Nursing Process: Overview, Assessment and Nursing Diagnosis

1. 3-1 Nursing Process: Overview, Assessment and Nursing Diagnosis

2. 3-2 Objectives History of the Nursing Process and Nursing Diagnosis Discuss characteristics of Nursing Process and Nursing Diagnosis Describe Assessment Formulate a Nursing Diagnosis The nursing process is a step-by-step method of providing care to clients. While progressing through each step, the nurse uses a variety of skills that are purposeful and promote a systematic, orderly thought process. Discoveries are communicated to the client and other health care professionals, promoting continuity of the client-centered care and giving structure to reality.The nursing process is a step-by-step method of providing care to clients. While progressing through each step, the nurse uses a variety of skills that are purposeful and promote a systematic, orderly thought process. Discoveries are communicated to the client and other health care professionals, promoting continuity of the client-centered care and giving structure to reality.

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4. 3-4 This is Brian on Nursing

5. 3-5 History of Nursing Diagnosis 1950�s Introduction only � mainly used in relationship to the care plan only sporadically in the literature 1970�s 1st National Conference for classification of Nursing Diagnosis and formed the North American Nursing Diagnosis Association (NANDA) ANA published standards of practice & a social policy statements

6. 3-6 History of Nursing Diagnosis 1970�s � continued ANA published standards of practice & a social policy statements Defined nursing as diagnosis and treatment of human response to actual or potential health problems 1990�s 9th Conference of NANDA was held and Taxonomy II was published

7. 3-7 Globalization of Nursing Nursing Diagnosis is recognized globally Provides common language for nursing to talk to each other, identifies problems, gives nursing greater accountability, and professional autonomy Captures nursing�s contributions to health, enables cross-country comparisons of nursing and promotes the development of nursing

8. 3-8 Pre-1955: No clearly identifiable boundaries defined for nursing practice 1955: Term nursing process coined by Lydia Hall 1973: ANA published Standards of Clinical Nursing Practice Timeline

9. 3-9 Timeline 1973: Classification of nursing diagnoses began: North American Nursing Diagnosis Association (NANDA) 1980: ANA published A Social Policy Statement 1982: NCLEX exams were revised to include concepts 1994: JCAHO initiated requirements for accredited hospitals to use the nursing process Current: Ongoing use of the five-step process In 2006 NANDA had their 13 Conference National conferences were initiated in 1973 as well, resulting in the beginning of classification of nursing diagnoses. NANDA�North American Nursing Diagnosis Association�conferences have been held every two years since. This organization meets to identify, clarify, and refine nursing diagnoses. The American Nurses Association�s publication A Social Policy Statement provided guidelines (standards) for individual professional nurses to follow in practice. National Council Licensure Examination (NCLEX) exams were revised to include the nursing process concepts as a basis for organization. Joint Commission on Accreditation of Healthcare Organization (JCAHO) required accredited hospitals to use the nursing process as a means of documenting all phases of client care.National conferences were initiated in 1973 as well, resulting in the beginning of classification of nursing diagnoses. NANDA�North American Nursing Diagnosis Association�conferences have been held every two years since. This organization meets to identify, clarify, and refine nursing diagnoses. The American Nurses Association�s publication A Social Policy Statement provided guidelines (standards) for individual professional nurses to follow in practice. National Council Licensure Examination (NCLEX) exams were revised to include the nursing process concepts as a basis for organization. Joint Commission on Accreditation of Healthcare Organization (JCAHO) required accredited hospitals to use the nursing process as a means of documenting all phases of client care.

