or responses of the individual nfamily or community to identified problems or conditions. Medical diagnoses ncenter on the disease state or pathological condition. For example, if the nmedical diagnosis for Sheila Barrington is breast cancer, appropriate nursing ndiagnoses may include Fear, Deficient Knowledge related to treatment measures, nAnticipatory Grieving, Body Image Disturbance, Powerlessness, and Ineffective Coping. In addition, the goals (aims, nintent, or ends) that accompany these nursing diagnoses differ, as do the nspecific, individualized therapeutic nursing interventions (nursing actions to npromote or restore health and enhance general well-being).
HISTORICAL PERSPECTIVE
The term nursing diagnosis has been in the literature since the nearly 1950s. Fry (1953) identified that nursing diagnosis is integral to the nplan of nursing care and is an important tool for individualizing client care. nHowever, these ideas were slow to gain momentum despite the interests of nseveral nurse theorists and the focus on client-centered problems in the 1960s nand the 1970s. In 1973, the First National Conference for the Classification of nNursing Diagnoses convened in St. Louis, Missouri. nNurses met at that time and “began the formal effort to identify, develop, and nclassify nursing diagnoses” (NANDA, 1996, p. 107). In 1982, at the fifth nnational conference, the organization was renamed the North American Nursing nDiagnosis Association (NANDA) (Kim, McFarland, & McLane, n1984). Since its inception, NANDA continues to hold conference meetings every 2 nyears.
Additional endorsement for nursing diagnosis came from the AmericaNurses Association (ANA) in 1973in the publication entitled Standards of Nursing nPractice (ANA, 1973). Ongoing discussions occurred in the nursing nliterature, with increasing support evident by the 1980s for nursing diagnosis nand the diagnostic process. The ANA continued to support nursing ndiagnosis as the second step of the nursing process through publication of Nursing: nA Social Policy Statement (ANA, 1995) and Standards nof Clinical Nursing Practice (ANA, 1998). See the accompanying display for nthe standard of care related to nursing diagnosis.
At nthe 13th conference in 1998, NANDA developed 21 new nursing diagnoses and nrevised 37 nursing diagnoses by clarifying existing diagnoses and their ndefinitions, defining their characteristics, and related factors.
Following the biennial conference in April 1994, nthe Taxonomy Committee identified the need to revise the structure of Taxonomy nI. During the 14th biennial conference in April 2000, NANDA adopted the ntaxonomy, Taxonomy II. “Taxonomy II was designed to be multiaxial in its form, thereby substantially improving the nflexibility of the nomenclature and allowing for easy additions and nmodifications” (NANDA, 2001, p. 212). With the publication of these nstandards, the nurse has both a professional and legal obligation to practice nas defined by the professional organization for nurses.
RESEARCH
With the inception of the first nconference oursing diagnoses, NANDA supported research endeavors on the ndevelopment of a nursing diagnosis classification system. The first type of nresearch conducted was identification studies, where the clinician repeatedly nobserved a condition in order to label a nursing diagnoses. nAt the sixth conference in 1986, Fehring identified nthe need for two standardized research methodologies for data collection: (1) ndiagnostic content validity (DCV), retrospective evidence from experts on the ncharacteristics of a given label; and (2) clinical diagnostic validity (CDV), nprospective evidence on the characteristics from a clinical perspective n(Whitley, 1999). In 1989, NANDA sponsored an invitational conference oresearch methodologies for generating and validating existing diagnoses and to ndevelop new methodologies to direct future studies.
Although there is an abundance of DCV nstudies, only a few clinical studies have been conducted because the CDV model nis more complicated to execute. Nursing Diagnosis: The nJournal of Nursing Language & Classification is the official npublication of NANDA. The journal was first published in 1989 to promote the ndevelopment, refinement, and utilization of nursing language and nclassification.
Roberts, Madigan, Anthony, and Pabst (1996) conducted a secondary nanalysis study to examine the congruence betweeursing diagnoses and nclinically relevant data of clients being transferred from intensive care to nmedical-surgical units. The results of this study showed that diagnoses were nnot made or were made less frequently than indicated by the supporting clinical nevidence (see the Research Focus). One of the findings indicated that a system nstill needs to be developed for determining that clients being observed have nthe diagnosis being studied and that nurses accurately identify all relevant ndiagnoses in the clinical setting.
Whitley (1999) suggests the development nof a “research agenda” to promote research in a coordinated fashion since ninterest about nursing diagnoses has spread in the international community, at na time when a commoursing language is needed to strengthen nursing’s bases for practice. In 1998, the NANDA Board ninstituted an ad hoc research committee to coordinate nursing diagnosis nresearch and funding and to develop a “research agenda.”
PURPOSES OF NURSING DIAGNOSIS
Nursing diagnosis is unique in that nit focuses on a client’s response to a nhealth problem, rather than on the problem itself, and it provides the nstructure through which nursing care can be delivered. Although these ncharacteristics have always been in existence withiursing, they were nunidentified prior to the mid-20th century. One of the requisites of a nprofession is a unique body of knowledge or frame of reference (Adams, 1983). Wooldridge, Brown, and Herman (1993) n“propose that nursing diagnoses collectively, as contained within a taxonomy, provide a central focus for conceptualization of nthe domain of nursing”. Clearer conceptualization of knowledge unique to nnursing increases both professional accountability and autonomy (Carpenito, 1995). Therefore, nursing diagnosis contributes nto the professional status of the discipline.
Nursing diagnosis also provides a means for effective communication. It nis generally agreed among nurses, health care practitioners, and other health ncare professionals that there is a need for a common language within the health ncare sector. A mutual vocabulary that can be used for describing practice, nresearch, and education benefits both the profession and the consumer. With nthis language, collaboration and international exchanges regarding nursing and nhealth care are possible and benefit from “common definitions of the phenomena nof concern within the discipline” (Fitzpatrick & Zanotti, n1995, p. 42). In addition, communication about nursing diagnoses is possible nthrough computer search.
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) nhas listed the term nursing diagnosis since 1983 (Dougherty, Jankin, Lunney, & Whitley, n1993).
Holistic client, family, and ncommunity-focused care are facilitated with the use of nursing diagnosis. The list nof NANDA-approved nursing diagnoses (NANDA, 2001) for clinical use provides nassistance for the nurse in individualizing care and developing comprehensive ntherapeutic nursing interventions. Quality care and continuity of care are nenhanced with identified nursing diagnoses as part of the client’s plan of nnursing care. The accompanying display illustrates the value of applying nnursing diagnosis to a home health care situation.
Nursing diagnoses also have the potential of providing an avenue for ntheory development and nursing research. Dougherty, Jankin, nLunney, and Whitley (1993) published a listing of ntheory and research-based articles on accepted nursing diagnoses from 1950 to n1993.
Nursing diagnosis has an important impact on the health care delivery system: n“Nursing diagnoses provide a method for synthesizing and communicating nurses’ nobservations and judgements” and “the ability to ncommunicate the health needs of clients can influence funding of preventive and ncomprehensive health care services” (Gordon, 1994, p. 12).
In summary, nursing diagnosis allows for nempowerment of the profession of nursing, facilitates effective communication, nand provides a means to individualize nursing care. Nursing diagnosis is nessential to clinical practice and education and pivotal for theory development nand research.
