Application of Nursing Process and Nursing Diagnosis:

An Interactive Text for Diagnostic Reasoning

Sixth Edition

Copyright 2013 F.A. Davis Company

Chapter 1

The Nursing Process:

Delivering Quality Care

"Do everything as quietly as possible. Step lightly and gently and avoid creaking shoes."

"Use no snuff, or any article of food, the smell of which may be offensive to weak nerves."

"Ask no unnecessary questions."

The Nursing Profession

Definition of Nursing

The diagnosis and treatment of human responses to health and illness (ANA, 1995)

The Nursing Profession:

Has defined what makes nursing unique

Has identified a body of professional knowledge

The Nursing Profession

The American Nurses Association, in its Nursing Social Policy Statement, identified four essential features of today’s contemporary nursing practice...

The Nursing Profession

1. Attention to the full range of human experiences….

2. Integration of objective data…3. Application of scientific knowledge…4. Provision of a caring relationship…

The Nursing Process

Offers an orderly, logical, problem-solving approach to patient care

Incorporates an interactive/ interpersonal approach for problem-solving and decision-making.

The Nursing Process

FIVE STEPS Assessment Diagnosis/Analysis Planning Implementation Evaluation

Diagram of the Nursing Process

The steps of the nursing process are interrelated, forming a continuous circle of thought and action.

The Nursing Process

STEP 1

Assessment—

the systematic collection of data relating to clients

The Nursing Process

STEP 2Diagnosis—

the analysis of collected data to identify the client’s needs or problems

The Nursing Process

STEP 3

Planning—

a two-part process of: identifying goals and desired outcomes

selecting appropriate nursing interventions

The Nursing Process

STEP 4

Implementation—

putting the plan of care into action

The Nursing Process

STEP 5

Evaluation—

determining the client’s progress

monitoring the client’s response

How the Nursing Process Works

A process you routinely use to solve problems

Applies readily to client-care situations

Basic skills the nurse must posses:

A thorough knowledge of science and theory Creativity Adaptability Intelligence

Well-developed interpersonal skills Competent technical skills Commitment to practice according to the standards of

care

Nursing Process Resources

ANA Code of Ethics for Nurses provides guidance

Refer to Appendix A

Standards of Care

WHAT A REASONABLE PRUDENT PROFESSIONAL WITH SIMILAR EXPERTISE AND RESPONSIBILITIES WOULD HAVE DONE UNDER SIMILAR CIRCUMSTANCES

Standards of Care

Describes a competent level of nursing care Demonstrated by use of the nursing process Describes roles expected of all professional

nurses appropriate to their: education position practice setting

Practice Advantages of the Nursing Process

Organizing framework Human response focus Structured decision making Patient involvement Control over practice Common language Means to assess economic contribution of

nursing to patient care

CRITICAL THINKING

WHAT IS IT? PURPOSEFUL, FOCUSED THINKING GUIDED BY STANDARDS, POLICIES, ETHICS ,

AND THE LAW. BASED ON PRINCIPLES OF NURSING

PROCESS DRIVEN BY PATIENT NEEDS. IMPROVES WITH PRACTICE!

CRITICAL THINKING“THE ART OF THINKING WHILE YOU ARE

THINKING IN ORDER TO MAKE YOUR THINKING BETTER: MORE CLEAR, MORE ACCURATE, OR MORE DEFENSIBLE.” (Paul, Binker, Adamson, and Martin)

CRITICAL THINKING

ASSUMPTIONS

INFERENCES

BIASES

Chapter 2

The Assessment Step: Developing the Client Database

The Assessment Step

Assessment involves three basic activities:

1. Systematically gathering data

2. Sorting and organizing data

3. Documenting data in a retrievable format

The Client Database

The compilation of data collected about a client Consists of:

nursing history (*interview) physical examination results of diagnostic studies

The Client Database

Subjective data – what the client reports, believes, or feels

Objective data – what can be observed; for example, vital signs, behaviors, diagnostic studies

Framework for Data Collection

Two commonly used nursing models: Doenges & Moorhouse’s Diagnostic Divisions Gordon’s Functional Health Patterns

Others: body systems, head-to-toe

Framework for Data Collection

Nursing assessment model focuses data collection on the nurse’s concern—the human responses to health, illness, life processes

See Appendix B for a sample assessment tool

The Interview Process: 10 Key Elements

Clear sense of the underlying purpose Preliminary research Request to conduct the interview Sound interviewing strategy Effective use of icebreakers

The Interview Process: 10 Key Elements (cont.)