10. 3-10 Basic Characteristics of the Nursing Process Method of providing care Purposeful, systematic, and orderly Method of problem solving and decision making Scientifically based�understanding of the human body Philosophically based�understanding of philosophical views The nursing process is a step-by-step method of providing care to clients. While progressing through each step, the nurse uses a variety of skills that are purposeful and promote a systematic, orderly thought process. Discoveries are communicated to the client and other health care professionals, promoting continuity of the client-centered care and giving structure to reality. The nursing process is a problem-solving and decision-making method that is scientifically based, as well as philosophically based. The nurse uses learned knowledge and comprehension of the human body to identify actual or potential health problems resulting from physical or psychological disease or disorders. Knowledge and understanding of fundamental philosophical views are essential to the practice of nursing. This understanding aids in recognizing the client�s response to illness or the client�s sense of wellness. Educator Note Abraham Maslow theorized that all human beings have common basic needs that must be met to some degree before higher-lever needs are met. Other frameworks are discussed in chapter 2, �Assessment.� The nursing process is a step-by-step method of providing care to clients. While progressing through each step, the nurse uses a variety of skills that are purposeful and promote a systematic, orderly thought process. Discoveries are communicated to the client and other health care professionals, promoting continuity of the client-centered care and giving structure to reality. The nursing process is a problem-solving and decision-making method that is scientifically based, as well as philosophically based. The nurse uses learned knowledge and comprehension of the human body to identify actual or potential health problems resulting from physical or psychological disease or disorders. Knowledge and understanding of fundamental philosophical views are essential to the practice of nursing. This understanding aids in recognizing the client�s response to illness or the client�s sense of wellness. Educator Note Abraham Maslow theorized that all human beings have common basic needs that must be met to some degree before higher-lever needs are met. Other frameworks are discussed in chapter 2, �Assessment.�

11. 3-11 Nursing Process Characteristics Method for organization Promotes wellness Restores wellness Maintains present state of health The nursing process is a map used to progress from point a to point b. It is a method used to organize nursing activities. The ultimate goal of the nursing process is to promote and restore client wellness or to maintain the client�s present state of health or wellness.The nursing process is a map used to progress from point a to point b. It is a method used to organize nursing activities. The ultimate goal of the nursing process is to promote and restore client wellness or to maintain the client�s present state of health or wellness.

12. 3-12 Nursing Process Characteristics Promotes quality care Promotes coordinated, ongoing care Serves as a guide to avoid omissions or inaccuracies Provides a framework for nursing The nursing process is effective in promoting quality of care. The client who enters the health care continuum receives a thorough, initial assessment. The needs and strengths of the client are identified. A care plan (documentation of the first, second and third steps of the nursing process) is developed and communicated to other health care professionals, so that care is coordinated and ongoing. The client is monitored for changing needs. The plan is evaluated for its appropriateness. Continuous assessment and evaluation play a key role in determining client needs, strengths, and response to treatment. Health care professionals review, revise, and validate the care plan, enhancing and promoting quality of care. The nursing process serves as a guide to ensure deliberate steps are taken�steps to help avoid omissions and premature conclusions. It provides a framework for which nurses use knowledge and skill to express human caring and to help clients meet their needs. The nursing process is effective in promoting quality of care. The client who enters the health care continuum receives a thorough, initial assessment. The needs and strengths of the client are identified. A care plan (documentation of the first, second and third steps of the nursing process) is developed and communicated to other health care professionals, so that care is coordinated and ongoing. The client is monitored for changing needs. The plan is evaluated for its appropriateness. Continuous assessment and evaluation play a key role in determining client needs, strengths, and response to treatment. Health care professionals review, revise, and validate the care plan, enhancing and promoting quality of care. The nursing process serves as a guide to ensure deliberate steps are taken�steps to help avoid omissions and premature conclusions. It provides a framework for which nurses use knowledge and skill to express human caring and to help clients meet their needs.