Nursing Diagnoses and nDiagnostic-Related Groups
Diagnostic-related groups (DRGs) were ndeveloped and implemented in the health care industry in 1983 as a response to nescalating health care costs in America.
Diagnostic-related groups were developed on the basis of the medical nmodel of identifying signs and symptoms that then result in the formulation of nmedical diagnoses.
Therefore, this reimbursement system nis centered on medical diagnoses, not nursing diagnoses. As a result, this nfederally regulated system lacks a mechanism for direct financial reimbursement nbased oursing diagnoses.
Over the years, in light of the fact nthat 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 nat attempting to isolate nursing care delivered to the client (McKibbin, Brimmer, Clinton, & nGalliher, 1985; Wolf, Lesic, n& Leak, 1986). Through the use of elaborate formulas, nursing care costs nhave been derived for many of the DRGs. However, few nstudies have evaluated the relationship betweeursing diagnoses and DRGs.
One of the best attempts to identify nnursing costs has been described by Adams n(1983). At one hospital, a computerized client classification system that nintegrates client acuity with client care plans and nursing diagnoses has beedeveloped (Adams, 1983). Through the use of nthis system, direct cost accounting of nursing care is possible, nnurses must explore every avenue to be appropriately compensated for their nshare of the health care dollar.
According to Fitzpatrick (1995), if the nursing profession does not have nand use a common language, nurses will be unable to assign a monetary status to ntheir services for reimbursement. At present, consensus still needs to be nestablished by the profession for use of nursing diagnosis language. With nagreement on what nurses define as client problems or conditions, the nprofession will be able to establish a system that reimburses nurses for what nthey contribute to the health care industry.
COMPONENTS nOF A NURSING DIAGNOSIS
There are several formats that have been used to structure nursing ndiagnosis statements. Two formats that are frequently seen in the nursing nliterature are the two- and three-part statements. The two-part statement is nNANDA approved and is used by most nurses, in large part because of its brief nand precise format. The three-part statement is preferred by those nurses ndesiring to strengthen the diagnostic statement by including specific nmanifestations, an attribute that is not possible through the use of the ntwo-part format.
The nTwo-Part Statement
The components of a nursing diagnosis typically consist of two parts. nHence, the nursing diagnosis is often described as a “two-part statement.” The nfirst component is a problem statement or diagnostic label that describes the nclient’s response to an actual, possible, and risk health problem or a wellness ncondition.
Table 7-1 presents the list of NANDA-approved nursing diagnoses.
The second component of a two-part nnursing diagnosis is the etiology. The etiology is the related cause or contributor nto the problem. The diagnostic label and etiology are linked by the term related nto (RT). Examples of nursing diagnoses are Disturbed Body Image RT nloss of left lower extremity and Activity Intolerance RT decreased noxygen-carrying capacity of cells. Descriptive words or terms may be added to nclarify specific nursing diagnoses. These descriptive words are called nqualifiers and include Acute, Chronic, Decreased, Deficient, Depleted, nDisturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, nIneffective, Intermittent, Potential for, and Risk. These terms specify a ndegree of qualification for the identified nursing diagnosis and are placed n(used) before the problem statement.
THE nTHREE-PART STATEMENT
The nursing diagnosis can also be nexpressed as a threepart statement. As in the ntwo-part statement, the first two components are the diagnostic label and the netiology.
The third component consists of defining ncharacteristics (collected data that are also known as signs and symptoms, nsubjective and objective data, or clinical manifestations).
In the three-part nursing diagnosis nformat, the third part is joined to the first two components with the nconnecting phrase “as evidenced by” (AEB). Defining characteristics list the nrelevant clinical manifestations, such as signs or symptoms for the identified nclient problem and the related etiology. Defining characteristics are nidentified for each NANDA-approved diagnosis. These characteristics continue to nevolve as they are reviewed and updated at the biennial conference. It is nimportant to emphasize that defining characteristics may assist the nurse iidentifying client goals, measurable client outcome criteria, and relevant nnursing interventions.
Some nurses believe that the nthree-part statement strengthens the diagnostic process. However, other nurses nprefer the two-part statement and refer to the defining characteristics as part nof the original database.
Table 7-2 depicts the components and nrelationship of the one-, two-, and three-part statements. Although the most ncommonly used format is the two-part statement, it is beneficial for the nurse nto be knowledgeable about the use of the threepart nstatement for development of a nursing diagnosis.
Table 7-3 for a ncomparison of selected approved NANDA diagnoses in the two- and three-part nstatements.
CATEGORIES OF NURSING DIAGNOSES
Nursing diagnoses may be classified ninto three categories: actual, risk, and wellness. The most commoursing ndiagnoses used are actual and risk diagnoses.
Wellness diagnoses were adopted by NANDA 1996, and Carpenito n(1995) described possible nursing diagnoses.
• Actual ndiagnoses are nthose problems identified by the nurse that are already in existence. Actual ndiagnoses may include Excess Fluid Volume related to (RT) intravenous ninfusion therapy overload and Anxiety RT unknown results of breast nbiopsy.
• Risk ndiagnoses are nidentified by the nurse in situations in which problems might occur but are not ncurrently in existence. Examples of risk diagnoses may include Risk nfor Poisoning RT increased mobility of infant and failure to have house nchildproofed and Risk for Deficient Fluid Volume RT excessive number of nstools.
• Wellness ndiagnoses identify nthe individual or aggregate condition or state that may be enhanced by healthpromoting activities. These consist of a one-part nstatement (no “related to” phrase) that uses the label “Potential for Enhanced” nfollowed by the state the nurse desires to enhance. Examples of wellness ndiagnoses may include Readiness for Enhanced Community Coping and Readiness nfor Enhanced Spiritual Well-Being.
TAXONOMY OF NURSING DIAGNOSIS
The taxonomy of nursing diagnoses is the ntype of classification under which the diagnostic label nis grouped based on which human response the client is demonstrating to the nactual or perceived stressor. Rather than consult the alphabetical listing of nNANDA diagnoses, some nurses might find it more helpful to review the NANDA nlisting by pattern of human response. This listing is called the NANDA Taxonomy nII and organizes the NANDA-approved nursing diagnoses under the corresponding nhuman response category.
The NANDA nursing diagnosis taxonomy nis composed of nine patterns of human response:
• Exchanging
• Valuing
• Perceiving
• Communicating
• Choosing
• Knowing
• Relating
• Moving
• Feeling
Although the word taxonomy nmay be somewhat overwhelming for the beginning practitioner, remember it is nonly an organizational framework and one should not be intimidated by nit. Rather, view this approach as another way to find appropriate nursing ndiagnoses for clients on the basis of the classification of human response.
DEVELOPING A NURSING DIAGNOSIS
The development of a nursing ndiagnosis is a systematic process in which certain activities need to be nexecuted.
The accompanying display illustrates the steps in the development of nnursing diagnoses.
ASSESSING nDATABASE
In the assessment phase, the nurse collects data cues from the client. Cues nare small amounts of data that are applied to the decision-making process. nNurses should be attentive to the cues gathered from the interview, health nhistory, symptom analysis, physical examination, and laboratory and diagnostic ndata since they increase the index of suspicion and stimulate further nobservation of additional sets of cues. Examples of cues might be poor skin turgor, parched lips, dry skin, decreased urine output, and ncomplaint of thirst. The expert nurse immediately processes these cues and ndetermines a nursing diagnosis, plans client outcomes, and implements ntherapeutic nursing interventions. The novice nurse must proceed more ncautiously and use additional time to process these data cues.
