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LIST OF PROCEDURES
CONTRIBUTORS
Surman, BSN, RN, CNOR, CHT, CETN sår- og stomienhed, Our Lady of Lake Regional Medical Center. Direktør for Simulation Learning School of Nursing and Dental Hygiene University of Hawaii i Manoa Honolulu, Hawaii.
REVIEWERS
University of Alabama Capstone College of Nursing Tuscaloosa, Alabama Renee Harrison, MS, RN Tulsa Junior College Tulsa, Oklahoma. Janic Tazbir, RN, MS, CS, CCRN Associate Professor of Nursing, Purdue University Calumet Hammond, Indiana.
PREFACE
CONCEPTUAL APPROACH
The community, as a common client and as a care delivery environment, is illustrated in Chapter 17 and in Community Critical Thinking frameworks that are distributed throughout the text. Caring, a universal value that guides nursing practice, is included throughout the text and is also detailed in a separate chapter.
ORGANIZATION OF TEXT
Nursing: An active, interpersonal, professional practice that seeks to improve the health status of individuals. Alternative and complementary modalities are treatment approaches that can be used alongside conventional medical therapies.
NEW TO THIS EDITION
Spirituality—one's relationship with self, feeling connected to others, and a relationship with a higher power or divine source—is discussed in depth in Chapter 24. Free StudyWARECD—with 3-D animations, NCLEX-style chapter quizzes, heart and lung sounds, and an audio library of medical terminology—included.
EXTENSIVE TEACHING/
LEARNING PACKAGE
O NLINE C OMPANION
S TUDY G UIDE
S KILLS C HECKLIST
I NSTRUCTOR R ESOURCES
The Image Library is a software tool that contains an organized digital library of more than 700 illustrations and photographs from the text. Correlated with the text, the WebTutor Advantage includes quizzes and discussion questions, 3D animations, concept maps, a glossary, and instructor resources.
HOW TO USE THIS TEXT
Concept maps are used in this edition to visually illustrate five of the nursing care plans included in the text. The purpose of this study was twofold: (1) to identify frequently used nursing interventions and (2) to describe patterns of interventions used for each of the three selected groups of clients.
SAFETY FIRST
ACKNOWLEDGMENTS
ABOUT THE AUTHOR
Nursing’s Perspective
COMPETENCIES
The social forces that have influenced the development of nursing and nursing education are examined. The various educational programs of the United States and Canada are presented in terms of their characteristics and the nursing role of the graduate in the provision of health care.
EVOLUTION OF NURSING
This aspect of nursing also includes helping a client with a terminal illness maintain comfort and dignity in the last phase of life. Applying the lessons of a historical review, nurses will truly be a vital force in the new millennium.
O RIGINS OF N URSING
By studying the history of nursing, the nurse can better understand issues such as autonomy (self-direction), unity within the profession, supply and demand, salary, education, and current practice. History is the study of the past, which includes events, situations, and individuals (see Figure 1-1). Empowerment and autonomy go together and are necessary for nursing to bring about positive change in health care today (see Figure 1-2).
KEY TERMS
Jerome, through one of his disciples, Fabiola, was responsible for introducing hospitals in the West. Most of the nursing care was still carried out in the home by female relatives of the sick.
R ELIGIOUS I NFLUENCES
Because of their travels, commercial trade flourished and industries were developed to provide trade on the world market. The dominant caretakers in the Byzantine setting were men; however, this was not true in the rural parts of the Eastern Roman Empire and in the West.
D EMANDS OF W AR
The fall of the Roman Empire in 476 AD. ushered in the Middle Ages, the medieval period (500–1450 AD), which was marked by the growth of the Christian Church. After the Civil War, nursing education in the United States and Canada began using curricula based on those of the Nightingale School.
F LORENCE N IGHTINGALE (1820–1910)
The Sisters of the Holy Cross were the first to respond to the need for nurses during that war. During the Civil War, nursing care was provided by the Sisters of Mercy, Daughters of Charity, Dominican Sisters, and Franciscan Sisters of the Poor.
N URSING P IONEERS AND L EADERS
Dock wrote many other books and was the first editor of the American Journal of Nursing (AJN). Thoms was one of the first to recognize public health as a field of nursing.
N URSING IN THE T WENTIETH C ENTURY
During the first half of the twentieth century, a number of reports on nursing education and practice were issued. Through the joint efforts of the Canadian Nurses Association and the Canadian Medical Association, a nationwide study of nursing education in Canada was established in 1929.
S OCIAL F ORCES A FFECTING N URSING
See accompanying screen showing the Pew Health Professions Commission's Health Care Professionals competencies. Although worldwide communication and globalization make health care accessible to larger populations, there are legal issues regarding licensing that the provider must consider.