Addressing the business of the interview Rapport Sensitivity to client’s needs Adequate time for recovery Closure

Effective Data Collection Techniques

Open-ended questions Hypothetical questions Reflecting or mirroring responses Focusing

Giving broad openings Offering general leads Exploring Verbalizing the implied Encouraging evaluation

Data Collection Techniques to Avoid

Closed-end questions Leading questions Probing Agreeing/disagreeing

The Client History

Client history involves: Reviewing data

Organizing and determining the relevance of each item

Documenting the facts

Guidelines for History Taking

Listen carefully

Use active listening skills

Be objective

Keep detail manageable

Sequence information

Document clearly

Record data in a timely manner

PRACTICE HEALTH HISTORY

NAME_____J.F______________________AGE__42____DOB_______SEX___F________MARITAL STATUS____Divorced_______OCCUPATION_Radiology Technician__________

PHYSICIAN (OR USUAL SOURCE OF HEALTHCARE): Dr. Scot, Family physician

CHIEF COMPLAINT: Ear hurting for past 4 days.

HISTORY OF PRESENT ILLNESS (HPI): Worsening dull pain in right ear for past 3 days. Ear feels "blocked". Pain worse when lying down, relieved slightly with Tylenol. No pain in left ear. Denies sore throat or headache. Has not noticed any drainage from ear.

PAST MEDICAL HISTORY (PMH): HTN x 5 years, seasonal allergies, Migraine headaches.

PAST SURGICAL HISTORY (PSH): Appendectomy as child, carpal tunnel surgery left hand 2 years ago.

MEDICATIONS: Toprol XL 50 mg daily, hydrochlorothiazide 25 mg daily, Frova 2.5 mg as needed for migraine (uses approx 1/month). Baby ASA once daily. Motrin 1-2 times/week for muscle "aches and pains."

ALLERGIES/REACTIONS: Benedryl - rash.

SOCIAL HISTORY: Smoked 1 pack/day x 20 years, quit 2 months ago. 1-2 glasses wine q eve. Denies street drugs. Lives with boyfriend.

FAMILY HISTORY: Father has HTN, mother has osteoporosis, diabetes. 1 sister in good health. 2 sons, ages 17, 21, in good health.

REVIEW OF SYSTEMS: (ALL-INCLUSIVE):

NEUROLOGICAL_____Denies tremors, difficulty walking. Has aura with migraines, otherwise

no vision problems.

CARDIOVASCULAR Occasional "skipped" heartbeats, denies chest pain, denies swelling in

legs.

RESPIRATORY No SOB, no cough. ______________________________________________________________________________________________________

Physical Examination

Four methods used: Inspection Palpation Percussion Auscultation

COLLECTING DATA

PHYSICAL ASSESSMENT ORGANIZATION – GUIDED EITHER BY PT

COMPLAINT OR DONE IN A ROUTINE FLOW PATTERN (HEAD-TO-TOE OR SYSTEMS)

DEVELOP AN APPROACH AND USE IT CONSISTENTLY.

COLLECTING DATA

Physical exam

GENERAL APPEARANCE MAY INCLUDE HEIGHT AND WEIGHT

VITAL SIGNS TPR, BP INCLUDES PAIN MAY INCLUDE COUGH, SpO2

COLLECTING DATA

PHYSICAL EXAM (CONT.) – SYSTEMS

NEURO - LOC, ORIENTATION, PUPIL REACTION (Example of documentation.: Alert, oriented x 3,

PERRL, speech clear ). ** May include ext. movement. (Glasgow coma scale)

COLLECTING DATA

CARDIOVASC - HT RHYTHM/SOUNDS, PULSES, CAPILLARY REFILL (Doc. ex: HR 78 & regular, pedal pulses palpable

bilaterally, cap. refill <3 sec.)

RESP - RESP, LUNG SOUNDS, PULSE OX (Doc. ex: Resp. easy, lungs clear bilaterally, non-

productive cough. SpO2 98 on room air.)

COLLECTING DATA

GI - ABD SHAPE, BS, TENDERNESS, BM (Doc. ex: Abd soft and non-distended, BS

auscultated x 4 quads. No tenderness on palpation. Soft brown, formed BM.

GU - URINE, FOLEY?, (Documentation: Voided clear yellow urine.

COLLECTING DATA

SKIN - TEMP, MOISTURE, COLOR, LESIONS? (Doc. ex: Skin warm, dry, and fleshtone.)

MS - range of motion, active/passive? (Doc. ex: Active, full ROM in all 4 ext..)

Laboratory Tests and Diagnostic Procedures Part of information-gathering stage

Used to: Diagnose disease Follow the course of a disease Adjust therapy

When analyzing laboratory tests, consider drugs being administered

Organizing Information Elements

Cluster the collected data

Review data

Validate findings

Chapter 3The Diagnosis Step: Analyzing the Data

(Need/Problem Identification)

The Diagnosis Step

Purpose: To draw conclusions regarding a client’s specific needs or human responses so that effective care can be planned and delivered

The Diagnosis Step

These terms may be used interchangeably:

Analysis

Need (or problem) identification

Nursing diagnosis

The Diagnosis Step

What is Diagnosis?

Forming a clinical judgment identifying a disease/condition or human response through scientific evaluation of signs/symptoms, history, and diagnostic studies.