VALIDATING nCUES
After reviewing the data cues, the nurse validates that information and nexamines it carefully. Verification can be done by interviewing Mr. Zachary nagain and reassessing data cues, for example, weighing him and measuring nabdominal girth.
INTERPRETING nCUES
Through interpretation of data cues and use of critical-thinking nstrategies, the nurse assigns a meaning to the data cues. In order to interpret nMr. Zachary’s subjective and objective data cues, the nurse should ask the nfollowing questions:
• What is this information telling me?
• Is there a pattern?
• Can this information be put together?
• Is the information falling into a logical narrangement?
• Is the information forming natural ngroupings?
Critical nThinking in Nursing Diagnosis
Contemporary nursing practice, with its focus oursing diagnoses, ninterventions, and outcomes, requires critical thinking (Pesut n& Herman, 1999). Interpreting data cues is one example of critical thinking nthat the nurse must do on a daily basis when working with clients. nSpecifically, the synthesis of information that takes place when interpreting ndata cues demonstrates how essential it is for the nurse to think critically. nInterpreting Mr. Zachary’s cues is pivotal for correctly diagnosing his actual, nor at-risk problem, or wellness state. The accompanying display provides nquestions that are helpful in developing appropriate diagnoses.
CLUSTERING CUES
Once the cues have been collected, nvalidated, and interpreted, the data are then grouped into clusters. A cluster nis a set of data cues in which relationships between and among cues are nestablished to identify a specific health state or condition. Related pieces of ninformation about the client are grouped together. Conclusions are drawn from nthe data cues. One piece of information by itself can be misleading.
This idea is analogous to the nassembly of a jigsaw puzzle.
One puzzle piece by itself does not give an accurate idea of the npicture. In the same way, one data cue (or piece of assessment data) does not nhave much relevance by itself. When more pieces of the puzzle are put together nor when more data assessment cues are put together, the nurse may have a nbeginning 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 ninclude: Subjective: “I always seem to be hungry and I eat five or six times a nday” and “I’ve gained 12pounds in the past year.” Objective: weight 204 pounds, protruding nabdomen, double chin, fleshy loose upper arms, and dimpling of buttocks.
Consulting NANDA List of Nursing nDiagnoses
After the data have been organized into clusters, the nurse needs to nconsult the NANDA list to ascertain similarities and differences between the nclusters and NANDA diagnoses. The clustered data are then matched with a nparticular NANDA diagnosis. In Mr. Zachary’s case, the NANDA-approved diagnosis nis Imbalanced Nutrition: More Than Body Requirements.
WRITING THE NURSING DIAGNOSIS nSTATEMENT
The nursing diagnosis selected from the nNANDA list becomes the diagnostic label, the first part of the diagnosis nstatement. Etiologies are also identified from the NANDA list. The appropriate netiology is selected and joined to the first part of the statement with the n“related to” phrase. Because the NANDA list of nursing diagnoses is constantly nevolving, there may be times wheo etiology is provided. In such cases, the nnurse should attempt to describe likely contributing factors to the client’s ncondition.
In a two-part statement, the nursing diagnosis for Mr. Zachary would be Imbalanced nNutrition: More Than Body Requirements RT excessive food intake. The threepart statement would be Imbalanced Nutrition: More nThan Body Requirements AEB weight gain, increased appetite, nexcess adipose tissue, and increased abdominal girth.
AVOIDING nERRORS IN DEVELOPING A NURSING DIAGNOSIS
Following is a discussion of commoerrors that may occur in the process of developing nursing diagnoses.
PROBLEM WITH ASSESSMENT DATA
There is an underlying assumptiothat nurses have adequate assessment skills and are knowledgeable about what ndata need to be collected. However, this is not always the case. The novice nnurse may have only rudimentary assessment skills and limited clinical nexperience. Experienced nurses are challenged to keep current and sometimes are nill-equipped to collect appropriate assessment data.
Because of the potential for these ndeficits, there may be errors made when writing a nursing diagnosis related to nan incomplete database or inappropriately collected assessment data. Wheassessment data are missing, regardless of the cause, the end result is either nan omission of nursing diagnoses, inaccurate diagnoses, or incorrect qualifying nstatements about the diagnoses.
INCOMPLETE COLLECTION OF ASSESSMENT nDATA
Incomplete collection can occur whethe nurse has neither had nor taken the time to appropriately address all nsubjective and objective data. For example, during admission of a new client to na health care facility, a nurse is interrupted during the data collection and nfails 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 nto provide the necessary data. An example would be a newly admitted client with na cerebrovascular accident who has impaired speech nand can only provide limited assessment data.
FAILURE TO VALIDATE DATA
Failure to validate occurs when the nurse does not confirm previously ncollected data. An example would be failure by the nurse to recheck aadmission blood pressure that was elevated. A follow-up blood pressure may have nrevealed 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 nincorrect. An example would be a client who comes to the ambulatory care clinic nand presents with several signs and symptoms, including a reported 4-pound nweight gain that month. Further investigation indicates this finding is not nrelated to increased adipose tissue but, rather, is nassociated with fluid retention that accompanies an edematous state.
INAPPROPRIATE DATA CLUSTERING nASSOCIATED WITH LACK OF CLINICAL KNOWLEDGE
Inappropriate data clustering may occur nwhen the nurse lacks sufficient theoretical and clinical expertise and nknowledge to appropriately cluster data cues. An example would be the client nwho visits an industrial clinic with complaints of flulike nsymptoms, stomach cramps, and vomiting. The nurse attributes the vomiting to nthe influenza, but further analysis indicates that, in addition to this ncondition, this client is actually manifesting symptoms of a toxic reaction to nprescribed drug therapy that is causing the vomiting.
INCORRECT WRITING OF THE NURSING nDIAGNOSIS STATEMENT
Incorrect writing of the statement ncan occur when the nurse does not follow the nguidelines for formulating a two- or three-part statement. An example would be nin the two-part statement Imbalanced Nutrition: Less Than Body Requirements RT nrenal disease. Renal disease is a medical diagnosis, and, according to the nguidelines, the etiology must be a human response that the nnurse is licensed and competent to treat. This diagnosis would be better stated nas Imbalanced Nutrition: Less Than Body Requirements RT inadequate nintake of an appropriate renal diet.
In conclusion, when the nurse makes premature nconclusions without allowing sufficient time for analysis and interpretation of ndata, the subsequent care plan may be inappropriate for the client (Dobrzyn, 1995).
The nNursing Checklist provides selected questions that nurses ncan ask themselves in order to avoid making mistakes when developing nursing ndiagnoses.
Values play an important role in interpretatioof data, clustering of data, and ultimately the development of the diagnosis. nNurses must be cognizant of personal biases, being careful not to impose their nvalue systems on clients. Personal prejudices should be avoided in the ndiagnostic statement.
Nurses must also remember to focus on the client when developing a nnursing diagnosis. The problem statement is client centered, not nurse ncentered. Kim (1985) stated that the diagnosis plays a pivotal role in the nnursing process by directing nursing actions and providing the focus for nevaluating outcomes.
