Diversity in Nursing
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Ackley_et_al_2020_Nursingprocessclinicalreasoningnursingdiagnosisandevidence-basednursing.pdf
I SECTION Nursing Process, Clinical I Reasoning, Nursing Diagnosis,
and Evidence-Based Nursing . -
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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
PART
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
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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).
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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
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
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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.
Consider a second case study:
Case Study 2-Woman with Insomnia
As before, the nurse always begins with an assessment. To make the nursing diagnosis, the nurse follows the steps below.
A. Underline the Symptoms
A 45-year-old woman comes to the clinic and asks for medi cation to help her sleep. She states that she is worrying too much and adds, "It takes me about an hour to i:et to sleep. and it is very hard to fall asleep. I feel like I can't do anything because I am so tired. My job has become very stressful because of a new boss and too much work."
B. List the Symptoms (Subjective and Objective)
Asks for medication to help her sleep; states she is worrying about too much; "It takes me about an hour to get to sleep"; "it is very hard to fall asleep"; "I feel like I can't do anything because I am so tired"; "My job has become very stressful because of a new boss and too much work."
C. Cluster Similar Symptoms
Asks for medication to help her sleep "It takes me about an hour to get to sleep." "It is very hard to fall asleep." "I feel like I can't do anything because I am so tired." "I am worrying too much:' "My job is stressful." "Too much work."
D. Analyze/Interpret the Symptoms Subjective Symptoms
• Asks for medication to help her sleep; "It takes me about an hour to get to sleep"; "it is very hard to fall asleep''; "I feel like I can't do anything because I am so tired:' (All defining characteristics = verbal complaints of difficulty with sleeping.)
• States she is worrying too much (anxiety): "My job is stressful:'
Objective Symptoms
• None
E. Select a Nursing Diagnosis with Related Factors and Defining Characteristics
Look up "sleep" in Section II. Listed under the heading "Sleep pattern, disturbed" in Section II is the following information:
Insomnia (nursing diagnosis) r/t anxiety and stress
This client states she is worrying too much, which may indicate anxiety; she also recently has increased job stress.
Look up Insomnia in Section III. Check the definition: "A disruption in amount and quality of sleep that impairs functioning" (Herdman & Kamitsuru, 2014). Does this describe the client in the case study? What are the related factors? What are the symptoms? Write the diagnostic statement:
Problem-Insomnia Etiology-r/t anxiety, stress Symptoms-Difficulty falling asleep, "I am so tired, I can't
do anything."
The nursing diagnostic statement is written in this format: Insomnia r/t anxiety and stress aeb (as evidenced by) diffi culty falling asleep.
Note: There are more than 30 case studies available for both student and faculty use on the Evolve website that accompanies this text.
After the diagnostic statement is written, proceed to the next step: planning.
STEP 3: PLANNING (ADPIE) The planning phase of the nursing process includes the identification of priorities, as well as the determination of appropriate client-specific outcomes and interventions. The nurse in collaboration with the client and family (as appli cable) and the rest of the health care team must determine the urgency of the identified problems and prioritize client needs. Mutual goal setting, along with symptom pattern rec ognition and triggers, helps prioritize interventions and deter mine which inter ventions are going to provide the greatest impact. Symptom pattern recognition and/or triggers is a process of identifying symptoms that clients have related to their illness, understanding which symptom patterns require intervention, and identifying the associated timeframe to intervene effectively. For example, a client with heart failure is noted to gain 5 pounds overnight. Coupling this symptom with other symptoms of edema and shortness of breath while walking can be referred to as "symptom pattern recogni tion" -in this case, that the client is retaining fluid. The nurse, and often the client/family, recognize these symptoms as an immediate cause and that more action/intervention is needed to avoid a potential adverse outcome.
Nursing diagnoses should be prioritized first by immedi ate needs based on ABC (airway, breathing, and circulation). The highest priority should also be determined by using Maslow's hierarchy of needs. ln this hierarchy, priority is given to immediate problems that may be life-threatening (thus ABC). For example, ineffective Airway clearance, as evidenced by the symptoms of increased secretions and increased use of inhaler related to asthma, creates an immedi ate cause compared to the nur�ing diagnosis of Anxiety, a love and belonging or security need, which makes it a lesser
8 SECTION I
priority than ineffective Airway clearance. Refer to Appendix A, Nursing Diagnoses Arranged by Maslow's Hierarchy of Needs, for assistance in prioritizing nursing diagnoses.