NURSING EDUCATION OVERVIEW
For example, because of globalization and technology, nurses and other health care providers practice across state and national borders. Many healthcare institutions, schools and communities have educational programs to prepare for natural disasters or nuclear, chemical or biological attacks.
D IPLOMA E DUCATION
Early diploma programs were established based on AMA recommendations, and nursing education was largely of the apprenticeship type. Some of the current diploma programs have evolved into what is called a single-purpose institution that has baccalaureate degree-granting privileges for nursing.
A SSOCIATE D EGREE P ROGRAMS
B ACCALAUREATE P ROGRAMS
M ASTER ’ S P ROGRAMS
D OCTORAL P ROGRAMS
Upon completion of the program, the graduate is eligible to write the NCLEX-RN exam.
S TAFF D EVELOPMENT AND
C ONTINUING E DUCATION
PREPARING NURSES FOR TOMORROW’S CHALLENGES
The nursing curriculum is the student's first introduction to the process of socialization into the profession. In order for the nursing profession to advance, and for nursing education to respond to the changes taking place in society and healthcare, nursing programs must adapt their educational methods to provide graduate competencies that respond to the challenges in the field of twentieth century healthcare. first century.
D IFFERENTIATED P RACTICE
The process of socialization is based on professional values, which are learned by exposing students to learning opportunities that support compassionate, sensitive, empathic care for individuals, groups and communities.
A CCELERATED D EGREE P ROGRAMS
T ECHNOLOGY C HANGES IN N URSING E DUCATION
SPOTLIGHT ON
Other innovations in technology, such as virtual reality (VR), are also helping to bridge the education gap between knowledge and application by providing students with the opportunity to practice essential nursing skills.
S ERVICE L EARNING
KEY CONCEPTS
UNCOVERING THE
The early history of nursing was heavily influenced by religious organizations and the need for nurses to care for soldiers in wartime. The Brown Report (1948) addressed the need for nurses to demonstrate greater professional competence by moving nursing education to the university setting.
REVIEW QUESTIONS
Florence Nightingale shaped the future of nursing and education as a result of her experience training nurses to care for soldiers. The professionalization of nursing has been and continues to be done through the development and application of nursing theory.
COMPONENTS OF THE
Nursing theory provides a perspective from which to define the what of nursing, describe the who of nursing (who is the client), and when nursing is needed, and identify the limits and goals of nursing's therapeutic activities. This chapter first addresses basic ideas about the meaning of nursing theory and its relevance to professional nursing.
THEORETICAL FOUNDATION
This chapter explores the theoretical foundation on which the knowledge base of the nursing profession has been and is being built. The main ideas of selected nursing theories are explained and examples of their use in nursing situations are given.
These different explanations share a common notion of the purpose of the theory, namely description, explanation and prediction. For example, when telling a friend about a mystery novel you're reading, you might have said, ''I have a theory about who committed the crime.'' Or you might have heard a Little League coach say to the players, ' 'I have a theory about how we can improve our performance.'' The way this expression is used in these statements is a useful way to think about the meaning of the theory.
USE OF THEORIES FROM OTHER DISCIPLINES
A theory not only helps us organize our thoughts and ideas, but can also help us direct what to do, when and how to do it.
IMPORTANCE OF NURSING THEORIES
Nursing research therefore influences the development of nursing theory which in turn transforms nursing practice. Regardless of the approach chosen, nurses will recognize the value and usefulness of nursing theory as a tool for effective nursing practice.
SCOPE OF THEORIES
It provides the raw material for the ideas that are systematically developed and organized in the form of nursing theory. The ideas of nursing theory must be tested and validated through nursing research.
G RAND T HEORIES
New knowledge emerging from nursing research, however, is used to transform and inform nursing practice. Nurses may use a particular nursing theory to help guide their practice, or they may choose a more eclectic approach and adopt ideas from multiple theories.
M IDDLE -R ANGE T HEORIES
As nurses learn more about specific nursing theories, they may find that they may relate more to one theory than another or that they may appreciate the ideas contained in several different theories. In that case, one theory may be used with a client in a home health care setting, while another theory may be more applicable to a client in an acute care setting.
M ICRO -R ANGE T HEORIES
For example, the Neuman systems model, explained later in this chapter, provides clear direction to the researcher interested in describing stressors; explain the factors that influence responses to those stressors; and testing the effects of primary, secondary, and tertiary prevention on stressor responses within the context of a holistic, open systems perspective (Fawcett & Gigliotti, 2001). When nurses explore various nursing theories, they gain new insights into patient care, open up new options that are otherwise hidden, and stimulate innovative interventions (Woodward, 2003).