LIMITATIONS OF NURSING DIAGNOSIS
There are a number of limitations and nprofessional concerns associated with nursing diagnosis. The primary concern is ndirected toward the lack of consensus among nurses regarding the NANDA-approved nnursing diagnosis list. Criticisms about the list include disagreement over nspecific labels in the classification system and the perception that the list nis confining, incomplete, medically oriented, and confusing. Many nurses are nnot familiar with the NANDA list and do not know how to use it or feel “it ndoesn’t have the diagnosis” they need. It should be noted that this list is not nmeant to be inclusive.
Development and refinement of ndiagnoses continue to be a focus of NANDA conferences. In addition, nurses may ndisagree with or refuse to use diagnoses such as noncompliance or knowledge ndeficit (Carpenito, 1995). In this instance, the nnurse then has the choice and the right to not use these specific diagnoses.
Novice nurses need to know nursing diagnosis and nursing process iorder to understand how the discipline of nursing intersects with the other nhealth care providers. NANDA (1999) recognizes that health care is moving into nan interdisciplinary, client-focused care environment that requires nstandardization of languages across disciplines. Many acute care facilities use nan interdisciplinary care plan such as care maps and/or critical pathways to nmonitor client outcomes. All health care providers use the same care plan to ndocument the client’s response to specific interventions. Common “client nproblems” listed on a critical pathway are written as nursing diagnoses such as nrisk for infection or risk for injury.
There are also legal considerations nconcerning the use of nursing diagnoses. Nurses are accountable for their nactions and must document their interventions. If a nursing diagnosis is ninappropriate or a nursing diagnosis list is incomplete and, as a result, the ninterventions are inappropriate or lacking, the nurse is liable for these nerrors in clinical judgment. These errors can be avoided by collecting ncomprehensive assessment data and by critically analyzing these data.
OVERCOMING BARRIERS TO NURSING nDIAGNOSIS
According to Iyer, nTaptich, and Bernocchi-Losey n(1994), objections to using nursing diagnoses include: (1) nurses are more noverworked than ever and have less time to spend with clients; (2) care is nstill organized around the medical diagnosis and nurses are involved in the ncompletion of tasks based on this focus; (3) nurses are afraid they may be nridiculed for using nursing diagnoses; and (4) the nursing diagnosis list does nnot always fit the client situation. Carlson-Catalano (1993) asserted that nhealth care agency administrators and health care practitioners dominate nursing’s focus and activities. This domination may ncontribute to the devaluation of the nursing diagnosis language and promote the nuse of the medical diagnosis.
NANDA’s language is still relatively new (approximately 25 years) compared to nmodern medical language that has existed for several hundred years. Some nurses nwould rather wait until the NANDA listing is complete before they use it. nHowever, it is unrealistic to think that a system such as NANDA should not be nused until it is completed. The ever-changing health care scene dictates that nnurses participate in evolving methods to communicate within the health care nindustry.
Another nbarrier to the use of nursing diagnoses is the numerous approaches for napplication that are found in the nursing literature. Due to these various nmethods, it may be difficult for nurses to choose “one” method that they feel ncomfortable with. Nurses may also be unable and unwilling to use nursing ndiagnoses because of incomplete knowledge about the process and disagreements nabout wording. As a result, they elect not to participate at all.
After identifying the existence of barriers to nthe use of nursing diagnoses, it is possible to design strategies to overcome nthem. According to Carlson-Catalano (1993), the only way society will nunderstand professional nursing is through the language used by nurses. Nursing ndiagnoses serve as a language that can be shared among the entire community of nnurses (Carlson-Catalano, 1993). Familiarity with this language empowers the nnurse to communicate more effectively with other nurses and health care team nmembers. Effective communication, in turn, improves the accuracy iursing ndiagnoses.
Ultimately, the quality of care should improve nand the costs associated with that care should decrease.
Due to the fact that many acute-care facilities nare asking nurses to do more with fewer resources, nurses are challenged to nlearn more efficient ways of performing their duties. Nurses’ time is spent nmore efficiently if less time is spent deciphering meanings of words.
Health care agency administrators and medical nstaffs need to be more supportive of the use of nursing diagnoses in their nrespective settings. In a survey by Thomas and Newsome (1992), findings nsuggested that institutional support makes a difference in the nurses’ use of nnursing diagnoses. As the nursing profession becomes more confident in the use nof the language, nurses will speak more sincerely and enthusiastically about nnursing diagnoses. Increased professional confidence will then empower nurses nto become more supportive of each other and less subject to ridicule.
When a nurse encounters client situations that do nnot readily fit the nursing diagnosis language, every attempt should be made to ndescribe the phenomena.
The nnurse may be on the threshold of documenting the need for a new, nas-yet-undiscovered nursing diagnosis.
As nurses collaborate on the refinement of nnursing diagnoses, it may be possible to agree on certain aspects of the nlanguage. The achievement of this goal will end the use of multiple approaches nand will make choices less complicated. Enhanced communication among nurses ieveryday settings and among professionals who convene nationally and ninternationally to exchange ideas about nursing diagnoses is essential.
Most nursing educational programs now offer nstandardized content related to nursing diagnoses. In addition, experienced nnurses need opportunities to review principles of nursing diagnoses, especially nsince so many are working in settings that tend to favor medical diagnoses and nfocus on achievement of tasks by the nurse (Brackstone, n1993). See the Nursing Checklist for a list of strategies that are helpful iovercoming barriers to the use of nursing diagnoses.
SPECIALTY nFORMATS
Specialty areas such as outpatient surgery, labor nand delivery, and psychiatric facilities may use abbreviated formats focused ndirectly on assessment needs for the particular service provided. In addition, nspecialty assessment forms may be included together with comprehensive nassessment forms for clients at particular risk for various conditions (e.g., nfalls, impaired skin integrity).
Documentatioof assessment data is essential as a means of communication among health care nteam members to assure accurate problem identification, determination of nappropriate client outcomes, and continuity of care.
THE MINIMUM DATA SET (MDS)
The Minimum Data Set (MDS) was developed by the nHealth Care Financing Administration (HCFA) to promote the development of a ncomprehensive care plan for every resident of Medicare/Medicaid certified nnursing homes. As such, the MDS is a standardized assessment instrument used iall long-term care facilities that are funded by HCFA. The MDS is a ncomprehensive assessment tool designed to collect data on the following nresident characteristics:
• nActivities of daily living (ADLs)
• nMedical needs
• nMental status
• nTherapy use (American Nurses Association, 2000)
MDS is a comprehensive assessment tool designed nto collect data on the following resident characteristics:
• nActivities of daily living (ADLs)
• nMedical needs
• nMental status
• nTherapy use (American Nurses Association, 2000)
Physical nassessment, an essential nursing function, is performed on every nclient. The measurement of vital signs and the execution of the physical nexamination as part of the assessment process are done to gather informatioregarding the physiological functioning of the body. This chapter discusses the nnormal physiological functioning of the body and the common deviations from nnormal, measurement and evaluation of these functions, preparation of the nclient for the physical examination, and the techniques used to perform a nphysical examination.