The planning phase should be done-whenever possible with the client/family and the multidisciplinary team to max imize efforts and understanding, and increase compliance with the proposed plan and outcomes. For a successful plan of care, measurable goals and outcomes, including nursing interventions, must be identified.
SMART Outcomes
When writing outcome statements, it can be helpful to use the acronym SMART, which means the outcome must be:
Specific Measurable Attainable Realistic Timed
The SMART acronym is used in business, education, and health care settings. This method assists the nurse in identify ing patient outcomes more effectively.
Once priorities are established, outcomes for the client can be easily identified. Client-specific outcomes are determined based on the mutually set goals. Outcomes refer to the mea surable degree of the client's response. The client's response/ outcome may be intentional and favorable, such as leaving the hospital 2 days after surgery without any complications. The client's outcome can be negative and unintentional, such as demonstrating a surgical site infection. Generally, outcomes are described in relation to the client's response to interven tions, for example, the client's cough becomes more produc tive after the client begins using the controlled coughing technique.
Based on the "patient's story," the nursing assessment, the mutual goals and outcomes identified by the caregiving team and the client/family, and the clinical reasoning that the nurse uses to prioritize his or her work, the nurse then decides what interventions to employ. Based on the nurse's clinical judg ment and knowledge, nursing interventions are defined as all treatments that a nurse performs to enhance client outcomes.
The selection of appropriate, effective interventions can be individualized to meet the mutual goals established by the client/family. It is then the nurse's education, experience, and skill that allow them to select and carry out interventions to meet that mutual goal.
e mes I After the appropriate priority setting of the nursing diagnoses and interventions is determined, outcomes are developed or examined and decided upon. This text includes standardized Nursing Outcomes Classification (NOC) outcomes written by a large team of University of Iowa College of Nursing faculty and students in conjunction with clinicians from a variety of settings (Moorhead et al, 2013). "Nursing-sensitive
outcome (NOC) is an individual, family or community state, behavior or perception that is measured along a continuum in response to nursing interventions. The outcomes are stated as concepts that reflect a client, caregiver, family, or commu nity state, perception of behavior rather than as expected goals" (Moorhead et al, 2013).
It is very important for the nurse to involve the client and/ or family in determining appropriate outcomes. The use of outcomes information creates a continuous feedback loop that is essential to ensuring evidence-based care and the best possible client outcomes, not only for the patient care experi ence, but also for improving the population's health and reducing health care costs (Weston & Roberts, 2013). The minimum requirements for rating an outcome are when the outcome is selected (i.e., the baseline measure) and when care is completed (i.e., the discharge summary). This may be suf ficient in short-stay, acute-care settings. Depending on how rapidly the client's condition is expected to change, some set tings may evaluate once· a day or once a shift. Community agencies may evaluate every visit or every other visit, for example. Because measurement times are not standardized, they can be individualized for the client and the setting (Moorhead et al, 2013).
Development of appropriate outcomes can be done one of two ways: using the NOC list or developing an appropriate outcome statement, both of which are included in Section III. There are suggested outcome statements for each nursing diagnosis in this text that can be used as written or modified as necessary to meet the needs of the client.
The Evolve website includes a list of additional NOC out comes. The use of NOC outcomes can be helpful to the nurse because they contain a five-point, Likert-type rating scale that can be used to evaluate progress toward achieving the outcome. In this text, the rating scale is listed, along with some of the more common indicators; for example, see the rating scale for the outcome Sleep (Table 1-1).
Because the NOC outcomes are specific, they enhance the nursing process by helping the nurse measure and record the outcomes before and after interventions have been per formed. The nurse can choose to have clients rate their own progress using the Likert-type rating scale. This involve ment can help increase client motivation to progress toward outcomes.
After client outcomes are selected or written, and discussed with a client, the nurse plans nursing care with the client and establishes a means that will help the client achieve the selected outcomes. The usual means are nursing interventions.
Interventions
Interventions are like roadrnaps directing the best ways to provide nursing care. The more clearly a nurse writes an inter vention, the easier it will be to complete the journey and arrive at the destination of desired client outcomes.
