Diagnosis 1. Analyze data 2. Identify nursing diagnoses and collaborative problems Assessment
1. Collect data 2. Organize data
Evaluation 1. Monitor client outcomes 2. Resolve, continue, revise the current plan for care
1. Carry out the nursing orders 2. Document the nursing care and client responses
Planning
1. Prioritize problems 2. Identify measurable outcomes (goals) 3. Select nursing interventions 4. Document the plan of care
Implementation
FIGURE 2-1
•
The steps in the nursing process.BOX 2-1 ● Standards of Clinical Nursing Practice
Standard I. Assessment The nurse collects patient health data.
Standard II. Diagnosis
The nurse analyzes the assessment data in determining diagnoses.
Standard III. Outcome Identification
The nurse identifies expected outcomes individualized to the patient.
Standard IV. Planning
The nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Standard V. Implementation
The nurse implements the interventions identified in the plan of care.
Standard VI. Evaluation
The nurse evaluates the patient’s progress toward attainment of outcomes.
Reprinted with permission from American Nurses Association. (1998).
Standards of clinical nursing practice,(2nd ed.). Washington, DC:
American Nurses Association.
18 U N I T 1 ● Exploring Contemporary Nursing
with the nurse’s first contact with a client and continues as long as a need for health care exists. During assess- ment, the nurse collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths (Alfaro-LeFevre, 2005).
Types of Data
Data are either objective or subjective (Box 2-2). Objective dataare observable and measurable facts and are referred to as signsof a disorder. An example is a client’s blood pressure measurement. Subjective dataconsist of informa- tion that only the client feels and can describe, and are calledsymptoms. An example is pain.
Sources for Data
The primary source for information is the client. Sec- ondary sources include the client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers.
Types of Assessments
There are two types of assessments: a data base assess- ment and a focus assessment (Table 2-1).
DATA BASE ASSESSMENT. Adata base assessment(initial information about the client’s physical, emotional, social, and spiritual health) is lengthy and comprehensive. The nurse obtains data base information during the admis- sion interview and physical examination (see Chap. 13).
Health care facilities generally provide a printed form to use as a guide (Fig. 2-2). Information obtained during a data base assessment serves as a reference for comparing all future data and provides the evidence used to iden- tify the client’s initial problems. Comparisons of ongoing assessments with baseline data help determine whether the client’s health is improving, deteriorating, or remain- ing unchanged.
FOCUS ASSESSMENT. A focus assessment is information that provides more details about specific problems and expands the original data base. For instance, if during the initial interview the client tells the nurse that constipa- tion is the rule rather than the exception, more questions follow. The nurse obtains data about the client’s dietary habits, level of activity, fluid intake, current medications, frequency of bowel elimination, and stool characteris- tics. The nurse may ask the client to save a stool speci- men for inspection.
Focus assessments generally are repeated frequently or on a scheduled basis to determine trends in a client’s con- dition and responses to therapeutic interventions. Exam- ples include conducting postoperative surgical assessments BOX 2-2 ● Examples of Objective and Subjective Data
OBJECTIVE DATA SUBJECTIVE DATA
Weight Pain
Temperature Nausea
Skin color Depression
Blood cell count Fatigue
Vomiting Anxiety
Bleeding Loneliness
COMPARISON OF DATA BASE AND FOCUS ASSESSMENTS
TABLE 2-1
DATA BASE ASSESSMENT FOCUS ASSESSMENT
Obtained on admission
Consists of predetermined questions and systematic head-to-toe examination
Performed once
Suggests possible problems
Findings documented on an admission assessment form Time-consuming; may take 1 hour or more
Supplies a broad, comprehensive volume of data Provides breadth for future comparisons
Reflects the client’s condition on entering the health care system
Compiled throughout subsequent care
Consists of unstructured questions and collection of physical assessments
Repeated each shift or more often Rules out or confirms problems
Findings documented on a checklist or in progress notes Completed in a brief amount of time (about 15 minutes) Collects limited data
Adds depth to the initial data base
Provides comparative trends for evaluating the client’s response to treatment
Stop • Think + Respond BOX 2-1 Which of the following represent objective data?
1. A client rates his pain as 8 on a scale of 0 to10, with 10 being the most pain he has ever experienced.
2. A client has an incisional scar in the right lower quad- rant of the abdomen.
3. A client says she slept very well and feels rested.
4. A client’s blood pressure is 165/86 mm Hg.
5. A client’s heart rate is irregular.
FIGURE 2-2
•
One page of a multipage admission assessment form is shown. (Courtesy of the Commu- nity Health Center of Branch County, Coldwater, MI.)C H A P T E R 2 ● Nursing Process 19
20 U N I T 1 ● Exploring Contemporary Nursing
(see Chap. 27), monitoring the client’s level of pain before and after administering medications, and checking the neurologic status of a client with a head injury.