VITAL SIGNS
The “taking of vital signs” refers to measurement nof the client’s body temperature (T), pulse (P) and respiratory (R) rates, and nblood pressure (BP). Vital signs are fundamental to physical assessment (the nfirst step in the physical examination) to establish baseline values of the nclient’s cardiorespiratory integrity. Baseline values establish the norm against nwhich subsequent measurements can be compared. Variations from normal findings nmay indicate potential problems with the client’s health status. Nurses should nconfirm “normal” measurements with clients because the perception of what is nnormal may vary among clients.
Vital nsigns are taken whenever the client is admitted to a health care facility or nservice, for example, home health care, clinic, or other ambulatory setting, nand on a routine basis in the hospital. The frequency of vital sigmeasurements for the hospitalized client is determined by the client’s health nstatus, physician orders, and the established standards of care for the nparticular clinical setting or service. Whenever a change is suspected in the client’s nstatus, the nurse should measure
the vital signs, regardless of nthe setting.
The sequence for recording vital signs nmeasurement in the nurses’ notes is T-P-R and BP. Agencies usually have special ngraphic forms used to record vital signs findings. These forms facilitate data ncomparison at a glance because the data are plotted on a graph.
THERMOREGULATION
Thermoregulatiois the body’s physiological function of heat regulation to maintain a constant internal nbody temperature. The heat of the body is measured in units called degrees. The n“core” internal temperature of 98.6° Fahrenheit (F) (37° centigrade [C]) does nnot vary more than 1.4°F n(0.77°C) nand is higher than the skin and external temperature. In contrast, the skitemperature rises and falls in accordance with changes in environmental ntemperature.
RESPIRATION
Respiration is nthe act of breathing. Respiration is defined by physiological functioning as:
• nExternal respiration—the exchange of oxygen and carbon dioxide between the nalveoli of the lungs and the pulmonary blood system
• nInternal respiration—the interchange of oxygen and carbon dioxide between the ncirculating blood and cells throughout the body
• Inspiration (inhalation)—the nintake of air into the lungs
• Expiration (exhalation)—the nmovement of gases from the lungs to the atmosphere
• nVital capacity—the amount of air exhaled from the lungs after a minimal full ninspiration
The following five major physiological pulmonary nfunctions provide oxygen to the tissues and remove carbon dioxide:
1. nVentilation—the inflow and outflow of air between the atmosphere and the lung nalveoli.
2. nCirculation—the quantity of blood flowing through the lungs is approximately 4 nto 6 L/min.
3. nDiffusion—the exchange of oxygen and carbon dioxide between the alveoli and the nblood.
4. nTransport—the carrying of oxygen and carbon dioxide in the blood and body nfluids to and from the cells.
5. nRegulation—the neurogenic system that adjusts the nrate of alveolar ventilation to meet the demands of the body. The arterial nblood oxygen pressure (Po2) and arterial blood carbon dioxide pressure (Pco2) nmay be altered during times of strenuous exercise and other types of nrespiratory stress.
The mechanics of pulmonary ventilation depend oabdominal recti and internal intercostal nmuscles that cause lung expansion and contraction. Normal breathing is naccomplished by:
1. nThe downward and upward movement of the diaphragm to lengthen or shorten the nchest cavity
2. nThe elevation and depression of the ribs to increase and decrease the anteroposterior diameter of the chest cavity
Childreand meormally breathe with their diaphragm muscles; adult women generally nbreathe with their upper chest muscles (Firth & Watanabe, 1996).
PULSE
The pulse is the bounding of blood flow in aartery that is palpable at various points on the body. The pulse is caused by nthe stroke volume ejection and distension of the walls of the aorta, which ncreates a pulse wave as it travels rapidly toward the distal ends of the narteries. As the pulse wave reaches a superficial peripheral artery and travels nover an underlying bone or muscle, the pulse can be palpated by applying gentle npressure over a pulse point (a specific area where the peripheral pulses can be npalpated).
Figure n27–1 shows the location of pulse points throughout the body.
BLOOD PRESSURE
Both the blood pressure and pulse are nmeasurements that determine the volume of ejected blood into the arterial nsystem with each ventricular contraction. nBlood pressure is the measurement of pressure pulsations exerted against nthe blood vessel walls during systole and diastole. It is measured in terms of nmillimeters of mercury (mm Hg). In a healthy young adult, the pressure at the nheight of each pulse (the systolic pressure) is approximately 120 mm Hg, and the pressure nat the lowest point of each pulse (diastolic pressure) is approximately 80 mm Hg. The pulse pressure nis the difference between these pressures, which is 40 mm Hg. If 1 mm Hg caused a vessel originally ncontaining 10 ml of blood to increase its volume by 1 ml, the distensibility would be 0.1/mm Hg, or 10%/mm Hg (Guyton, nHall, & Schmitt, 1997).
The body has four hemodynamic nregulators for blood pressure control:
1. nBlood volume—the volume of blood in the circulatory system. Blood pressure is nproportional to the blood volume. Hemorrhage causes a loss in blood volume nthat, in turn, lowers the blood pressure. Rapid infusion of intravenous fluids ncauses an increase in volume and subsequent rise in pressure.
2. nCardiac output—the major factor that influences systolic pressure.
3. nPeripheral vascular resistance—the size and distensibility nof the arteries, which is the most important determinant of diastolic pressure. nArterial resistance (decreased distensibility) is nencountered when the left ventricle pumps blood from the heart under pressure nduring the systolic phase. The arteries contain smooth muscles that allow them nto contract, which decreases their compliance (tone) and causes resistance. The nvarying degrees of tone allow some of the arterioles to remain constricted nwhile others dilate to protect the body’s circulatory system from accommodating na greater blood capacity than the actual blood volume.
If all of the arterioles were to dilate at one ntime, there would not be enough blood to fill them.
4. nViscosity—the thickness of the blood based on the ratio of proteins and cells nto the liquid portion of blood. The greater the viscosity, the harder the heart nmust work to pump blood, with a resultant increase in blood pressure.
These regulators work in unison to create a nconstant blood pressure. For instance, when the blood volume decreases, the nbody compensates with an increased heart rate and vasoconstriction that nincreases peripheral resistance to maintaiormal pressure and functions of nthe vital organs.
Blood pressure is a result of the cardiac output nand peripheral vascular resistance. Normal arteries expand during systole and ncontract during diastole, creating two distinct pressure phases:
• nSystolic blood pressure is a measurement of the maximal pressure exerted nagainst arterial walls during systole (when myocardial fibers contract and ntighten to eject blood from the ventricles), primarily a reflection of cardiac noutput.
• nDiastolic blood pressure is a measurement of pressure remaining in the arterial nsystem during diastole (period of relaxation that reflects the pressure nremaining in the blood vessels after the heart has pumped), primarily a nreflection of peripheral vascular resistance.
Serial blood pressure readings provide nsignificant clinical data relative to the client’s cardiovascular and fluid nvolume status.
FACTORS INFLUENCING VITAL SIGNS
Several nfactors can cause changes in one or more of the vital signs: age, gender, nheredity, race, lifestyle, environment, medications, pain, and other factors nsuch as exercise and metabolism, anxiety and stress, postural changes, diurnal nvariations, and hormones.
