DIAGNOSIS
NANDA’s language is relatively new compared to medical language that has existed for several hundred years. Some
nurses would rather wait until the NANDA listing is complete before they use it. However, it is unrealistic to think that a sys- tem such as NANDA should not be used until it is completed.
Indeed, as nursing science continues to evolve, nursing diag- noses will be added, removed, or refined; there will never be a
‘‘completed’’ list of nursing or medical diagnoses for this very reason. The ever-changing health care scene dictates that nurses participate in evolving methods to communicate within the health care industry.
Another barrier to the use of nursing diagnoses is the numerous approaches for application that are found in the nursing literature. Due to these various methods, it may be difficult for nurses to choose one method with which they feel comfortable. Nurses may also be unable and unwilling to use nursing diagnoses because of incomplete knowledge about the process and disagreements about wording.
After identifying the existence of barriers to the use of nursing diagnoses, it is possible to design strategies to over- come them. One strategy is to develop a common nursing language that is globally used throughout the profession.
Nursing diagnostic terminology serves this purpose. Familiar- ity with this language empowers the nurse to communicate more effectively with other nurses and health care team members. Effective communication, in turn, improves the ac- curacy in nursing diagnoses. Ultimately, the quality of care should improve, and the costs associated with that care should decrease. Due to the fact that many health care facili- ties are asking nurses to do more with fewer resources, nurses are challenged to learn more efficient ways of per- forming their duties. Nurses’ time is spent more efficiently if less time is spent deciphering meanings of words.
The move toward electronic health records is making it more important than ever to have standardized nursing lan- guages. As health care settings are required to communicate with other organizations to improve client management, it will be important to have standardized languages within those electronic systems so that different information systems are able to ‘‘talk to’’ one another by sending and receiving data that diverse systems can readily understand. The current method of ‘‘free text charting’’ will become a thing of the past, and standardized nursing languages representing nursing diagnoses, interventions, and outcomes will be critical to the success of these information systems. See the Nursing Proc- ess Highlight on page 121 in order to practice developing a diagnostic statement. The accompanying Uncovering the Evidence display on page 121 describes how education can improve the use and documentation of nursing diagnoses.
When a nurse encounters client situations that do not readily fit the nursing diagnosis language, every attempt should be made to describe the phenomena. The nurse may be on the threshold of documenting the need for a new, as- yet-undiscovered nursing diagnosis. Indeed, the work of NANDA is done by nurses working in client care areas, edu- cation, and research. Potential diagnoses are submitted to NANDA for approval based on research in the area of con- cern. Nurses are strongly encouraged to share their needs for nursing diagnosis language with NANDA so that the lan- guage will grow, become more inclusive, and become more usable for nurses in practice.
As nurses collaborate on the refinement of nursing diag- noses, it may be possible to agree on certain aspects of the language. The achievement of this goal will end the use of multiple approaches and will make choices less complicated.
Enhanced communication among nurses in everyday settings and among professionals who convene nationally and inter- nationally to exchange ideas about nursing diagnoses is essential.
Most nursing educational programs now offer standar- dized content related to nursing diagnoses. In addition, expe- rienced nurses need opportunities to review principles of nursing diagnoses. See the Nursing Checklist for a list of strategies that are helpful for overcoming barriers to the use of nursing diagnoses.
UNCOVERING THE
Eviden ce Eviden ce
TITLE OF STUDY
‘‘Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study’’
AUTHORS
M. Muller-Staub, I. Needham, M. Odenbreit, M. A.
Lavin, and T. van Achterberg
PURPOSE
To evaluate the impact of the quality of nursing diagno- ses, interventions, and outcomes in an acute care set- ting after implementation of an educational program.
METHODS
This experimental design study utilized pre- and post- tests on nurses who participated in two educational sessions about the use of nursing diagnoses, interven- tions, and outcomes. Nursing records were randomly selected for analysis before and after the implementa- tion of the educational strategy.
FINDINGS
Significant improvements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of the educational program.