Section III includes suggested interventions for each nursing diagnosis. The interventions are identified as
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Adapted
(i TABLE 1-1
Example NOC Outcome
Sleep-0004
Domain-Functional Health (I) Care Recipient:
Class-Energy Maintenance (A) Data Source:
Scale(s)-Severely compromised to Not compromised (a) and Severe to None (n) Definition: Natural periodic suspension of consciousness during which the body is restored. Outcome Target Rating: Maintain at Increase to
Severely Substantially Moderately Mildly Not Compromised Compromised Compromised Compromised Compromised
Sleep Overall Rating 1 2 3 4 5
INDICATORS:
000401 Hours of sleep 1 2 3 4 5 NA
000402 Observed hours of sleep 1 2 3 4 5
000403 Sleep pattern 1 2 3 4 5 NA
000404 Sleep quality 1 2 3 4 5 NA
000405 Sleep efficiency 1 2 3 4 5 NA
000407 Sleep routine 1 2 3 4 5 NA
000418 Sleeps through the night 1 2 3 4 5 NA consistently
000408 Feelings of rejuvenation 1 2 3 4 5 NA after sleep
000410 Wakeful at appropriate times 1 2 3 4 5 NA
000419 Comfortable bed 1 2 3 4 5 NA
000420 Comfortable temperature in 1 2 3 4 5 NA room
000411 Electroencephalogram 1 2 3 4 5 NA findings
000412 Electromyogram findings 2 3 4 5 NA
000413 Electrooculogram findings 1 2 3 4 5 NA
Severe Substantial Moderate Mild None
000421 Difficulty getting to sleep 2 3 4 5 NA
000406 Interrupted sleep 1 2 3 4 5 NA
000409 Inappropriate napping 1 2 3 4 5 NA
000416 Sleep apnea 1 2 3 4 5 NA
p 000417 Dependence on sleep aids 1 2 3 4 5 NA
·- 000422 Nightmares 1 2 3 4 5 NA
000423 Nocturia 1 2 3 4 5 NA
000424 Snoring 1 2 3 4 5 NA �s
000425 Pain 1 2 3 4 5 NA
Adapted from Moorhead S, Johnson, M, Maas ML, & Swanson E. (Eds.). (2013). Nursing outromes classification (NOC) {5th ed.). St Louis: Elsevier.
10 SECTION I
independent (autonomous actions that are initiated by the nurse in response to a nursing diagnosis) or collaborative (actions that the nurse performs in collaboration with other health care profe�sionals, and that may require a health care provider's order and may be in response to both medical and nursing diagnoses). The nurse may choose the interventions appropriate for the client and individualize them accordingly, or determine additional interventions.
This text also contains several suggested Nursing Interven tions Classification (NIC) interventions for each nursing diagnosis to help the reader see how NIC is used along with NOC and nursing diagnoses. The NIC interventions are a comprehensive, standardized classification of treatments that nurses perform. The classification includes both physiological and psychosocial interventions, and covers all nursing spe cialties. A list of NIC interventions is included on the Evolve website. For more information about NIC interventions, refer to the NIC text (Bulechek et al, 2013).
Putting It All Together-Recording the Care Plan
The nurse must document the actual care plan, including prioritized nursing diagnostic statements, outcomes, and interventions. This may be done electronically or in writing. To ensure continuity of care, the plan must be documented and shared with all health care personnel caring for the client. This text provides rationales, most of which are research based, to validate that the interventions are appropriate and workable.
The Evolve website includes an electronic care plan con structor that can be easily accessed, updated, and individual ized. Many agencies are using electronic records, and this is an ideal resource. See the inside front cover of this text for information regarding access to the Evolve website, or go to http://evolve.elsevier.com/ Ackley/NDH.
STEP 4: IMPLEMENTATION (ADPIE}
The implementation phase includes the "carrying out» of the specific, individualized, jointly agreed upon interventions in the plan of care. Often, the interventions implemented are focused on symptom management, which is alleviating symp toms. Typically, nursing care does not involve "curinf the medical condition causing the symptom. Rather, nursing care focuses on caring for the client/family so they can function at their highest level.
The implementation phase of the nursing process is the point at which you actually give nursing care. You perform the interventions that have been individualized to the client. All the hard work you put into the previous steps (ADP) can now be actualized to assist the client. As the interventions are performed, make sure that they are appropriate for the client. Consider that the client who was having difficulty breathing was also older. He may need extra time to carry out any
activity. Check the rationale or research that is provided to determine why the intervention is being used. The evidence should support the individualized actions that you are implementing.