EVOLUTION OF NURSING THEORY
KNOWLEDGE DEVELOPMENT IN NURSING
M ETAPARADIGM OF N URSING
One example of this evolution in the discipline of nursing is the inclusion of caring as a basic core concept, central to the practice of nursing. Watson stated that “caring is the essence of nursing and the most central and unifying focus for nursing practice (1985, p. 35).
P ARADIGMS IN N URSING
Many of the nursing theories developed so far have a view of the discipline of nursing that fits the totality paradigm. Some nurses argue about the structural elements of the discipline; some debate the value of competing paradigms;.
SELECTED NURSING THEORIES
In the simultaneity paradigm, the whole means the unitary, and the unitary man has characteristics that are different from the parts and cannot be understood by knowing the parts. Moreover, man cannot be separated from the totality of the universe, as both are constantly changing in new, unpredictable ways and together create health, a value defined by humans for themselves (Parse, 2000).
F LORENCE N IGHTINGALE
The goals of nursing in the concurrency paradigm focus on quality of life from the person's perspective. But despite all the uncertainty created by these questions and alternative ideas, the continued dialogue is a healthy sign of the nursing profession's evolution.
E ARLY N URSING T HEORIES
Using her own knowledge and that of other disciplines, Peplau defined the concepts and stages involved in the development of the nurse-client relationship. Henderson's 14 basic needs were published in the Textbook of the Principles and Practice of Nursing, one of the first nursing textbooks.
C ONTEMPORARY N URSING T HEORIES
The relationship between the nurse and the client is established when there is a self-care deficit. In the supportive-educational nursing system, the nurse's actions are to help clients develop their own self-care skills through knowledge, support, and encouragement.
COMMUNITY CONSIDERATIONS Belief System
Roy's new definition of adaptation is 'The process and outcome by which thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create integration of person and environment' (Roy &. The purpose of nursing is 'to promote of adaptation in each of the four forms, contributing to the person's health, quality of life and dying with dignity'' (Andrews &.
T HEORIES FOR THE N EW W ORLDVIEW
Through these interventions, the nurse is trying to change both the person's internal and external environment. Within the framework of role function mode, the nurse would assist a disabled woman with arthritis to identify adaptive approaches to maintain the roles of wife and homemaker.
OF N URSING
Roy's views of the person and the person-environment interaction clearly represent characteristics of the totality paradigm. The entire person's energy field interacts with the entire environmental energy field, leading to the process of life.
CONTINUING EVOLUTION OF NURSING THEORY
Nursing is the study of unique, irreducible human beings and their respective environments.'' parts. . The development, use, and testing of nursing theory are necessary for the professionalization of the nursing discipline.
RESEARCH: SUBSTANTIATING THE SCIENCE OF NURSING
Nursing research is a ‘‘scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly affects nursing practice’’ (Burns & Grove, 2004, p. 4). The emphasis on quality care based on evidence and research is an increasing focus in all areas of healthcare.
H ISTORICAL D EVELOPMENT
Federal involvement in nursing research dates back to 1946 with the establishment of the Division of Nursing within the Office of the Surgeon General. In 1955, the first extracurricular nursing research program was established in the Division of Research Grants and Grants of the Department of Nursing Resources, and the National Institutes of Health (NIH) established the Division of Nursing Research within the Division of Research Grants to conduct scientific review into the field nursing care.
F RAMEWORK
In the planning phase of the research process, the researcher must determine how to protect the rights of research participants. Nurses who are expected to participate in the research process must have an adequate understanding of the nature of the study.
R ESEARCH U TILIZATION
N URSING S TUDENTS
By pursuing and applying research in their chosen field, nurses obtain valuable and reliable information that enables them to provide quality care.
EVIDENCED-BASED PRACTICE
COMMUNITY CONSIDERATIONS Nursing Research
The need for improved client outcomes, reduced health care costs, and client satisfaction are driving forces for the use of scientific data in the decision-making process for client care (Boswell, 2007). Early efforts to study client outcomes emerged from quality assurance or quality improvement studies involving nurses in the development of interdisciplinary care plans, such as critical pathways and care maps.
E VIDENCE R EPORTS
To achieve the goals of evidence-based practice, a culture of practice must be developed in which all clinicians from all disciplines are expected to justify their practices with the best evidence currently available” (Burns. Identifying the Knowledge Base for Nursing Practice contributes to client outcomes and the credibility of nursing practice.
T RENDS IN R ESEARCH AND
E VIDENCE -B ASED P RACTICE
This chapter discusses the types of health care services available, different settings in which these services are provided, and the members of the health care team. The economics of healthcare and the challenges within the healthcare delivery system are also discussed.
HEALTH CARE DELIVERY
Nurses must therefore understand the changes occurring within this system as well as their role in shaping the changes. In addition, this chapter discusses quality improvement in health care as well as continuity of care.
