Diversity In Nursing
I SECTION Nursing Process, Clinical I Reasoning, Nursing Diagnosis,
and Evidence-Based Nursing . –
Betty J. Ackley, MSN, EdS, RN, Gail B. Ladwig, MSN, RN,
Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN,
and Marina Martinez-Kratz, MS, RN, CNE
Section I is divided into two parts. Part A includes an overview of the nursing process. 1his section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “patient’s story.” Part B includes advanced nursing concepts.
Part A: The Nursing Process: Usin..,i Clinical Reasoning Skills to Determine Nursing Diagnosis and Plan Care
1. Assessing: performing a nursing assessment 2. Diagnosing: making nursing diagnoses 3. Planning: formulating and writing outcome statements and determining appropriate nursing interventions
based on appropriate best mdence (research) 4. Implementing care 5. Evaluating the outcomet and the JltlrSing care that has been implemented. Make necessary revisions in
care interventions as needed
Part B: Advanced Nursing Concepts
• Concept mapping • QSEN (Quality and Safety Education for Nurses) • Evidence-based nursing care • Quality nursing care • Patient-centered care • Safety • Informatics in nursing • Team/collaborative work with interprofessional team
2 SECTION I
A The Nursing Process: Using Clinical Reasoning Skills to
Determine Nursing Diagnoses and Plan Care
The primary goals of nursing are to (l) determine client/ family responses to human problems, level of wellness, and need for assistance; (2) provide physical care, emotional care, teaching, guidance, and counseling; and (3) implement inter ventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals. The nurse must al\\’.ays focus on assisting clients and families to their highest level of functioning and self-care. The care that is provided should be structured in a way that allows clients the ability to influence their health care and accomplish their self efficacy goals. The nursing process, which is a problem solving approach to the identification and treatment of client problems, provides a framework for assisting clients and families to their optimal level of functioning. The nursing process involves five dynamic and fluid phases: assessment, diagnosis, planning, implementation, and evaluation. Within each of these phases, the client and family story is embedded and is used as a foundation for knowledge, judg ment, and actions brought to the client care experience. A description of the “patient’s story” and each aspect of the nursing process follow.
THE “PATIENT’S STORY”
The “patient’s story” is a term used to describe objective and subjective information about the client that describes who the client is as a person in addition to their usual medical history. Specific aspects of the story include physiological, psychological, and family characteristics; availab!e resources; environmental and social context; knowledge; and motiva tion. Care is influenced, and often driven, by what the client states-verbally or through their physiologic state. The “patient’s story” is fluid and must be shared and understood throughout the client’s health care experience.
There are multiple sources for obtaining the patient’s story. The primary source for eliciting this story is through communicating directly with the client and the client’s family. It is important to understand how the illness (or wellness) state has affected the client physiologically, psychologically, and spiritually. The client’s perception of his or her health state is important to understand and may have an impact on subsequent interventions. At times, clients will be unable to tell their story verbally, but there is still much they can com municate through their physical state. The client’s family (as the client defines them) is a valuable source of information and can provide a rich perspective on the client. Other
valuable sources of the “patient’s story” include the client’s health record. Every time a piece of information is added to the health record, it becomes a part of the “patient’s story.” All nursing care is driven by the client’s story. The nurse must have a clear understanding of the story to effec tively complete the nursing process. Understanding the full story also provides an avenue for identifying mutual goals with the client and family aimed at improving client out comes and goals.
Note: The “patient’s story” is terminology that is used to describe a holistic assessment of information about the client, with the client’s and the family’s input as much as possible. In this text, we use the term “patient’s story” in quotes whenever we refer to the specific process. In all other places, we use the term client in place of the word patient; we think labeling the person as a client is more respectful and empowering for the person. Client is also the term that is used in the National Council Licensure Examination (NCLEX-RN) test plan (National Council of State Boards of Nursing, 2013).
Understanding the “patient’s story” is critically important, in that psychological, socioeconomic, and spiritual character istics play a significant role in the client’s ability and desire to access health care. Also knowing and understanding the “patient’s story” is an integral first step in giving client centered care. In today’s health care world, the focus is on the client, which leads to increased satisfaction with care. Improv ing the client’s health care experience is part of the Affordable Care Act and is tied to reimbursement through value-based purchasing of care: “participating hospitals are paid for inpa tient acute care services based on the quality of care, not just quantity of services they provide” ( Centers for Medicare & Medicaid Services, 2014).