Client outcomes are achieved by the performance of the nursing interventions in collaboration with other disciplines and the client/family. During this phase, the nurse continues to assess the client to determine whether the interventions are effective and the desired outcomes are met.
STEP 5: EVALUATION (ADPIE) The final phase of the nursing process is evaluation. Evalua tion occurs not only at the end of the nursing process, but throughout the process. Evaluation of an intervention is, in essence, another nursing assessment; hence the dynamic feature of the nursing process. The nurse reassesses the client, taking into consideration where the client was before the intervention (i.e., baseline) and where the client is after the intervention. Nurses are also in a great place (at the bedside) to evaluate how clients respond to other, multidisciplinary interventions, and their assessment of the client's response is valuable to determine whether the client's plan of care needs to be altered or not. For example, the client may receive 2 mg of morphine intravenously for pain (a pharmaceutical inter vention to treat pain), and the nurse is the member of the health care team who can best assess how the client responded to that medication. Did the client receive relief from pain? Did the client develop any side effects? The nurse's docu mented evaluation of the client's response will be very helpful to the entire health care team.
The client/family can often tell the nurse how the interven tion helped or did not help. This reassessment requires the nurse to revisit the mutual outcomes/goals set earlier and ask, "Are we moving toward that goal, or does the goal seem unreachable after the intervention?" If the outcomes were not met, the nurse begins again with assessment and determines the reason they were not met. Consider the SMART acronym and Case Study I. Were the outcomes Specific? Were the outcomes Measurable? Did the client's heart rate decrease? Did the client indicate that it was easier to breathe when walking from his bed to the bathroom? Were the outcomes Attainable and Realistic? Did he still report "being tired»? Did you allow adequate Time for a positive outcome? Also ask yourself whether you identified the correct nursing diag nosis. Should the interventions be changed? At this point, the nurse can look up any new symptoms or conditions that have been identified and adjust the care plan as needed. Decisions about implementing additional interventions may be neces sary; if so, they should be made in collaboration with the client/family if possible.
In some instances, the client/family/nurse triad will establish new, achievable goals and continue to cycle through the nursing process until the mutual goals are achieved.
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Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing I I
Another important part of the evaluation phase is docu mentation. The nurse should use the facility's tool for documentation and record the nursing activity that was per formed as well as the results of the nursing interventions. Many facilities use problem-oriented charting, in which the nurse evaluates the care and client outcomes as part of charting. Documentation is also necessary for legal reasons, because in a legal dispute, if it wasn't charted/recorded, it wasn't done.
PART
B
Conceptual Mapping and the Nursing Process Conceptual mapping is an active learning strategy that pro motes critical thinking and clinical judgment, and helps increase clinical competency (Jamison & Lis, 2014; George et al, 2014). The process involves developing a diagram or pictorial representation of newly generated ideas. A concept map begins with a central theme or concept, and then related information is diagrammed radiating from the center theme. A concept map can be used to diagram the critical thinking strategy involved in using the nursing process.
Start with a blank sheet of paper; the client should be at the center of the paper. The next step involves linking to the person, via lines, the symptoms (defining characteristics) from the assessment to help determine the appropriate nursing diagnosis.
Figure I-2 is an example of how a concept map can be used to begin the nursing diagnostic process.
After the symptoms are visualized, similar ones can be put together to formulate a nursing diagnosis using another concept map (Figure I-3).
The central theme in this concept map is the nursing diag nosis: Activity intolerance, with the defining characteristics/ client symptoms as concepts that lead to and support the nursing diagnosis. The conceptual map can then be used as a method for determining outcomes and interventions as desired. The nursing process is a thinking process. Using con ceptual mapping is a method to help the nurse or nursing student think more effectively about the client.
Quality and Safety Education for Nurses The Quality and Safety Education for Nurses (QSEN, 2014) project represents the nursing profession's response to the five health care competencies articulated by the Institute of Medi cine (2013). The QSEN project defined those five competen cies for nursing and also added the competency of safety. The
Many health care providers use critical pathways or care maps to plan nursing care. The use of nursing diagnoses should be an integral part of any critical pathway/care map to ensure that nursing care needs are being assessed and appropriate nursing interventions are planned and implemented.
Advanced Nursing Process Concepts
objective of the QSEN project is to provide nurses with the knowledge, skills, and attitudes critical to improve the quality and safety of health care systems.
The following are the competencies that were identified.