Organization of Data
Interpreting data is easier if information is organized.
Organization involves grouping related information. For example, consider the following list of words: apple, wheels, orchard, pedals, tree, and handlebars. At first glance, they appear to be a jumble of terms. If asked to cluster the related terms, however, most people would correctly group apple, tree, and orchard together, and wheels, pedals, and handlebars together.
Nurses organize assessment data similarly. Using knowledge and past experiences, they cluster related data (Box 2-3). Data organized into small groups is eas- ier to analyze and takes on more significance than when the nurse considers each fact separately or examines the entire group at once.
five groups: actual, risk, possible, syndrome, and wellness (Table 2-2).
THE NANDA LIST. The ANA has designated the North American Nursing Diagnosis Association (NANDA) as the authoritative organization for developing and approv- ing nursing diagnoses. NANDA is the clearinghouse for proposals suggesting diagnoses that fall within the inde- pendent domain of nursing practice. NANDA reviews the proposals for appropriateness. While research is ongoing, NANDA incorporates its findings into a list published for clinical use. The most recent index, which is revised every 2 years, is provided on the inside back cover.
Although entries in the NANDA list change, most authorities believe that nurses should use the language of approved diagnoses whenever possible. When a client’s problem does not fit into any of the NANDA-approved categories, the nurse can use his or her own terminology when stating the nursing diagnosis.
DIAGNOSTIC STATEMENTS. An actual nursing diagnostic statement contains three parts:
1. Name of the health-related issue or problem as iden- tified in the NANDA list
2. Etiology (its cause) 3. Signs and symptoms
The name of the nursing diagnosis is linked to the eti- ology with the phrase “related to,” and the signs and
BOX 2-3 ● Organization of Data
Assessment Findings
Lassitude; distended abdomen; dry, hard stool passed with difficulty; fever;
weak cough; thick sputum Related Clusters Lassitude, fever Weak cough, thick sputum
Distended abdomen; dry, hard stool passed with difficulty
Stop • Think + Respond BOX 2-2 Organize the following data into two related clusters:
cough, dry skin, infrequent urination, fever, nasal congestion, thirst.
Diagnosis
Diagnosis, the second step in the nursing process, is the identification of health-related problems. Diagnosis re- sults from analyzing the collected data and determining whether they suggest normal or abnormal findings.
Nursing Diagnoses
Nurses analyze data to identify one or more nursing diagnoses. A nursing diagnosisis a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility. Nursing diagnoses are categorized into
CATEGORIES OF NURSING DIAGNOSES
TABLE 2-2
TYPE EXPLANATION AND EXAMPLE Actual diagnosis
Risk diagnosis
Possible diagnosis
Syndrome diagnosis
Wellness diagnosis
A problem that currently exists Impaired Physical Mobility related to
pain as evidenced by limited range of motion, reluctance to move A problem the client is uniquely
at risk for developing Risk for Deficient Fluid Volume
related to persistent vomiting A problem may be present, but
requires more data collection to rule out or confirm its existence Possible Parental Role Conflict
related to impending divorce Cluster of problems predicted to
be present because of an event or situation (Carpenito-Moyet, 2007)
Rape Trauma Syndrome and Disuse Syndrome
A health-related problem with which a healthy person obtains nursing assistance to maintain or perform at a higher level Potential for Enhanced Breastfeeding
symptoms are identified with the phrase “as manifested (or evidenced) by” (Box 2-4).
Different types of diagnoses have different stems. Risk diagnosesare prefaced with the term “risk for,” as in Risk for Impaired Skin Integrity related to inactivity. The word “possible” is used in a diagnostic statement to indi- cate uncertainty—for example, Possible Sexual Dysfunc- tion related to anxiety. Wellness diagnoses are prefaced with the phrase “Potential for enhanced.”
Risk and possible nursing diagnoses do not include the third part of the statement. In risk nursing diagnoses, the signs or symptoms have not yet manifested; in possible nursing diagnoses, the data are incomplete. The factors that place the client at risk or make the nurse suspect such a diagnosis, however, are identified in the nursing assess- ment documentation. Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms.
Collaborative Problems
Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interven- tions. They represent an interdependent domain of nurs- ing practice (Fig. 2-3). The nurse is specifically responsible and accountable for
• Correlating medical diagnoses or medical treatment measures with the risk for unique complications.
• Documenting the complications for which clients are at risk.
• Making pertinent assessments to detect complications.
• Reporting trends that suggest development of compli- cations.
• Managing the emerging problem with nurse- and physician-prescribed measures.
• Evaluating the outcomes.
Collaborative problems are identified on a client’s plan for care with the abbreviation PC, which stands for Potential Complication (Table 2-3). Because a collabora- tive problem requires the nurse to use diagnostic processes, some nursing leaders are proposing the use of the term
“collaborative diagnosis” instead (Alfaro-LeFevre, 2005).