ORGANIZATIONAL FRAMEWORKS
P UBLIC S ECTOR
Sanitation, immunization and health surveillance are just some of the services provided at the local level. The threat of bioterrorism and natural disasters reinforces the need for access to health resources at the local level.
P RIVATE S ECTOR
HEALTH CARE TEAM
N URSE : R OLES AND F UNCTIONS
A DVANCED P RACTICE N URSE : R OLES
AND F UNCTIONS
Many APRNs advance the quality of health care by providing services to populations that are often underserved by other health care providers. They provide primary health care services by diagnosing and treating common acute illnesses and injuries.
REIMBURSEMENT METHODS
P RIVATE I NSURANCE
M ANAGED C ARE
Another common feature of health care organizations is the practice of a single point of access (entry to the health care system is required through a point designated by the plan) where primary care is provided. Primary health care is the client's access point to health care. system and includes assessment, diagnosis, treatment, coordination of care, education, preventive services and surveillance. PCPs act as “gatekeepers” for the healthcare system in that they determine what, if any, referrals to specialists are necessary for the client.
G OVERNMENT P LANS
States have a lot of influence over health care reimbursement because each state regulates insurance companies. Every state makes decisions about financing Medicaid and is therefore concerned about rising healthcare costs.
FACTORS INFLUENCING THE DELIVERY OF HEALTH CARE
Hospitals are reimbursed only for services that are determined to be medically necessary by CMS. When Medicare was created in 1965, it was intended to protect individuals over the age of 65 from excessive health care costs by providing public funds to cover most health care services.
C OST
Another trend is that CMS will no longer pay for certain incidents, called "never events." The Medicare Modernization Act and the Deficit Reduction Act of 2005 allow CMS to reduce or deny reimbursement to hospitals for certain medical events. Medicaid reimburses NPs and CNMs if APRNs are authorized by state regulations to provide CMS-specified services.
A CCESS
Q UALITY
N URSING S UPPLY AND D EMAND
RESPONSES TO HEALTH CARE CHANGES
N URSING A GENDA FOR H EALTH C ARE
R EFORM
A gradual introduction of essential services that target vulnerable populations with limited access to healthcare.
P UBLIC VERSUS P RIVATE P ROGRAMS
V ULNERABLE P OPULATIONS
C OMMUNITY N URSING O RGANIZATIONS
NURSINGCHECKLIST
CONTINUUM OF CARE
L EVELS OF C ARE
H EALTH C ARE S ETTINGS
COMMUNITY CONSIDERATIONS
F RAGMENTATION OF C ARE
ESTABLISHING SERVICES PROVIDING NURSE'S ROLES/RESPONSIBILITIES Comprehensive care. long-term care) facilities (eg nursing homes, skilled nursing facilities). For example, the client may be seen by one set of health care providers in an outpatient clinic, then admitted to the hospital, and then discharged to home health care.
QUALITY MANAGEMENT IN HEALTH CARE
Because of the many different settings and care providers, the person's individuality can be overlooked. Many healthcare providers and organizations (such as HMOs) are implementing the concept of seamless service to overcome the delivery of fragmented services.
D EFINING Q UALITY
Total Quality Management (TQM) is a way of managing and operating a system used to achieve CQI. TQM is a system of operations, while CQI is the desired outcome of a quality management program.
F ACTORS I NFLUENCING Q UALITY IN H EALTH C ARE
Quality assurance (QA) is the traditional approach to quality management in which monitoring and evaluation focus on individual performance, deviation from standards, and problem solving. The goal of a quality management program is to focus on process improvement, which will ultimately improve the quality of care.
Q UALITY AND H EALTH C ARE
Nurses, like other healthcare providers, must understand the role that legislation and regulations play in the quality movement. A number of federal agencies regulate health care standards, for example, the CMS, the Food and Drug Administration, and the Occupational Safety and Health Administration (OSHA).
E CONOMICS
There are also federal laws that prohibit substandard care, promote peer review of health care providers, and mandate the reporting of serious injury or death to clients resulting from the unsafe use of medical devices. Federal funding and payment for services may be denied for failure to provide quality care.
P RINCIPLES OF Q UALITY
I MPROVEMENT
C USTOMER S ATISFACTION
The loss of one admission is relatively insignificant for a multi-million dollar budget; however, multiple losses can have a significant effect on the financial well-being of a healthcare institution. Satisfaction is a subjective perception; therefore, healthcare providers must constantly listen to the customer to determine satisfaction and dissatisfaction.
ORGANIZATIONAL STRUCTURE FOR QUALITY MANAGEMENT
Therefore, the organization and every employee must understand the consequences of customer dissatisfaction from a financial point of view. There is an additional potential loss of revenue from associated post-hospitalization ancillary services such as home health care, laboratory procedures, pharmaceutical supplies, and office monitoring.