BODY TEMPERATURE
Body ntemperature is measured during the routine physical examination by using one of nthe instruments described in Table 27–3. Frequent monitoring is required for nclients who have or are at risk for infection; for example, postoperative nclients or those with suppressed white blood cell count. Accuracy of ntemperature measurement is essential because it guides nursing and medical ndecision making and interventions.
TEMPERATURE nSCALES
The nnurse should consistently measure and record the temperature using either the ncentigrade or Fahrenheit scale as defined in specific health care agency npolicies. A centigradecalibrated scale ranges from n34° to 42°C, nand a Fahrenheitcalibrated scale ranges from 94° to 108°F. Conversions nfrom one scale to another are based on the formula that 0°C is equal to 32°F (see the naccompanying display).
SITES
Although nthe physician may order a specific site to measure the temperature, nursing njudgment usually determines the best site based on the client’s age and nphysical and mental condition. Traditional sites for measuring the body’s ninternal (core) temperature are oral (OT), rectal (RT), and axillary n(AT), using either glass or electronic thermometers.
Advances nin clinical thermometry provide other devices and sites, such as thermistors for pulmonary artery temperature (PAT) and ninfrared thermometers for ear canal temperature (ET). ET is the most commosite used for temperature measurements in adults because it is a safe and nefficient method; however, it is less sensitive in detecting fever in infants nand young children. ET should not be used in infected or draining ears or if nadjacent lesions or incisions exist. The most reliable measure of core ntemperature is PAT. Since PAT requires placement of a thermodilution npulmonary artery catheter, it is impractical for routine care.
Oral and rectal temperature measurements are nhigher than axillary because the measuring device is nin contact with the mucous membrane. Rectal measurements are higher than oral nbecause of the seal created by the anal sphincter, which decreases contact with nenvironmental air.
With the availability of electronic measuring ndevices, a glass thermometer should never be used for oral readingsif nthere is danger that the client will bite and break the thermometer. The axilla is commonly used as a site for infants and childrewith disabilities because it is the safest, even though least accurate, method. nAxillary or rectal sites are used for clients who are nuncooperative, comatose, or who have a nasogastric or nfeeding tube in place.
ASSESSING BODY TEMPERATURE
Assess the client for the most appropriate site nand gather the necessary equipment. When checking the client’s oral ntemperature, the nurse should confirm that the client has neither consumed hot nor cold food or beverage nor smoked for 15 to 30 minutes before the nmeasurement. Mouth breathing and tachypnea may also ncause an inaccurate oral reading. The nurse should wear nonsterile ngloves when assessing oral temperature in clients with herpetic lesions (Crow, n1997). Herpes viruses are extremely contagious and require implementation of nStandard Precautions of the Centers for Disease Control and Prevention. Clients nwith herpetic lesions should have their own glass thermometer to prevent ntransmission to others.
When using a glass thermometer stored in a ndisinfectant solution, the nurse should rinse it under cold water to remove the nsolution. Hot water should not be used on the thermometer because it will cause nthe mercury to expand and could break the thermometer.
Procedure 27–1 describes the actions involved imeasuring body temperature according to site.
Alterations nin Thermoregulation
When heat production exceeds heat loss and body ntemperature rises above the normal range pyrexia occurs. This condition is ncaused by an elevation of the body’s set-point in the hypothalamus. When the nbody’s temperature rises above 37.4°C (101°F) orally or 38°C (100.4°F) rectally, nthe client is said to be febrile.
NURSING CONSIDERATIONS
The nurse should place the client experiencing nheat exhaustion in a cool environment. The goal of nursing care is to stop ndiaphoresis by administering fluid and electrolytes as prescribed by a nphysician.
Victims nof heat stroke do not perspire because of severe electrolyte loss and impaired nhypothalamic function as discussed in Table 27–4.
Heat stroke victims are usually discovered outdoors, nwith emergency measures instituted to lower the temperature during transport to nan emergency center. Nursing’s primary role relative nto heat stroke is prevention. The nurse is usually involved in teaching npreventive measures, such as drinking liquids before, during, and after nexercise; avoiding strenuous exercise in humid, hot weather; and wearing nlight-colored, loose-fitting clothing and covering the head when working noutdoors in hot climates.
Hypothermia and frostbite victims found injured nin cold weather or who were immersed in cold water are treated while in transit nto an emergency center with heating blankets and instillation of warm fluids ninto the stomach. Nursing’s role is to teach npreventive measures to groups at risk, such as the homeless, and to parents or nguardians of mentally ill or handicapped clients who live in cold environments.
DOCUMENTATION
Record the temperature measurement and the site non the designated medical record form. Schmitz and colleagues (1995) identify nthe importance of both consistency in the measurement process for the purpose nof establishing a client’s temperature trend and awareness of the method used nwhen interpreting clinical data.
Temperature measurements are usually plotted on a ngraph to identify alteration patterns, such as sharp elevations and declines itemperature (a condition known as spiking).
PULSE
Pulse nassessment is the measurement of a pressure pulsation created when the heart ncontracts and ejects blood into the aorta. Assessment of pulse characteristics nprovides clinical data regarding the heart’s pumping action and the adequacy of nperipheral artery blood flow.
SITES
There are multiple pulse points. The most naccessible peripheral pulses are the radial and carotid sites.
Because nthe body shunts blood to the brain whenever a cardiac emergency such as nhemorrhage occurs, the carotid site should always be used to assess the pulse nin these situations.
Variances exist among health care agencies nregarding which pulse sites to assess. The common sites for each type of nassessment are:
• nComplete physical assessment—apical and all bilateral peripheral pulses
• nInitial assessment—apical and bilateral peripheral radial and dorsalis pedis pulses
• nRoutine vital sign assessment—apical and radial pulses in adults and apical and ntemporal pulses in infants and children Disorders that alter the client’s ncardiovascular status require different pulse point assessments (Table 27–5).
Whenever circulation is compromised, the ncorresponding pulse point should be assessed.
ASSESSING PULSE RATE
The nurse should begin the assessment by speaking nwith the client about the normal pulse rate. The client’s medical record should nbe reviewed for baseline data, if available, and any medications that could naffect the heart rate should be noted. Because physical activity increases the nheart rate, ensure that the client rests 5 to 10 minutes before the pulse is nassessed.
Clinical data regarding the efficacy of blood ncirculation to an extremity are obtained by assessing the characteristics (quality, nrate, rhythm, and volume) of the peripheral pulses. These attributes are ndescribed in the section entitled
PULSE CHARACTERISTICS.
Palpate a peripheral pulse by placing the first ntwo fingers on the pulse point with moderate pressure. A firm pressure will nobliterate the pulse; if the pressure is too light, the pulse cannot be felt.
A nDoppler ultrasound stethoscope (DUS) is used osuperficial pulse points to detect and magnify heart sounds and pulse waves nwhen the peripheral pulse cannot be palpated. The DUS, which has an earpiece nsimilar to that of a stethoscope, is connected by a cord to volume-control naudio unit with an ultrasound transducer.
Normal radial and apical pulses are identical in rate.The stethoscope is used to auscultate nthe heart’s rate and rhythm. The stethoscope should be placed on the fifth intercostal space at the midclavicular nline, as described in Procedure 27–2.
COUNT THE RATE FOR A FULL MINUTE, NOTING THE REGULARITY (RHYTHM).