THE NURSING PROCESS
The nursing process is an organizing framework for profes sional nursing practice, a critical thinking process for the nurse to use to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving. This section is designed to help the nursing student learn how to use this thinking process, the nursing process. Key components of the process include the steps listed below. An easy, convenient way to remember the steps of the nursing process is to use an acronym, ADPIE (Figure 1-1):
Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 3
Figure 1-1 Nursing process.
1. Assess: perform a nursing assessment 2. Diagnose: make nursing diagnoses 3. Plan: formulate and write outcome/goal statements and
determine appropriate nursing interventions based on the client’s reality and evidence (research)
4. Implement care 5. Evaluate the outcomes and the nursing care that has been
implemented. Make necessary revisions in care interven tions as needed. The following is an overview and practical application of
the steps of the nursing process. The steps are listed in the usual order in which they are performed.
STEP I: ASSESSMENT (ADPIE) The assessment phase of the nursing process is foundational for appropriate diagnosis, planning, and intervention. Data on all dimensions of the “patient’s story; including biophysi cal, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the client. This is the first step needed to make an appropriate nursing diagnosis, and it is done using the assessment format adopted by the facility or educational institution in which the practice is situated.
The nurse assesses components of the “patient’s story” every time an assessment is performed. Often, nurses focus on the physical component of the story (e.g. , temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is the holistic theory that is applied to clients and families. Clients are active partners in the healing process. Nurses must increasingly develop the skills and systems to incorporate client preferences into care (Hess & Markee, 2014). “The challenge facing the nation, and the opportunity afforded by the Affordable Care Act, is to move from a culture of sickness to a culture of care and then to a culture of health” (Institute of Medicine, 2013). Assess ment information is obtained first by completing a thorough health and medical history, and by listening to and observing
the client. To elicit as much information as possible, the nurse should use open-ended questions, rather than questions that can be answered with a simple “yes” or “no.”
In screening for depression in older clients, the following open-ended questions are useful (Lusk & Pater, 2013): • What made you come here today? • What do you think your problem is? • What do you think caused your problem? • Are you worried about anything in particular? • What have you tried to do about the problem so far? • What would you like me to do about your problem? • Is there anything else you would like to discuss today?
These types of questions will encourage the client to give more information about his or her situation. Listen carefully for cues and record relevant information that the client shares. Even when the client’s physical condition or develop mental age makes it impossible for them to verbally com municate with the health care team, nurses may be able to communicate with the client’s family or significant other to learn more about the client. This information that is obtained verbally from the client is considered subjective information.
Information is also obtained by performing a physical assessment, taking vital signs, and noting diagnostic test results. This information is considered objective information.
The information from all of these sources is used to for mulate a nursing diagnosis. All of this information needs to be carefully documented on the forms provided by the agency or school of nursing. When recording information, the HIPAA (Health Insurance Portability and Accountability Act) (Foster, 2012) regulations need to be followed carefully. To protect client confidentiality, the client’s name should not be used on the student care plan. When the assessment is complete, proceed to the next step.
STEP 2: NURSING DIAGNOSIS (ADPJE)
In the diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulates an evaluative judgment about a client’s health status. Only after a thorough analysis-which includes recog nizing cues, sorting through and organizing or clustering the information, and determining client strengths and unmet needs-can an appropriate diagnosis be made. This process of thinking is called clinical reasoning. Clinical reasoning is a cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and determine the value of alternative actions (Benner, 2010). Benner (2010) describes this cognitive process as “thinking like a nurse.” Watson and Rebair (2014) referred to “noticing” as a precursor to clinical reasoning. By noticing the nurse can preempt possible risks or support subtle changes toward recovery. Noticing can be the activity that stimulates nursing act,ion before words are exchanged, preempting need The nurse synthesizes the
4 SECTION I
evidence while also knowing the client as part of clinical reasoning that informs client specific diagnoses ( Cappelletti, Engel, & Prentice, 2014).