Nursing diagnoses
Nursing Other health care professionals (medicine, social services, etc.) Collaborative
problems Medical diagnoses
FIGURE 2-3
•
These two overlapping circles illustrate that the nurse independently treats nursing diagnoses. Doctors, other health profes- sionals, and nurses work together on collaborative problems.Stop • Think + Respond BOX 2-3 Which of the following nursing diagnostic statements is written correctly based on the data and the information in this chapter?
Data: The client eats only bites of the food served. She has lost 15 lbs in the last 3 weeks and currently weighs 130 lbs, which is more than 10% underweight for her height. She has been experiencing chronic vomiting after eating for the last 3 weeks and is physically weak.
1. Risk for Imbalanced Nutrition: Less than Body Require- ments related to vomiting
2. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of food secondary to vomiting as manifested by caloric intake below daily requirements, recent weight loss of 15 lbs, and current weakness
3. Weight Loss related to vomiting as evidenced by reduced intake of food
4. Possible Malnutrition due to inadequate consumption of nutrients
BOX 2-4 ● Parts of a Nursing Diagnostic Statement
1.Disturbed Sleep Pattern =problem 2.Related to excessive intake of coffee =etiology
3.As manifested by difficulty in falling asleep, feeling tired during the day, and irritability with others =signs and symptoms
Planning
The third step in the nursing process is planning, or the process of prioritizing nursing diagnoses and collabora- tive problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. Whenever possible, the nurse consults the client while developing and revising the plan.
Setting Priorities
Not all clients’ problems can be resolved in a brief time.
Therefore, it is important to determine which problems require the most immediate attention. This is done by set- ting priorities. Prioritization involves ranking from those that are most serious or immediate to those of lesser importance.
C H A P T E R 2 ● Nursing Process 21
22 U N I T 1 ● Exploring Contemporary Nursing
There is more than one way to determine priorities.
One method nurses frequently use is Maslow’s Hierarchy of Human Needs (see Chap. 4). Problems interfering with physiologic needs have priority over those affecting other levels of needs (Table 2-4). The ranking can change as problems are resolved or new problems develop.
Establishing Goals
Agoal(expected or desired outcome) helps the nursing team know whether the nursing care has been appropri- ate for managing the client’s nursing diagnoses and collab- orative problems. Therefore, a written goal accompanies each one. Although the terms goal and outcome are some- times used interchangeably, outcomes are generally more specific (Box 2-5). What is important is that the goal state-
ment or outcome contains the criteria or objective evidence for verifying that the client has improved. Depending on the agency, nurses may identify short-term goals, long-term goals, or both.
SHORT-TERM GOALS. Nurses use short-term goals(outcomes achievable in a few days to 1 week) most often in acute care settings because most hospital stays are no longer than 1 week. Short-term goals have the following char- acteristics (Box 2-6):
• Developed from the problem portion of the diagnostic statement
• Client-centered,reflecting what the client will accom- plish, not the nurse
• Measurable,identifying specific criteria that provide evidence of goal achievement
• Realistic,to avoid setting unattainable goals, which can be self-defeating and frustrating
• Accompanied by a target datefor accomplishment, the predicted time when the goal will be met. Identifying a target date establishes a time line for evaluation.
LONG-TERM GOALS. Nurses generally identify long-term goals(desirable outcomes that take weeks or months to accomplish) for clients with chronic health problems that require extended care in a nursing home or who receive community health or home health services. An example of a long-term goal for the client with a cerebrovascular accident (stroke) is the return of full or partial function to a paralyzed limb. The client is unlikely to have achieved CORRELATION OF COLLABORATIVE PROBLEMS
TABLE 2-3
MEDICAL DIAGNOSIS OR MEDICAL TREATMENT POSSIBLE CONSEQUENCE COLLABORATIVE PROBLEM Myocardial infarction (heart attack)
Heart failure Severe burns
HIV positive (infected with AIDS virus) Gastric decompression
(suctioning stomach fluid) Cardiac catheterization (inserting a
catheter into the heart)
PC: Dysrhythmias PC: Pulmonary edema PC: Hypovolemic shock PC: Immunodeficiency PC: Alkalosis
PC: Electrolyte imbalance PC: Hemorrhage Abnormal heart rhythm
Fluid in the lungs
Serum moves into tissue, depleting blood volume
Decreased blood cells that fight infection Removes acid and electrolytes
Arterial bleeding
PRIORITIZING NURSING DIAGNOSES
TABLE 2-4
HUMAN NEED EXAMPLES OF NURSING DIAGNOSES Physiologic Imbalanced Nutrition: Less Than Body
Requirements
Ineffective Breathing Pattern Pain
Impaired Swallowing Urinary Retention Safety and security Risk for Injury
Impaired Verbal Communication Disturbed Thought Processes Anxiety
Fear
Love and belonging Social Isolation
Impaired Social Interactions Interrupted Family Processes Parental Role Conflict Esteem and Disturbed Body Image
self-esteem Powerlessness Caregiver Role Strain Ineffective Breastfeeding
Self-actualization Delayed Growth and Development Spiritual Distress
BOX 2-5 ● Goals versus Outcomes
Goal
The client will be well hydrated by 8/23.