When an irregular peripheral pulse is present, nthe nurse needs to assess for a pulse deficit (condition in which the apical pulse rate is ngreater than the radial pulse rate). A pulse deficit results from the ejectioof a volume of blood that is too small to initiate a peripheral pulse wave. nWhen a discrepancy exists between the apical and radial pulses, the deficit is nassessed by simultaneously measuring the apical and radial pulses for a minute. nThis procedure is usually performed by two nurses; however, it can be performed nby one nurse if necessary.
PULSE CHARACTERISTICS
***A normal pulse has defined characteristics: nquality, rate, rhythm, and volume (strength or amplitude)***
Pulse quality refers to the “feel” of the pulse, its nrhythm and forcefulness.
Pulse nrate is an indirect measurement of cardiac output obtained by ncounting the number of apical or peripheral pulse waves over a pulse point. A nnormal pulse rate for adults is between 60 and 100 beats per minute.
Bradycardia is a nheart rate less than 60 beats per minute in an adult. Tachycardia is a heart nrate in excess of 100 beats per minute in an adult.
Pulse nrhythm is the regularity of the heartbeat. It describes how nevenly the heart is beating: regular (the beats are evenly spaced) or irregular n(the beats are not evenly spaced).
Dysrhythmia n(arrhythmia) is an irregular rhythm caused by an early, late, or nmissed heartbeat.
Pulse nvolume is a measurement of the strength or amplitude of force nexerted by the ejected blood against the arterial wall with each contraction. nIt is described as normal (full, easily palpable), weak (thready nand usually rapid), or strong (bounding). To facilitate data comparison of this nmeasurement, a standard pulse volume scale should be used in documenting nfindings (see the accompanying display). Procedure 27-2 describes the actions ninvolved in assessing the pulse rate.
Clients on certain cardiac medications, such as ncardiovascular agents and cardiac glycosides, need to monitor their pulse rate. nClients receiving cardiovascular agents (verapamil nhydrochloride) and cardiac glycosides (digoxin) may nexperience an irregular pulse or pulse rate change that should be reported to ntheir physician. In addition, clients who follow an exercise regimen should nassess their pulse rate to measure their heart’s response to the exercise. nRoutine or regular exercise lowers the resting and activity pulses. Wheteaching clients how to monitor their own heart rate, nurses should show them nthe procedure in assessing the radial or carotid pulse points.
DOCUMENTATION
All pulse measurements are documented by nrecording in the client’s medical record on the appropriate forms (e.g., the nvital sign flow sheet). The nurse should report and document an irregular npulse.
RESPIRATIONS
Respiratory assessment is the measurement of the nbreathing pattern. Assessment of respirations provides clinical data regarding nthe pH of arterial blood.
SITES
Normal breathing is slightly observable, neffortless, quiet, automatic, and regular. It can be assessed by observing nchest wall expansion and bilateral symmetrical movement of the thorax. Another nmethod the nurse can use to assess breathing is to place the back of the hand nnext to the client’s nose and mouth to feel the expired air.
ASSESSING RESPIRATIONS
When assessing respirations nascertain the rate, depth, and rhythm of ventilatory nmovement. The nurse should assess the rate by counting the nnumber of breaths taken per minute. Note the depth and rhythm of ventilatory movements by observing for the normal thoracic nand abdominal movements and symmetry in chest wall movement.
Normal respirations are characterized by a rate nranging from 12 to 20 breaths per minute. Procedure 27-3 describes the actions ninvolved in assessing resiprations.
One ninspiration and expiration cycle is counted as one breath. The nurse should nobserve the rise and fall of the chest wall and count the rate by placing the nhand lightly on the chest to feel its rise and fall. Count the number of nrespirations as explained in Procedure 27-3.
MOVEMENT OF THE DIAPHRAGM
When the chest wall moves, so do the lungs, nbecause the lungs are attached to the inner wall of the thoracic cavity by the nouter layer of the pleura (lining of the chest cavity). The movement of the nchest wall should be even and regular, without noise and effort. On inspiratiothe chest changes shape and expands as the rib cage is nraised and the diaphragm is lowered. Before inspiration, the pressure inside nthe chest cavity is negative (–4.5 to –9.0 mm Hg below atmospheric pressure). nAir flows along the concentration gradient from a higher atmospheric pressure nto the lower intrathoracic pressure.
The opposite action occurs with expiration. The nmuscles relax, causing the rib cage to lower, and the diaphragm to rise, ncompressing the chest. Intrathoracic pressure ndecreases to –3 to –6 mm Hg to allow the air to escape into the atmosphere.
Characteristics of Normal nand Abnormal Breath Sounds Different respiratory wave patterns are ncharacterized by their rate, rhythm, and depth.
Eupnea refers nto easy respirations with a normal rate of breaths per minute that are nage-specific.
Bradypnea is na respiratory rate of 10 or fewer breaths per minute.
Hypoventilation is ncharacterized by shallow respirations.
Tachypnea is a respiratory rate greater tha24 breaths per minute.
Hyperventilation nis characterized by deep, rapid respirations.
The nnurse can also observe alterations in the movement of the chest wall:
1. ncostal (thoracic) breathing occurs when the nexternal intercostal muscles and the other accessory nmuscles are used to move the chest upward and outward;
2. ndiaphragmatic (abdominal) nbreathing occurs when the diaphragm contracts and relaxes as observed by nmovement of the abdomen.
Dyspnea nrefers to difficulty in breathing as observed by labored or nforced respirations through the use of accessory muscles in the chest and neck nto breathe. Dyspneic clients are acutely aware of ntheir respirations and complain of shortness of breath.
NURSING CONSIDERATIONS
Respiratory alterations may cause changes in skicolor as observed by a bluish appearance in the nail beds, lips, and skin. The nbluish color (cyanosis) results from reduced oxygen levels in the arterial nblood.
Changes in the level ofconsciousness nmay also occur with decreased oxygen levels. Dyspneic nclients will assume a forward-leaning position to increase the expansiocapacity of the lungs.
Clients with respiratory alterations require nadditional nursing assessment. Noninvasive oxygen assessment can be performed nwith an oximeter (a machine that measures the oxygesaturation of the blood through a probe clipped to the fingernail or earlobe) nor an apnea monitor (a machine with chest leads that monitors the movement of nthe chest).
Both noninvasive machines have alarm features nthat are set to specific parameters. For example, if the client’s respirations nfall below 6 breaths per minute, the apnea monitor alarm will sound. The apnea nmonitor is used in the home environment for apneic nclients; when the alarm sounds, it wakes the person and causes him to breathe.
DOCUMENTATION
Document the assessment findings for the nrespiratory rate, depth, rhythm, and character on the appropriate form (e.g., nthe vital sign flow sheet). Report a respiratory rate outside the normal age range, nan irregular rhythm, inadequate depth, or any abnormal characteristics such as dyspnea.
BLOOD PRESSURE
Blood pressure measurement is performed during a nphysical examination, at initial assessment, and as part of routine vital signs nassessment. Depending on the client’s condition, the blood pressure is measured nby either a direct or an indirect technique. The direct method requires ainvasive procedure in which an intravenous catheter with an electronic sensor nis inserted into an artery and the artery-transmitted pressure on an electronic ndisplay unit is read. The indirect method requires use of the sphygmomanometer nand stethoscope for auscultation and palpation as needed.