IMPLICATIONS
Education can be a viable strategy for improving docu- mentation of nursing diagnoses, interventions, and outcomes.
Muller-Staub, M., Needham, I., Odenbreit, M., Lavin, M. A., & van Ach- terberg, T. (2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study.International Journal of Nursing Terminologies & Classifications:
The Official Journal of NANDA International, 18(1), 1–2.
NURSINGCHECKLIST
Strategies for Optimizing the Use of Nursing Diagnoses
Nurses should implement the following strategies when working with nursing diagnoses:
• Agree on a common language.
• Acknowledge and embrace the fluid nature of the language of nursing diagnosis.
• Discuss the purpose and value of nursing diagno- sis with administrators and medical staff.
• Support colleagues when they use nursing diag- nosis language.
• Adopt a positive attitude toward the principles and taxonomy of nursing diagnosis.
• Be willing to add to the existing body of knowl- edge by describing unusual nursing phenomena.
• Participate in conferences, workshops, and other educational activities that advance and promote nursing diagnosis.
• Continue communicating with other nurses about nursing diagnosis.
NURSING PROCESS HIGHLIGHT
Diagnosis
Example
Mr. Lowder is a 62-year-old male who was admitted last night through the emergency room because of difficulty breathing. He was also experiencing some difficulty voiding. His lower extremities are very swol- len. History reveals he smokes one pack of ciga- rettes a day and has done this for the past 45 years.
His vital signs are P 112; R 30; BP 172/96; T 101.1F. He has an eighth-grade education, attends church every week, is estranged from his daughter, and says,
‘‘I hate hospitals because my mother died in one.’’
Questions
1. From the data cues in this case study, group data into clusters.
2. Look at the NANDA list of diagnoses and see which diagnoses ‘‘fit’’ best with your data clus- ters.
3. Write the first part of the NANDA diagnosis for each cluster.
4. Attempt to identify etiological (related to) fac- tors for the list you started in Step 3.
5. Write two-part nursing diagnosis statements by combining Steps 3 and 4.
6. Identify whether the nursing diagnoses on your list are actual, possible, risk, or wellness- oriented nursing diagnosis statements.
7. Prioritize the nursing diagnoses.
KEY CONCEPTS
• Nursing diagnosis is the second step in the nursing process and is the clinical judgment about individ- ual, family, or community (aggregate) responses to actual or risk problems, wellness states, or syndromes.
• Through the efforts of NANDA and the ANA, the identification and validation of nursing diagnosis as the second step of the nursing process has been sub- stantiated and forms the basis for professional accountability.
• Nursing diagnosis contributes to a clearer under- standing of knowledge unique to nursing, improves communication among nurses and other health care professionals, promotes individualized client care, and supports theory development and nursing research.
• Nursing diagnoses can be written as either two-part statements (diagnostic label and etiology) or three- part statements (diagnostic label, etiology, and defining characteristics).
• The NANDA nursing diagnosis taxonomy is com- posed of 13 domains: health promotion, elimina- tion/exchange, perception/cognition, role
relationship, coping/stress tolerance, safety/protec- tion, growth/development, nutrition, activity/rest, self-perception, sexuality, life principles, and comfort.
• The process of developing a nursing diagnosis includes analysis of assessment cues, validation of cues, interpretation of cues, clustering of data, con- sulting NANDA’s list of approved nursing diagno- ses, and writing the nursing diagnosis statement.
• The nurse who is knowledgeable about the compo- nents of the nursing diagnosis process and is equipped to develop the diagnostic statement is able to make appropriate decisions regarding therapeutic nursing interventions.
• To avoid committing errors in the nursing diagnos- tic process, nurses should ensure that the data col- lection is complete, that the interpretation of the data is accurate and based upon the nursing and not the medical diagnosis, and that the client’s response to a health problem is amenable to therapeutic nurs- ing interventions.