The nursing diagnoses that are used throughout this book are taken from North American Nursing Diagnosis Association-International (Herdman & Kamitsuru, 2014). The complete nursing diagnosis list is on the inside front cover of this text, and it can also be found on the EVOLVE website that accompanies this text. The diagnoses used throughout this text are listed in alphabetical order by the diagnostic concept. For example, impaired wheelchair mobil ity is found under mobility, not under wheelchair or impaired (Herdman & Kamitsuru, 2014).
The holistic assessment of the client helps determine the type of diagnosis that follows. For example, if during the assessment a client is noted to have unsteady gait and balance disturbance and states, ”I’m concerned I will fall while walking down my stairs,” but has not fallen previously, then the client would be identified as having a “risk” nursing diagnosis.
Once the diagnosis is determined, the next step is to deter mine related factors and defining characteristics. The process for formulating a nursing diagnosis with related factors and defining characteristics follows. A client may have many nursing and medical diagnoses, and determining the priority with which each should be addressed requires clinical reason ing and application of knowledge.
Formulating a Nursing Diagnosis with Related Factors and Defining Characteristics
A working nursing diagnosis may have two or three parts. The two-part system consists of the nursing diagnosis and the “related to” (r/t) statement: “Related factors are factors that appear to show some type of patterned relationship with the nursing diagnosis: such factors may be described as ante cedent to, associated with, relating to, contributing to, or abetting” (Herdman & Kamitsuru, 2014).
The two-part system is often used when the defining char acteristics, or signs and symptoms identified in the assess ment, may be obvious to those caring for the client.
The three-part system consists of the nursing diagnosis, the r/t statement, and the defining characteristics, which are “obser vable cues/inferences that cluster as manifestations of an actual or wellness nursing diagnosis” (Herdman & Kamitsuru, 2014).
Some nurses refer to the three-part diagnostic statement as the PES system:
P (problem)-The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues. The nursing diagnosis is taken from the official N ANDA I list.
E ( etiology)- “Related to” (r/t) phrase or etiology: related cause or contributor to the problem.
S (symptoms)-Defining characteristics phrase: symptoms that the nurse identified in the assessment.
Here we use the example of a beginning nursing student who is attempting to understand the nursing process and how to make a nursing diagnosis:
Problem: Use the nursing diagnosis label deficient Knowl edge from the NANDA-I list. Remember to check the definition: “Absence or deficiency of cognitive information related to a specific topic” (Herdman & Kamitsuru, 2014).
Etiology: r/t unfamiliarity with information about the nursing process and nursing diagnosis. At this point the beginning nurse would not be familiar with available resources regarding the nursing process.
Symptoms: Defining characteristics, as evidenced by (aeb) verbalization of lack of understanding: “I don’t understand this, and I really don’t know how to make a nursing diagnosis.”
When using the PES system, look at the S first, then for mulate the three-part statement. (You would have gotten the S, symptoms, which are defining characteristics, from your assessment.)
Therefore, the three-part nursing diagnosis is: deficient Knowledge r/t unfamiliarity with information about the nursing process and nursing diagnosis aeb verbalization of lack of understanding.
Types of Nursing Diagnoses
There are three different types of nursing diagnoses. Problem-Focused Diagnosis. “A clinical judgment con
cerning an undesirable human response to a health condition/ process that exists in an individual, family, group or com munity” (Herdman & Kamitsuru, 2014, p 22).
“Related factors are an integral part of all problem-focused diagnoses. They are etiologies, circumstances, facts or influ ences that have some type of relationship with the nursing diagnosis” (Herdman & Kamitsuru, 2014, p 26).
Example of a Problem-Focused Nlll’Sing Diagnosis. Overweight related to excessive intake in relation to meta bolic needs, concentrating food intake at the end of the day aeb weight 20% over ideal for height and frame. Note: This is a three-part nursing diagnosis.
Risk Nursing Diagnosis. Risk nursing diagnosis is a “clinical judgment concerning the vulnerability of an indi vidual, family, group, or community for developing an unde sirable human response to health conditions/life processes” (Herdman & Kamitsuru, 2014, p 22). “The risk diagnosis is supported by risk factors that increase the vulnerability of a client, family, group, or community to an unhealthy event” (Herdman & Kamitsuru, 2014, p 26). Defining characteristics and related factors are obser vable cues and circumstances or influences that have some type of relationship with the nursing diagnosis that may contribute to a health problem. Identification of related factors allows nursing interventions to be implemented to address the underlying cause of a nursing diagnosis (Herdman & Kamitsuru, 2014, p 26).
Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 5
Example of a Risk Nursing Diagnosis. Risk for Over weight: Risk factor: concentrating food at the end of the day. Note: This is a two-part nursing diagnosis.
Health Promotion Nursing Diagnosis. A clinical judg ment concerning motivation and desire to increase well being and to actualize human health potential that may be expressed by a readiness to enhance specific health behav iors or health state. Health promotion responses may exist in an individual, family, group, or community (Herdman & Kamitsuru, 2014, p 22). Health promotion is different from prevention in that health promotion focuses on being as healthy as possible, as opposed to preventing a disease or problem. The difference between health promotion and disease prevention is that the reason for the health behavior should always be a positive one. With a health promotion diagnosis, the outcomes and interventions should be focused on enhancing health.
Example of a Health Promotion Nursing Diagnosis. Readiness for enhanced Nutrition aeb expresses willingness to change eating pattern and eat healthier foods. Note: This is a two-part nursing diagnosis.
Application and Examples of Making a Nursing Di agnosis When the assessment is complete, identify common patterns/ symptoms of response to actual or potential health problems from the assessment and select an appropriate nursing diag nosis label using clinical reasoning skills. Use the steps with Case Study 1. (The same steps can be followed using an actual client assessment in the clinical setting or in a student assessment.) A. Highlight or underline the relevant symptoms (defining
characteristics). As you review your assessment informa tion, ask: Is this normal? Is this an ideal situation? Is this a problem for the client? You may go back and validate information with the client.
B. Make a list of the symptoms ( underlined or highlighted information).
C. Cluster similar symptoms. D. Analyze/interpret the symptoms. (What do these symp
toms mean or represent when they are together?) E. Select a nursing diagnosis label from the NANDA-I list
that fits the appropriate defining characteristics and nursing diagnosis definition.
Case Study I-An Older Client with Breathing Problems
A. Underline the Symptoms (Defining Char acteristics)
A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty: breathing when walking short distances:’ He also states that his “heart feels like it is racing” (heart rate is 110 beats per minute) at the same time. He states that he is “tired all the time,” and while talking to you about
his story, he is continually wringing his hands and looking out the window.
B. List the Symptoms (Subjective and Objective) “Difficulty breathing when walking short distances”; “heart feels like it is racing”; heart rate is 110 beats per minute; “tired all the time”; continually wringing his hands and looking out the window.
C. Cluster Similar Symptoms “Difficulty breathing when walking short distances” “Heart feels like it is racing”; heart rate= 110 bpm “Tired all the time” Continually wringing his hands Looking out the window
D.An alyze Interpret the Subjective Symptoms (What the Client Has Stated) • “Difficulty breathing when walking short distances” =
exertional discomfort: a defining characteristic of Activity intolerance
• “Heart feels like it is racing” = abnormal heart rate response to activity: a defining characteristic of Activity intolerance
• “Tired all the time” = verbal report of weakness: a defining characteristic of Activity intolerance
Interpret the Objective Symptoms (Observable Information) • Continually wringing his hands = extraneous movement,
hand/arm movements: a defining characteristic of Anxiety • Looking out the window = poor eye contact, glancing
about: a defining characteristic of Anxiety • Heart rate = 110 beats per minute
E. Select the Nursing Di agnosis Label In Section II, look up dyspnea (difficulty breathing) or dys rhythmia (abnormal heart rate or rhythm), chosen because they are high priority, and you will find the nursing diagnosis Activity intolerance listed with these symptoms. Is this diagnosis appropriate for this client?
To validate that the diagnosis Activity intolerance is appropriate for the client, turn to Section III and read the NANDA-I definition of the nursing diagnosis Activity intol erance: “Insufficient physiological or psychological energy to endure or complete required or desired daily activities” (Herdman & Kamitsuru, 2014, p 225). When reading the definition, ask, “Does this definition describe the symptoms demonstrated by the client?” “Is any more assessment infor mation needed?” “Should I take his blood pressure or take an apical pulse rate?” If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.
The client may also have defin41,g characteristics for this particular diagnosis. Are the client symptoms that you
6 SECTION I
identified in the list of defining characteristics (e.g., verbal report of fatigue, abnormal heart rate response to activity, exertional dyspnea)?