O RGANIZATIONAL C ULTURE
A customer's dissatisfaction with one aspect of service can be generalized to all relevant delivery systems. Seemingly simple actions such as the following can result in client dissatisfaction despite a positive health outcome:
P ROCESS I MPROVEMENT
NURSING’S ROLE IN QUALITY MANAGEMENT
TRENDS IN HEALTH CARE DELIVERY
Nursing Process: The Standard of CareStandard of Care
List the tasks involved in the outcome identification and planning steps in the nursing process.
CRITICAL THINKING
C OMPONENTS OF C RITICAL T HINKING
One of the most important attitudes a critical thinker needs is a sense of curiosity that allows a person to question the assumptions on which decisions are based. Analyzing basic assumptions allows a person to plan and act in a rational way, rather than out of habit or routine.
D EVELOPMENT OF C RITICAL
The attitude of open-mindedness helps the nurse to better care for clients whose lifestyle choices and values differ from those of the nurse; see the Respecting Our Differences box on reflective thinking and value systems. Critical thinkers question their assumptions and the effect of those assumptions on their actions.
T HINKING S KILLS
RESPECTING OUR DIFFERENCES
C RITICAL T HINKING AND C REATIVITY
C RITICAL T HINKING AND P ROBLEM
S OLVING
C RITICAL T HINKING AND D ECISION M AKING
Through a process of problem solving, one gets to the point where decisions can be made. The nursing process is the specific problem-solving method used by nurses to get to the point where decisions about client care can be made.
THE NURSING PROCESS
Nurses exercise clinical judgment by making sound decisions; clinical judgment can be seen as the application of critical thinking. It is important that those decisions are the best decisions possible, are based on reliable information and are made with as much critical thinking as possible.
H ISTORICAL P ERSPECTIVE
O VERVIEW OF THE N URSING P ROCESS
A SSESSMENT
NURSING PROCESS
The data that is collected must be organized so that it is useful to the health care professional collecting the data, as well as to others involved in the client's care. Gathering similar pieces of information helps the nurse build a picture of the client's problems and strengths.
D IAGNOSIS
The nurse makes a judgment about which data should be reported immediately and which data should only be recorded at that time. It is composed of the diagnostic label preceded by the phrase 'readiness for enhanced'. For example, a client who is neither overweight nor underweight tells the nurse that she knows she can improve her diet in some ways.
O UTCOME I DENTIFICATION AND P LANNING
Once formulated, the list of diagnoses is presented to the client for confirmation if possible. As with other steps in the nursing process, the list of interventions is not static.
I MPLEMENTATION
Once interventions are determined for each diagnosis, the interventions are recorded in the client's care plan. Critical thinking is essential in every step of the nursing process, especially in developing client outcomes and appropriate intervention strategies.
E VALUATION
If the goal is partially achieved or not achieved, the nurse should reassess the situation. Nurses continually evaluate data to make informed decisions during other phases of the nursing process.
CRITICAL THINKING APPLIED IN NURSING
Data is collected to determine why the goal is not being met and what changes to the plan of care are needed. Critical thinking promotes evaluation by helping nurses look at the big picture to determine client status.
COMMUNITY CONSIDERATIONS Priorities and Referrals
Assessment is the first step in the nursing process and involves collecting, validating, organizing, categorizing and recording data. The second step in the nursing process involves further analysis and synthesis of data and results in a list of nursing diagnoses.
PURPOSE OF ASSESSMENT
Assessment is the first step in the nursing process and involves the systematic collection, verification, organization, interpretation and documentation of data for use by healthcare professionals. Assessment is the collection and analysis of data used in formulating nursing diagnoses, determining outcomes and planning care, and developing nursing interventions.
TYPES OF ASSESSMENT
This chapter discusses the purpose of evaluation, the types of evaluation, and the use of data in the evaluation process.
C OMPREHENSIVE A SSESSMENT
F OCUSED A SSESSMENT
Focused assessments are not as detailed as comprehensive assessments and are often used in health care settings where a short stay is expected (eg, ambulatory surgical centers and emergency departments), in specialty areas such as labor and delivery, and in mental health settings. or for the purposes of screening for specific problems or risk factors (e.g., Good Kids Clinics).
O NGOING A SSESSMENT
DATA COLLECTION
T YPES OF D ATA
S OURCES OF D ATA
COMMUNITY CONSIDERATIONS Assessing Clients at Home
M ETHODS OF D ATA C OLLECTION
The client's reason for seeking care is also discussed early in the work phase. The nurse uses a sensitive, nonjudgmental approach in assessing the client's use of all healing practices.
DATA VERIFICATION
Shape and consistency of organs or masses: Best detected by grasping the organ or mass between the fingertips. Percussion uses short, pounding strokes on the surface of the skin to create vibrations of underlying organs.