SITES
The most common site for indirect blood pressure nmeasurement is the client’s arm over the brachial artery. When the client’s ncondition prevents auscultation of the brachial artery, the nurse should assess nthe blood pressure in the forearm or leg sites (see the accompanying display).
When pressure measurements in the upper extremities nare not accessible, the popliteal artery, located nbehind the knee, becomes the site of choice. The nurse can also assess the nblood pressure in other sites, such as the radial artery in the forearm and the nposterior tibial or dorsalis npedis artery in the lower leg. Because it is ndifficult to auscultate sounds over the radial, tibial, and dorsalis pedis arteries, these sites are usually palpated to obtaia systolic reading.
ASSESSING BLOOD PRESSURE
Selecting the proper equipment and following procedural ntechnique are basic to ensuring an accurate reading. Psychomotor skills, nacquired with practice, are needed to manipulate the blood pressure equipment.
Procedure 27-4 describes the actions involved iassessing blood pressure.
As shown in Table 27-3, a sphygmomanometer is a ndevice used to measure indirect blood pressure. A sphygmomanometer consists of na mercury or aneroid manometer and a cuff that contains an inflatable rubber nbladder connected to two pieces of rubber tubing. One piece of tubing connects nthe bladder to the manometer or gauge, and the second tubing is attached to a npressure bulb with a release valve to inflate and deflate the cuff. Whepressure is applied to the bulb, air enters the bladder and inflates the cuff.
The sphygmomanometer wears with usage. If there nis a defect in any part of the system, the blood pressure reading will be ninaccurate. The aneroid gauge needle or mercury in the manometer column should nbe at a zero reading when the cuff is deflated and should rise evenly whepressure is applied to the bulb. The valve should turn freely and all tubing nshould be intact, with secured connections to prevent air from leaking out of nthe system.
An accurate reading also requires the correct width nof the blood pressure cuff as determined by the circumference of the client’s nextremity. The bladder cuff must encircle the width and length of the site. nAccording to the American Heart Association (1987), the bladder width should be napproximately 40% of the circumference or 20% wider than the diameter of the nmidpoint of the extremity. To measure the width of the bladder, the nurse nshould place the cuff lengthwise on the client’s extremity and extend the width nto cover 40% of the extremity’s circumference (Figure 27-14).
The nlength of the sphygmomanometer bladder should be twice the width.
Table n27-6 recommends bladder sizes based on different arm circumferences. A falsely nelevated reading will result if the bladder is too narrow, and a falsely low reading nwill result if it is too wide.
Electronic sphygmomanometers are used by clients nfor self-measurements. A stethoscope is not required because the device nelectronically inflates and deflates the cuff while simultaneously reading and ndisplaying the systolic and diastolic pressures. The electronic device is nuseful for clients who must monitor their own pressure at home. However, it nmust be recalibrated routinely to ensure an accurate reading.
KEY CONCEPTS FOR NURSING ASSESSMENT
• nAssessment includes collection, verification, organization, interpretation, and ndocumentation of data.
• nThe nurse uses the process of assessment to establish a database about the nclient, to form an interpersonal relationship with the client, and to provide nthe client with an opportunity to discuss health care concerns.
• nAssessment can be comprehensive, focused, or ongoing, depending on the health ncare setting and needs of the client.
• nThe two types of data collected during the assessment process are subjective n(data from the client’s point of view) and objective (observable and measurable ndata that are obtained through both the physical examination and laboratory and ndiagnostic tests).
• nAlthough a variety of sources should be used in data collection, the client is nthe primary source of information.
• nAssessment models such as Gordon’s Functional Health Patterns, NANDA’s Human Response Patterns, Orem’s Theory of Self-Care nModel, Roy’s Adaptation Model, the body systems model, and Maslow’s nhierarchy of needs model ensure comprehensive data collection and organization.
• nData are collected through the interview, health history, symptom analysis, nphysical examination, and laboratory and diagnostic tests.
• nThe three stages of assessment interview are the introduction, working, and nclosure phases.
• nA comprehensive health history is useful in determining the client’s functional nhealth patterns, responses to changes in health status, and alterations ilifestyle.
• nThe elements of the health history are demographic information; reason for nseeking health care; perception of health status; previous illnesses, nhospitalizations, and surgeries; client/family medical history; nimmunizations/exposure to communicable disease; allergies; current medications; ndevelopmental level; psychosocial history; sociocultural nhistory; activities of daily living; and review of systems.
• nThe purposes of the physical examination are to gather baseline data, confirm ndata obtained in the interview and health history, and evaluate progress toward nestablished goals. The examination includes the techniques of inspection, npalpation, percussion, and auscultation. • Accurate and complete documentatioof assessment findings is essential for communication to other health care team nmembers and may be recorded on a variety of assessment tools, such as nopen-ended, checklist, combination, and specialty formats.
KEY nCONCEPTS DIAGNOSTIC nOF HUMAN RESPOND.
• Nursing diagnosis is the second step ithe nursing process and is the clinical judgment about individual, family, or ncommunity (aggregates) responses to actual or risk problems, wellness states, nor syndromes.
• Through the efforts of NANDA and ANA, the nidentification and validation of nursing diagnosis as the second step of the nursing nprocess has been substantiated and forms the basis for professional naccountability.
• Nursing diagnosis contributes to a clearer nconceptualization of knowledge unique to nursing, improved communication among nnurses and other health care professionals, promotion of individualized client ncare, and support for theory development and nursing research.
• Nursing diagnoses can be written as either ntwo-part statements (diagnostic label and etiology) or threepart nstatements (diagnostic label, etiology, and defining characteristics).
• The NANDA nursing diagnosis taxonomy is ncomposed of nine human response patterns: exchanging, communicating, relating, nvaluing, choosing, moving, perceiving, knowing, and feeling.
• The process of developing a nursing ndiagnosis includes analysis of assessment cues, validation of cues, ninterpretation of cues, clustering of data, consulting NANDA’s nlist of approved nursing diagnoses, and writing the nursing diagnosis nstatement.
• When the nurse is knowledgeable about the ncomponents of the nursing diagnosis process and is equipped to develop the ndiagnostic statement, the nurse is able to make appropriate decisions regarding ntherapeutic nursing interventions.
• To avoid committing errors in the nursing ndiagnostic process, nurses should ensure that the data collection is complete, nthat the interpretation of the data is accurate and based upon the nursing and nnot the medical diagnosis, and that the client’s response to a health problem nis amenable to therapeutic nursing interventions.
• The barriers that have been identified as npreventing the use of nursing diagnosis in a more universal manner are the nconstraints on the time nurses can devote to client care; the continuing norganization of health care according to medical diagnosis; the misunderstanding nand ridicule that nurses can encounter when using nursing diagnoses; the nonapplicability of the list of nursing diagnoses to every nclient situation; the constantly evolving refinement of the nursing diagnosis nlanguage; and the availability of numerous approaches for formulation and napplication of nursing diagnoses.
• Although barriers to the use of nursing ndiagnosis may be present, they may be overcome by employing specific strategies nsuch as agreeing on a common language; supporting colleagues’ attempts to use nnursing diagnoses; adopting a nonjudgmental attitude; and continuing to ncommunicate with other nurses at national and international levels.