Another way to use this text and to help validate the diagnosis is to look up the client’s medical diagnosis in Section II. This client has a medical diagnosis of COPD. Is Activity Intolerance listed with this medical diagnosis? Con sider whether the nursing diagnosis makes sense given the client’s medical diagnosis (in this case, COPD). There may be times when a nursing diagnosis is not directly linked to a medical diagnosis (e.g., ineffective Coping) but is neverthe less appropriate given nursing’s holistic approach to the client/family.
The process of identifying significant symptoms, cluster ing or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reason ing ( critical thinking) skills that must be learned in the process of becoming a nurse. This text serves as a tool to help the learner in this process.
“Related to” Phrase or EtiologY
The second part of the nursing diagnosis is the “related to” (r/t) phrase. Related factors are those that appear to show some type of patterned relationship with the nursing diagno sis. Such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. Pathophysiologi cal and psychosocial changes, such as developmental age and cultural and environmental situations, may be causative or contributing factors.
Often, a nursing diagnosis is complementary to a medical diagnosis and vice versa. Ideally the etiology (r/t statement), or cause, of the nursing diagnosis is something that can be treated independently by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis.
If medical intervention is also necessary, it might be iden tified as a collaborative nursing diagnosis. A carefully written, individualized r/t statement enables the nurse to plan nursing interventions and refer for diagnostic procedures, medical treatments, pharmaceutical interventions, and other inter ventions that will assist the client/family in accomplishing goals and return to a state of optimum health. Diagnoses and treatments provided by the multidisciplinary team all con tribute to the client/family outcome. The coordinated effort of the team can only improve outcomes for the client/family and decrease duplication of effort and frustration among the health care team and the client/family.
The etiology is not the medical diagnosis. It may be the underlying issue contributing to the nursing diagnosis, but a medical diagnosis is not something the nurse can treat inde pendently, without health care provider orders. In the case of the man with COPD, think about what happens when someone has COPD. How does this affect the client? What is happening to him because of this diagnosis?
For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors (r/t)” in Section III. These r/t factors may or may not
be appropriate for the individual client If they are not appro priate, the nurse should develop and write an r/t statement that is appropriate for the client. For the client from Case Study 1, a two-part statement could be made here:
Problem = Activity Intolerance Etiology= r/t imbalance between oxygen supply and demand
It was already determined that the client had Activity intolerance. With the respiratory symptoms identified from the assessment, imbalance between oxygen supply and demand is appropriate.
Defining Characteristics Phrase
The defining characteristics phrase is the third part of the three-part diagnostic system, and it consists of the signs and symptoms that have been gathered during the assessment phase. The phrase “as evidenced by” (aeb) may be used to connect the etiology (r/t) with the defining characteristics. The use of identifying defining characteristics is similar to the process that the health care provider uses when making a medical diagnosis. For example, the health care provider who observes the following signs and symptoms-diminished inspiratory and expiratory capacity of the lungs, complaints of dyspnea on exertion, difficulty in inhaling and exhaling deeply, and sometimes chronic cough-may make the medical diagnosis of COPD. This same process is used to identify the nursing diagnosis of Activity intolerance.
Put It All Together:Writing the T hree-Part Nursing Diagnosis Statement
Problem-Choose the label (nursing diagnosis) using the guidelines explained previously. A list of nursing diagnosis labels can be found in Section II and on the inside front cover.
Etiology-Write an r/t phrase (etiology). These can be found in Section II.
Symptoms-Write the defining characteristics (signs and symptoms), or the “as evidenced by” (aeb) list. A list of the signs and symptoms associated with each nursing diagno sis can be found in Section III.
Case Study 1-73-Year-Old Male Client with COPD (Continued)
Using the information from the earlier case st udy/example, the nursing diagnostic statement would be as follows:
Problem-Activity intolerance Etiology-r/t imbalance between oxygen supply and demand Symptoms-Verbal reports of fatigue, exertional dyspnea
(“difficulty breathing when walking”), and abnormal heart rate response to activity (” racing heart”), heart rate 110 beats per minute.
Therefore, the nursing diagnostic statement for the client with COPD is Activity intolerance r/t imbalance between
Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 7
oxygen supply and demand aeb verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response to activity.