DATA ORGANIZATION
A SSESSMENT M ODELS
Second, safety and security needs – both physical (e.g., protection from bodily harm) and psychological (e.g., safety and stability). Fifth: Self-actualization needs – the need to function at optimal levels and be personally fulfilled.
DATA INTERPRETATION
HIERARCHY OF NEEDS Maslow's hierarchy of needs model (1971) suggests that an individual's basic physiological needs must be satisfied before progressing to higher-level needs. Use of a hierarchy of needs model requires initial assessment of all physiological needs, followed by assessment of higher level needs.
DATA DOCUMENTATION
Although nurses often use this method as well, the body systems model does not facilitate the formulation of nursing diagnoses. Third: The need for love and belonging - humans have an innate need to be part of a group and to feel accepted by others.
T YPES OF A SSESSMENT F ORMATS
In addition, psychosocial aspects of the client's status are often neglected, resulting in fragmentation of care. The purpose of a nursing diagnosis is to effectively communicate the client's needs among members of the health care team.
WHAT IS A NURSING DIAGNOSIS?
This chapter describes the nature of a nursing diagnosis, the purpose and types of nursing diagnoses, and the components of a nursing diagnosis statement. Development of nursing diagnoses and methods to avoid diagnostic errors in the formulation of nursing diagnoses are also presented.
C OMPARISON OF N URSING AND
When a nursing diagnosis is part of the client's care plan, the nurse can communicate the client's needs to other professionals involved in that care. To determine individualized therapeutic nursing interventions, the nurse must develop appropriate nursing diagnoses based on organized assessment data.
M EDICAL D IAGNOSES
The purpose of a nursing diagnosis is to focus on the human response or responses of the individual, family, or community to the identified problems or conditions. For example, if the medical diagnosis for a client is breast cancer, appropriate nursing diagnoses might include fear, lack of knowledge about treatment measures, grief, disturbed body image, helplessness, and ineffective coping.
HISTORICAL PERSPECTIVE
An example of these similarities can be illustrated by considering a client who has a medical diagnosis of asthma. The physician would use this information to treat the asthma disease and the nurse would use this information to focus on the client's response to the disease, which would result in a nursing diagnosis of an ineffective breathing pattern.
R ESEARCH
Medical diagnosis is the terminology used for a clinical judgment by the physician that identifies or diagnoses a specific disease, condition, or pathological condition. Nursing diagnosis is the terminology used for a clinical judgment by the professional nurse that identifies the client's actual, risk, wellness, or syndrome responses to a health condition, problem, or condition.
PURPOSES OF NURSING DIAGNOSES
Similarities include (1) the use of a diagnostic process, where "process" means purpose, organization, and creativity (Bevis uses cognitive, interpersonal, and psychomotor skills; (3) gathering and critically analyzing assessment data; (4) evaluating outcomes to determine follow-up, dismissals or changes to the established diagnosis and (5) operating within the legal dimensions and standards of the profession in question.
P ROFESSIONALISM
C OMMUNICATION
H OLISTIC , I NDIVIDUALIZED C ARE
N URSING D IAGNOSES AND N URSING I NFORMATICS
COMMUNITY CONSIDERATIONS Home Health Care Setting
The advent of the electronic health record has advanced standardized nursing languages—perhaps faster than any other movement in healthcare. As more and more healthcare organizations automate documentation, it becomes necessary for nursing to be able to efficiently and completely document both the nursing care provided and the clinical judgments (nursing diagnoses) that underlie that care.
COMPONENTS OF A NURSING DIAGNOSIS
The challenge is therefore to bring together different computer systems to meet the needs of clients and clinicians in these new ones. The three-part statement is preferred by those nurses who wish to strengthen the diagnostic statement by including specific manifestations, an attribute not possible using the two-part form.
Two formats commonly found in nursing literature are the two- and three-part statements. The two-part statement has been approved by NANDA and is used by most nurses, largely due to its short and precise format.
T HE T HREE -P ART S TATEMENT
CATEGORIES OF NURSING DIAGNOSES
Examples of actual diagnoses include excessive fluid volume, RT, intravenous infusion therapy, strain and anxiety, RT, unknown breast biopsy results. Risk diagnoses are identified when there is a recognized vulnerability for the client to exhibit a problem, but that response has not yet manifested.
TAXONOMY OF NURSING DIAGNOSES
CLINICAL JUDGMENT IN
NURSING: DEVELOPING NURSING DIAGNOSES
G ENERATING C UES
V ALIDATING C UES
I NTERPRETING C UES
The accompanying nursing checklist contains questions to assist in making appropriate diagnoses.