• The barriers that have been identified as preventing the use of nursing diagnosis are the constraints on the time nurses can devote to client care, the con- tinuing organization of health care according to medical diagnosis, the inapplicability of the list of nursing diagnoses to every client situation, the con- stantly evolving refinement of the nursing diagnosis language, and the availability of numerous approaches for formulation and application of nursing diagnoses.
• Although barriers to the use of nursing diagnosis may be present, they may be overcome by employ- ing specific strategies such as agreeing on a common language, supporting colleagues’ use of nursing diag- noses, adopting a nonjudgmental attitude, contribut- ing to the development of nursing diagnosis
language through submission of new diagnoses or revising existing diagnoses in the NANDA taxon- omy, and continuing to communicate with other nurses at national and international levels.
REVIEW QUESTIONS
1. A nurse reads the following list of nursing diagnoses on a client’s plan of care. Which of these statements is written correctly as a nursing diagnosis?
a. Acute pain RT pain in right foot
b. Impaired skin integrity RT infrequent reposi- tioning by staff
c. Impaired swallowing RT stasis of food in oral cavity after chewing
d. Chronic confusion RT Alzheimer’s disease 2. A client limps into the clinic with pain in the right
foot. The physical examination shows that the cli- ent is 5 feet 6 inches tall, weighs 275 pounds, and has edema in the right lower extremity. Which of the following statements would be an accurate nursing diagnosis for this client?
a. Acute pain RT pain in right foot b. Imbalanced nutrition: more than body
requirements
c. Impaired mobility RT pain d. Risk for injury RT obesity
3. A client who underwent hip replacement surgery has a nursing diagnosis of impaired physical mobil- ity RT pain. Which of the following nursing inter- ventions would be a priority for a client with this diagnosis?
a. Elevating the client’s foot
b. Administering the prn analgesic medication as ordered
c. Providing a walker for ambulation
d. Teaching the client techniques for safely trans- ferring from the bed to a wheelchair
4. An elderly client with thin, dry skin has a nursing di- agnosis of impaired skin integrity. Which of the fol- lowing nursing interventions should be
implemented? Select all that apply.
a. Repositioning the client every 2 hours
b. Keeping the bed linens dry c. Reducing the client’s fluid intake
d. Encouraging the client to consume a high-fiber diet
e. Making sure that the bed linens are wrinkle-free f. Instructing the client to take deep breaths and
cough
5. The nurse makes a nursing diagnosis of risk for impaired physical mobility RT pain. Which of the following is the risk factor for this client?
a. Immobility
b. Impaired skin integrity c. Malnutrition
d. Pain
online companion
Visit the DeLaune and Ladner online companion resource atwww.delmar.cengage.comfor additional content and study aids. Click on Online Companions, then select the Nursing discipline.
persistently.
—WILLIAMA. WARD
CHAPTER 8
Planning and Outcome Identification
COMPETENCIES
1. Explain the purposes of outcome identification and planning.
2. Describe four elements of the planning component.
3. Describe characteristics of goals and expected outcomes.
4. Discuss the five components in the construction of goals and expected outcomes.
5. Describe problems frequently encountered in planning nursing care.
6. Explain strategies to improve the planning of nursing care.
7. Differentiate dependent, independent, and interdependent nursing interventions.
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lanning, the third step of the nursing process, includes the formulation of guidelines used to establish the cli- ent’s plan of care. Preceding this step is the collection of assessment data and the formulation of nursing diagnoses.After a nurse thoroughly assesses a client and determines the client’s unique nursing diagnoses (or problems), a plan of action is developed with specific goals to resolve the nursing diagnoses or health problems. Following the planning com- ponent, the nursing process continues with implementation of nursing interventions and evaluation of the client’s response to the plan of care.
This chapter explains the planning component of the nursing process. The planning concept is illustrated with theory and examples. Strategies for effective planning of qual- ity nursing care are described together with problems fre- quently encountered in this stage of the nursing process. The role of critical thinking in planning and outcome identifica- tion is emphasized.