Patient-Centered Care The QSEN project defines patient-centered care as the ability to "recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated
Difficulty breathing
Figure 1-2 Example of a concept map.
12 SECTION I
Figure 1-3 Formulating a nursing diagnosis using a concept map.
care based on respect for patient's preferences, values, and needs" (QSEN, 2014).
Patient-centered care begins with the nurse learning as much as possible about the client, including their "patient's story" as explained in Part A of this text. The nursing process using nursing diagnosis is intrinsically all about patient centered care. Here the client/family is a full partner in the entire process, including assessment, nursing diagnosis selection, outcomes, interventions, and evaluation. This competency is about giving care with the client and family in control as they are able, not giving care to them where the nurse is in complete control. The client, family, nurse, health care provider, and other health care workers form a team to partner with the client and family in every way possible.
Client education needs to be centered around the needs of the client, with behavior-changing techniques such as use of motivational interviewing to accomplish the defined goals. At present, too often new health information is given to clients in the form of a lecture, handout, admonishment, or direction where the client is powerless. Motivational interviewing is based on reinforcement of the client's present thoughts and motivations on behavior change, and on respect for the client as an individual (Miller & Rollnick, 2013). This technique has been used for almost 30 years and has an extensive research base showing effectiveness. To learn more about motivational interviewing, refer to the appendix.
Addressing the unique cultural needs of clients is another example of patient-centered care. Nurses who are culturally competent base care planning on cultural awareness and
assessments that enables them to identify client values, beliefs, and preferences. Cultural awareness can ensure safe and quality outcomes for all clients by assisting clients to become "safety allies" who can alert professionals to their preferences and deviations from their usual routines (Sherwood & Zomorodi, 2014). This text provides the addition of multicul tural interventions that reflect the client's cultural prefer ences, values, and needs.
Patient-centered care can help nurses change attitudes toward clients, especially when caring for older clients (Pope, 2012). Caring for the retired school teacher who raised four children can be different from just caring for the client woman in Room 234 who has her call light on frequently and is incontinent of urine at too-frequent intervals.
Teamwork and Collaboration
Teamwork and collaboration are defined by the QSEN project as the ability to "function effectively within nursing and inter professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality client care" (QSEN, 2014). Interprofessional collaboration has the potential to shift the attitudes and perceptions of health care providers so there is an increased awareness of each other's roles, values, and disciplinary knowledge (Wilson et al, 2014). The need for collaboration by health care professionals is a reality of contemporary health care practice and is written into this text. Collaborative interventions are designated with a triangular symbol a. In addition, many nursing interven tions are referrals to other health care personnel to best meet the client's needs.
IS
Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 13
Evidence-Based Practice
Evidence-based practice is defined by the QSEN project as "integrat[ing] best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care" (QSEN, 2014). It is well established that evidence-based practice results in higher quality care for clients than care that is based on traditional nursing knowl edge (Makic et al, 2014). Now it is imperative for each nurse and nursing student to develop clinical inquiry skills, which means the nurse continually questions whether care is being given in the best way possible based on research evidence when possible (Blazeck et al, 2011). Basing nursing practice on evidence or research is a concept that has been added to the nursing process, entitled evidence-based nursing (EBN). EBN is a systematic process that uses current evidence in making decisions about the care of clients, including evalua tion of quality and applicability of existing research, client preferences, clinical expertise, and available health care resources (Melnyk & Fineout-Overholt, 2011). To determine the best way of giving care, use of evidence-based practice is needed. To make this happen, nurses need ready access to the evidence.
This text includes evidence (research)-based rationales whenever possible. The research ranges along a continuum from a case study about a single client to a systematic review performed by experts that gives quality information to guide nursing care. Every attempt has been made to supply the most current research for the nursing interventions. In Section III, the abbreviation EBN is used when interventions have a sci entific rationale supported by nursing research. The abbrevia tion EB is used when interventions have a scientific rationale supported by research that has been obtained from disci plines other than nursing. CEB is used as a heading for classic research that has not been replicated or is older. It may be either nursing research or research from other disciplines. Many times the CEB-labeled research will be the most impor tant studies that have been done on that nursing issue or intervention.