C LUSTERING C UES
U SING NANDA-A PPROVED N URSING D IAGNOSES
W RITING THE N URSING D IAGNOSIS
S TATEMENT
AVOIDING ERRORS IN
DEVELOPMENT AND USE OF NURSING DIAGNOSES
A SSESSMENT E RRORS
An example of this is the nurse's inability to recheck an elevated admission blood pressure. An example of this is a client who comes to the outpatient care clinic and presents with various signs and symptoms, including a reported weight gain of 4 pounds that month.
D IAGNOSTIC E RRORS
An example of this is a newly admitted client with a cerebral infarction, who has a speech disorder and can provide only limited assessment data. A blood pressure check may have revealed a temporary increase due to the stress of the admission process.
LIMITATIONS OF NURSING DIAGNOSIS
OVERCOMING BARRIERS AND LIMITATIONS TO NURSING
See the Nursing Checklist for a list of strategies useful in overcoming barriers to using nursing diagnoses. Following the planning component, the nursing process continues with implementation of nursing interventions and evaluation of the client's response to the care plan.
PURPOSES OF PLANNING AND OUTCOME IDENTIFICATION
Planning, the third step of the nursing process, includes the formulation of guidelines used to establish the client's plan of care. Strategies for effective planning of quality nursing care are described along with problems frequently encountered at this stage of the nursing process.
PROCESS OF PLANNING AND OUTCOME IDENTIFICATION
This step is preceded by the collection of assessment data and the formulation of nursing diagnoses. After a nurse has thoroughly assessed a client and determined the client's unique nursing diagnoses (or problems), an action plan is developed with specific goals to address the nursing diagnoses or health problems.
C RITICAL T HINKING
Discharge planning is a multidisciplinary team effort that focuses on providing a seamless transition across the continuum of care. The formulation of objectives is accomplished by using valid and reliable data previously collected during the assessment phase of the nursing process.
E STABLISHING P RIORITIES
Despite the fact that the client does not currently have problems in this area, this diagnosis is indeed the basis for a protocol of close monitoring of the client in the postanesthesia care unit. However, it is sometimes critical that the nurse and client properly prioritize the client's nursing diagnoses so that most effort can be directed toward resolving the most urgent diagnosis; see Table 8-2.
E STABLISHING G OALS AND E XPECTED
For example, a client on a postanesthesia care unit may have a high-priority nursing diagnosis of ineffective breathing pattern related to anesthesia and sedation.
O UTCOMES
C OMPONENTS OF G OALS AND E XPECTED O UTCOMES
The next component to include in writing effective goals is the conditions under which the client is expected to complete or demonstrate mastery of the task. The final component to include in proper goal writing is the time frame in which the client must complete or demonstrate mastery of the task.
P ROBLEMS F REQUENTLY E NCOUNTERED IN P LANNING
On Saturday, the customer will walk around the entire corridor three times a day. What is the action the client is expected to take in each of the previous examples.
P LANNING N URSING I NTERVENTIONS
The nurse is responsible for writing nursing orders that include health promotion, observation, prevention and treatment (Wilkinson, 2006). The nurse assumes responsibility for being both the primary coordinator of the client's nursing care plan and the mediator of interdepartmental collaboration (Doenges et al., 2006).
E VALUATING C ARE
The nurse may not order medication, but when administering it, the nurse is responsible for knowing the classification, pharmacological action, normal dosage, side effects, side effects, contraindications, and nursing implications. Given the emphasis on critical thinking in the planning stage of the nursing process, the nurse does not automatically perform a prescribing practitioner without due process.
NURSING OUTCOMES CLASSIFICATION (NOC)
Nurse researchers who observe, measure, and study client outcomes believe that outcomes indicate the quality or effectiveness of the nursing interventions provided. Strengthening the links between nursing interventions and client outcomes will not only benefit clients, but also nursing.
PLAN OF CARE
The NOC system can be used to improve decision making in clinical practice and research. Solid research evidence documenting the effectiveness of nursing care on client outcomes will inform policy and financial decisions related to nursing care.
T YPES OF C ARE P LANS
The NOC taxonomy focuses on function, physiology, psychosocial aspects, health knowledge and behavior, and perceived self and family health. The NOC system, which defines over 330 client outcomes sensitive to nursing interventions, allows nurses to evaluate client status over time.
COMMUNITY CONSIDERATIONS Nursing Outcomes Classification
Institutional nursing care plans are concise documents that become part of the client's medical record after discharge from the hospital. In addition, the Kardex nursing care plan can be expanded to include assessment, nursing diagnosis, goal setting, implementation, and evaluation.
STRATEGIES FOR EFFECTIVE CARE PLANNING
Strategies for effective care planning include communicating the client's care plan within the health care team, establishing a realistic care plan, and formulating measurable and future-oriented goals. Implementation, the fourth step in the nursing process, involves carrying out the nursing plan of care developed during the planning phase.