Defining Nursing DiagnosisNursing Diagnoses are: Derived from the assessment data

Validated with the patient/others

Documented within a nursing plan of care

Medical vs. Nursing Diagnoses

Medical diagnoses illnesses/conditions; reflect alteration of the structure or function of organs/systems; verified by medical diagnostic studies

Nursing diagnoses address human responses to actual and potential health problems/life processes

TERMINOLOGY

NANDA - North American Nursing Diagnosis Association International

Ex: Actual: Impaired Skin Integrity

Potential: Risk for Injury

Defining Nursing Diagnosis

NANDA’s Definition

Nursing diagnosis is a clinical judgment about responses to actual and potential health problems.

Nursing diagnoses provide the basis for selecting nursing interventions to achieve results for which the nurse is accountable.

The Use of Nursing Diagnoses

Benefits of the nursing diagnosis 1. Gives nurses a common language2. Promotes identification of appropriate goals3. Provides acuity information4. Can create a standard for nursing practice5. Provides a quality improvement base

Identifying Client Needs

During the Assessment step, the collection, clustering, and validation of client data flow directly into the Diagnosis step of the nursing process

Analyzing the Client Database

Six Steps in Problem Identification

1. Problem-Sensing

2. Rule-Out Process

3. Synthesizing the Data

4. Evaluating or Confirming the Hypothesis

5. Listing the Client’s Needs

6. Reevaluating the Problem List

Analyzing the Client Database

Step 1: Problem-Sensing Data are reviewed and analyzed to identify

cues (signs and symptoms) suggesting patient needs.

Analyzing the Client Database

Step 2: Rule-Out Process

Alternative explanations considered

Compare and contrast relationships among data

Analyzing the Client Database

Step 3: Synthesizing the Data

Looking at all the data as a whole

Creating a hypothesis

Analyzing the Client Database

Step 4: Evaluating or Confirming the Hypothesis

Test hypothesis for fit by: reviewing the nursing diagnosis definition comparing the assessed data with NANDA’s

related or risk factors comparing the signs/symptoms with NANDA’s

defining characteristics

Analyzing the Client Database

Step 5: Listing the Client’s Needs Combine the accurate nursing diagnosis

label with the assessed etiology and signs/symptoms

“PES” STATEMENT

Analyzing the Client Database

Step 6: Reevaluating the Problem List List all nursing diagnoses according to

priority and classify according to status: an actual needa risk need

Identifying Client Problems:Other Considerations The medical/psychiatric diagnosis can provide a

starting point for identifying associated client needs.

Even if the need seems to exist only in the mind of the patient, it needs to be addressed and resolved.

Reduce the problem to its basic component to identify more clearly the appropriate interventions to be taken.

Writing a Client Diagnostic Statement

Nursing diagnoses identify client needs that can be positively affected, or possibly prevented, by nursing actions.

Some diagnoses permit greater independent function; others are more collaborative.

Writing a Client Diagnostic Statement

The extent of independent function is influenced by the nurse’s— experience expertise work setting established protocols

Writing a Nursing Diagnosis

P-E-S Statement – 3 part statement Problem - Diagnosis according to NANDA Etiology - the cause or risk factors, stated as “related to”- Signs and symptoms – called defining characteristics, the

evidence that showed your diagnosis or problem. Stated as “as evidenced by”

PROBLEM R/T ETIOLOGY AEB SIGNS AND

SYMPTOMS. (No “S” if potential problem)

Writing a Nursing Diagnosis

(P) Constipation R/T (E)use of opioid analgesics AEB (S) abdominal discomfort and hard, small stools.

Impaired verbal communication R/T aphasia AEB inability to communicate basic needs.

Imbalanced nutrition: Less than body requirements R/T vomiting AEB weight loss of 3 lbs over 2 days.

Writing a Nursing Diagnosis

Knowledge deficit of med administration R/T lack of recall AEB patient statement “I can never remember to take those pills”

Risk for fluid volume deficit R/T fluid loss secondary to NGT to continuous suction.

Writing a Client Diagnostic Statement

Collaborative problem: A need identified by another discipline that contains a nursing component requiring nursing intervention

Writing a Client Diagnostic Statement

Common Errors:

Using the medical diagnosis: Self Care deficit r/t stroke

Confusing the etiology or signs/symptoms for the need:

Postoperative lung congestion r/t bedrest

Use of a procedure instead of the “human response”:

Catheterization r/t urinary retention

Writing a Client Diagnostic Statement

Common Errors:

Lack of specificity:

Constipation r/t nutritional intake

Combining two nursing diagnoses: Anxiety and Fear r/t separation from parents

Writing a Client Diagnostic Statement

Common Errors:

Relating one nursing diagnosis to another: Ineffective coping r/t anxiety

Use of judgmental or value-laden language: Chronic pain r/t secondary/monetary gain

Writing a Client Diagnostic Statement

Common Errors:

Making assumptions: Risk for impaired Parenting, risk factors of inexperience (new mother)

Writing a legally inadvisable statement: Impaired Skin Integrity r/t not being turned every 2 hours