When using EBN, it is vitally important that the client's concerns and individual situations be taken into consider ation. The nurse must always use critical thinking when applying evidence-based guidelines to any particular nursing situation. Each client is unique in his or her needs and capa bilities. To improve outcomes, clinicians and clients should collaborate to formulate a treatment plan that incorporates both evidence-based data and client preferences within the context of each client's specific clinical situation (Muhrer, 2012). This text includes both research and the nursing process. By integrating these concepts, it assists the nurse in increasing the use of evidence-based interventions in the clinical setting.
Quality Improvement
Quality improvement has been used for many years, with processes in place to ensure that the client receives appropri-
ate care. The QSEN project defines quality improvement as the ability to "use data to monitor the outcomes of care pro cesses and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems" (QSEN, 2014). QSEN resources support ing quality improvement initiatives are available at their website(http://qsen.org/ competencies/ quality-improvement resources-2/). As with EBP, quality improvement initiatives need to critically examine research in supporting process changes. Research is the basis upon which best practice should be supported (Odom, 2013). It is essential for nurses to participate in the work of quality and performance improvement, which is key to attaining excellence in nursing care. As nurses are educated about performance and quality measures, they are more likely to value these activities and make quality improvement part of their nursing practice (Nelson, 2014). There is potential overlap of work in quality departments and EBN/research departments. These authors hope that the measurement of quality and quality depart ments in health care collaborate closely with EBN depart ments so that quality measurement always include relevant nursing research/evidence to effectively improve the practice of nursing.
Safety
Safety is the competency that QSEN added to the five com petencies identified by the Institute of Medicine. QSEN defines safety as "minimiz[ing] risk of harm to clients and providers through both system effectiveness and individual performance" (QSEN, 2014).
Client safety is a priority when health care is delivered. Nurses are required to adhere to established standards of care as a guideline for providing safe client care. Internal standards of care are policies and procedures established by health care institutions and are based on the most relevant and current evidence. External standards of care are established by regula tory agencies (e.g., The Joint Commission), professional orga nizations (e.g., the American Nurses Association), and health care organizations.
Client safety was identified as a priority of care by The Joint Commission through the launch of National Patient Safety Goals in 2002. The Joint Commission (2014) has estab lished standards for improving client safety that include the need for increased handwashing, better client identification before receiving medications or treatments, and protection of suicidal clients from self-harm. Many of these safety stan dards have been incorporated into the care plans in this text. A safety icon is used to designate specific safety nursing inter ventions in this text.
Informatics
QSEN defines informatics as the nurse's ability to "use infor mation and technology to communicate, manage knowledge, mitigate error, and support decision making" (QSEN, 2014). Informatics is now a critical part of the nurse's professional role, and every nurse must be computer literate (T IGER,
14 SECTION I
2014). Key computer proficiencies for nursing practice should include basic computer system and desktop skills, the ability to search for client information, communication using email, ability to search electronic health care databases, and use of technology for client education, client documentation, and client monitoring (Gracie, 2011; Tiger, 2014).
In addition to computer literacy, nurses must also acquire informatic knowledge that addresses client privacy and the security of health care information as it applies to the use of technology (Foster, 2012; TIGER, 2014). Because nurses document on the electronic medical record and use smartphones for access to information on medications, diag noses, and treatments, there are constant threats to client confidentiality.
Nurses also use clinical decision support systems in many facilities that contain order sets tailored for conditions or types of clients. These systems include information vital to nurses and also may provide alerts about potentially danger ous situations that should not be ignored when giving client care.
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Benner, P. (2010). Educating nurses: a call for radical transformation (p. 2010). San Francisco: Jossey-Bass.
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Bulechek, G., et al. (2013). Nursing interventions classification (NIC) (6th ed.). St Louis: Mosby/Elsevier.
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Foster, C. (2012). Advocates of privacy. HIPPA 101. Washington Nurse, 42(3), 37.
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Nurses need access to technology to effectively bring evi dence to the client bedside, because evidence is constantly evolving and books are often out of date before they are pub lished. Use of informatics is integral to use of EBN practice as explained previously.
EBN, safety initiatives, informatics, patient-centered care, teamwork, and quality work together in a synergistic manner lead to excellence in nursing care. Quality care needs to be more than safe; the care should result in the best outcome possible for the client. For this to happen, the client should receive care that is based on evidence of the effectiveness of the care.
The nursing process is continually evolving. This text is all about thinking for the nurse to help the client in any way pos sible. Our goal is to present state-of-the art information to help the nurse and nursing student provide the best care possible.
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Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 15
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