PURPOSES OF IMPLEMENTATION
REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION
C OGNITIVE S KILLS
P SYCHOMOTOR S KILLS
I NTERPERSONAL S KILLS
IMPLEMENTATION ACTIVITIES
While demonstrating the use of this equipment, the nurse notes that the client cannot easily press the button with the fingers of her right hand. The nurse's assessment and clinical judgment often determine whether the client requires continued care or referral to other health care providers.
E STABLISHMENT OF P RIORITIES
The client tells the nurse that she forgot to mention that her joints swell occasionally and that she has very little hand strength during these times. Continuous assessment requires attention to verbal and nonverbal cues from the client and knowledge of expected responses to specific interventions.
COMMUNITY CONSIDERATIONS Care in the Home
Goals, expected outcomes, and interventions may need to be changed as new data are collected or progress toward outcome achievement is evaluated. The time allocated for activities depends on the complexity of the task and the amount of assistance the client requires.
A LLOCATION OF R ESOURCES
The primary care nurse establishes health care goals with the client and plans care to achieve those goals. CASE MANAGEMENT In a case management system, the nurse assumes responsibility for planning, implementing, coordinating, and evaluating care for a given client, regardless of the client's location at any given time.
N URSING I NTERVENTIONS
The nurse assesses the client's progress in relation to what is expected, investigates and follows up on any deviations in the time required or the amount of improvement noted. The goal of case management is to help the client maintain optimal health with the least possible intervention from health care providers.
COMMUNITY CONSIDERATIONS Factors Influencing a Case Manager’s
If the rejected intervention is prescribed by another healthcare professional, this person must be informed of the rejection of treatment. MONITORING AND MONITORING Observation of the client's response to treatment is an integral part of the implementation of any intervention.
E VALUATING I NTERVENTIONS
Although the nurse may delegate certain tasks to other staff, it is still her responsibility to ensure that the task has been performed according to the standard of care and to record the client's response to assess progress toward expected outcomes. Regardless of management style or type of facility, coordination of client activities among various health care providers remains the nurse's responsibility.
D OCUMENTATION OF I NTERVENTIONS
Which of the following best describes the purpose of continuous evaluation in the implementation of nursing activities. Which of the following should nurses do initially when performing a procedure that they have never done before.
EVALUATION OF CLIENT CARE
Although it is the final phase of the nursing process, assessment is an ongoing part of daily nursing activities. Evaluation is not only part of the nursing process, but also an integral process in determining the quality of healthcare provided.
COMPONENTS OF EVALUATION
Evaluation is the fifth step in the nursing process and involves determining whether the client's goals have been met, partially met, or not met. The main purpose of evaluation is to determine the effectiveness of these activities in helping clients achieve expected results.
T ECHNIQUES
Assessment is a collaborative process between the nurse, client, family, and other health care providers. The nurse's verbal and nonverbal communication establishes an atmosphere in which clients and families freely share their comments, both positive and negative.
G OALS AND E XPECTED O UTCOMES
When the nurse communicates an assessment of the client's response to an actual or potential health problem, clients and families are empowered to discuss their concerns and questions. When feedback is given, the nurse should avoid being defensive, as this may discourage clients or families from being open and honest.
E STABLISHING S TANDARDS
As a result, clients may say only what they think the nurse wants to hear or they may refuse to participate in the assessment process.
C OLLECTING D ATA
D ETERMINING G OAL A CHIEVEMENT
R ELATING N URSING A CTIONS TO C LIENT S TATUS
J UDGING THE V ALUE OF N URSING
I NTERVENTIONS
R EASSESSING THE C LIENT ’ S S TATUS
M ODIFYING THE P LAN OF C ARE
For example, the home nurse continuously evaluates the care provided through the client's relationship with the agency. Evaluation of the home care client is performed to determine if care was delivered effectively, to modify the care plan as needed, and to decide when the client is ready to discontinue home care. .
C RITICAL T HINKING AND E VALUATION
The accompanying Community Considerations display provides an example of evaluation performed by the home health nurse.
EVALUATION AND QUALITY OF CARE
E LEMENTS IN E VALUATING THE
Q UALITY OF C ARE
COMMUNITY CONSIDERATIONS Evaluation in the Home Health Care
Process evaluation determines the nurse's ability to establish an environment that promotes the client's health. Evaluating the effectiveness of preoperative interventions: the appropriateness of using the Child Emotional Manifestation Scale''.
N URSING A UDIT
The accompanying nursing process emphasis demonstrates the application of the North American Nursing Diagnostic Association (NANDA), NOC, and NIC systems with a client experiencing problems with his or her feeding.
P EER E VALUATION
EVALUATION AND ACCOUNTABILITY
MULTIDISCIPLINARY COLLABORATION IN
NURSING CARE PLAN
Professional Accountability