Outcome
The client will have adequate hydration as evidenced by an oral intake between 2,000–3,000 mL/24 hours and a urine output ±500 mL of the intake amount by 8/23.
this goal by discharge. If a client achieves short-term goals in the hospital, however, he or she is more likely to achieve long-term goals during care at home or in other community settings.
GOALS FOR COLLABORATIVE PROBLEMS. Goals for collab- orative problems are written from a nursing rather than a client perspective. They focus on what the nurse will monitor, report, record, or do to promote early detection and treatment (Alfaro-LeFevre, 2005).
The format for writing a nursing goal is, “The nurse will manage and minimize (identify complication) by (insert evidence of assessment, communication, and treat- ment activities),” or “(identify complication) will be man- aged and minimized by (evidence).” For example, if the nurse identifies gastrointestinal bleeding as a PC, he or she may state the goal, “The nurse will examine emesis and stools for blood and report positive test findings, changes in vital signs, and decreased red blood cell counts to the physician” or “Gastrointestinal bleeding will be managed and minimized as evidenced by negative Hemoccult tests, red blood cell count greater than 2.5 million/dL, and vital signs within normal ranges.”
Selecting Nursing Interventions
Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking.
Nursing interventions are directed at eliminating the eti- ologies. The nurse selects strategies based on the knowl- edge that certain nursing actions produce desired effects.
Whatever interventions are planned, they must be safe, within the legal scope of nursing practice, and compati- ble with medical orders.
Initial interventions generally are limited to selected measures with the potential for success. Nurses should reserve some interventions in case a client does not accom- plish the goal.
Documenting the Plan of Care
Plans of care can be written by hand (Fig. 2-4), standard- ized forms, computer generated, or based on an agency’s
written standards or clinical pathways. Whatever method is used, the Joint Commission on Accreditation of Health- care Organizations (JCAHO) requires that every client’s medical record provide evidence of the planned nursing interventions for meeting the client’s needs (Carpenito- Moyet, 2007).
Nursing orders(directions for a client’s care) identify the what, when, where, and how for performing nursing interventions. They provide specific instructions so that all health team members understand exactly what to do for the client (Box 2-7). Nursing orders are also signed to indicate accountability.
Standardized care plans are preprinted. Both com- puter-generated and standardized plans provide general suggestions for managing the nursing care of clients with a particular problem. It is up to the nurse to trans- form the generalized interventions into specific nursing orders and to eliminate whatever is inappropriate or unnecessary.
Agency-specificstandards for care(policies that indicate which activities will be provided to ensure quality client care) and clinical pathways (see Chap. 1) relieve the nurse from writing time-consuming plans. Both tools help nurses use their time efficiently and ensure consistent client care.
Communicating the Plan of Care
Clients need consistency and continuity of care to achieve goals. Therefore, the nurse shares the plan of care with nursing team members, the client, and the client’s family. In some agencies, the client signs the plan of care.
The plan of care is a permanent part of the client’s med- ical record. It is placed in the client’s chart, kept separately at the client’s bedside, or located in a temporary folder at the nurses’ station for easy access. Wherever it is located, each nurse assigned to the client refers to it daily, reviews it for appropriateness, and revises it according to changes in the client’s condition.
Implementation
Implementation, the fourth step in the nursing process, means carrying out the plan of care. The nurse imple- ments medical orders as well as nursing orders, which should complement each other. Implementing the plan involves the client and one or more members of the health care team. A wide circle of care providers with assorted roles may be called on to participate, either directly or indirectly, in carrying out one client’s plan of care (Fig. 2-5).
The medical record is legal evidence that the plan of care has been more than just a paper trail. The information in the chart shows a correlation between the plan and the care that has been provided. In other words, the nurse’s BOX 2-6 ● Components of Short-Term Goals
Nursing Diagnostic Statement
Constipation related to decreased fluid intake, lack of dietary fiber, and lack of exercise as manifested by no normal bowel movement for the past 3 days, abdominal cramping, and straining to pass stool
Short-Term Goal
The client will_________________ client–centered
have a bowel movement _________ identifies measurablecriteria that reflect the problem portionof the diagnostic statement
in 2 days (specify date) __________ identifies a target datefor achieve- ment within a realistictime frame
C H A P T E R 2 ● Nursing Process 23