13. 3-13 Nursing Process Characteristics Client centered Assists to plan according to client needs Client participates Promotes collaboration with other disciplines Universally applicable The nursing process is client centered, meaning care is focused on the client. The care plan is organized according to client problems and/or strengths, rather than nursing goals. The client is encouraged to participate in the nursing process, by communicating needs and concerns, and through validation of collected data. This gives the client a sense of control over his or her care. The nursing process promotes collaboration, the communication with other disciplines to solve problems. Ongoing assessment of the client and response to care are monitored and recorded as physician orders and nursing interventions are carried out. Nursing professionals communicate necessary data through means of verbal reports and written documentation. Collaboration with the physician, nursing professionals, and other disciplines is often necessary to coordinate care and promote health. The nursing process is universally applicable. This means it is appropriate to institute and apply the nursing process with clients of all ages, at any point on the wellness-illness continuum, in a variety of health-related settings including schools, hospitals, home health care facilities, and clinics, and across specialties in hospital or acute care settings, such as intensive care, pediatrics, labor and delivery, medical surgical units, etc. The nursing process is client centered, meaning care is focused on the client. The care plan is organized according to client problems and/or strengths, rather than nursing goals. The client is encouraged to participate in the nursing process, by communicating needs and concerns, and through validation of collected data. This gives the client a sense of control over his or her care. The nursing process promotes collaboration, the communication with other disciplines to solve problems. Ongoing assessment of the client and response to care are monitored and recorded as physician orders and nursing interventions are carried out. Nursing professionals communicate necessary data through means of verbal reports and written documentation. Collaboration with the physician, nursing professionals, and other disciplines is often necessary to coordinate care and promote health. The nursing process is universally applicable. This means it is appropriate to institute and apply the nursing process with clients of all ages, at any point on the wellness-illness continuum, in a variety of health-related settings including schools, hospitals, home health care facilities, and clinics, and across specialties in hospital or acute care settings, such as intensive care, pediatrics, labor and delivery, medical surgical units, etc.

14. 3-14 Nursing Skills Interpersonal Technical Intellectual Through the nursing process the nurse utilizes skills, such as interpersonal, technical, and intellectual skills. Interpersonal Skills: Communicating, listening, conveying interest, compassion, knowledge, and information, as well as developing trust and obtaining data in a manner that enhances dignity of the client Technical Skills: Use of equipment, performing procedures Intellectual Skills: Analyzing, problem solving, critical thinking, and making nursing judgmentsThrough the nursing process the nurse utilizes skills, such as interpersonal, technical, and intellectual skills. Interpersonal Skills: Communicating, listening, conveying interest, compassion, knowledge, and information, as well as developing trust and obtaining data in a manner that enhances dignity of the client Technical Skills: Use of equipment, performing procedures Intellectual Skills: Analyzing, problem solving, critical thinking, and making nursing judgments

15. 3-15 Critical Thinking Purposeful thought process Strategy used in search for meaning Deliberate questions are asked Critical thinking is a purposeful thought process incorporating various strategies in search for the meaning of data. Deliberate questions are asked in order to validate and evaluate evidence. Critical thinkers seek out explanations for what is happening. Critical thinking is a purposeful thought process incorporating various strategies in search for the meaning of data. Deliberate questions are asked in order to validate and evaluate evidence. Critical thinkers seek out explanations for what is happening.

16. 3-16 Problem Solving Gather data Identify problem Interpret data Plan to resolve Implement plan Evaluate results The nursing process is a problem-solving method. However, there is a difference between this method and the method used in solving daily problems. In both methods, information is gathered, problems are identified, specific problems are labeled, a plan is developed for solving the problem, the plan is put into action, and then, the results are evaluated. However, in solving daily problems, plans are frequently based on incomplete data and sometimes on presumptions. This type of problem solving is more linear compared with the cyclic and ongoing nature of the nursing process. Nurses using the nursing process method of problem solving actively engage in taking deliberate steps and use critical thought to identify and solve problems. The nursing process is a problem-solving method. However, there is a difference between this method and the method used in solving daily problems. In both methods, information is gathered, problems are identified, specific problems are labeled, a plan is developed for solving the problem, the plan is put into action, and then, the results are evaluated. However, in solving daily problems, plans are frequently based on incomplete data and sometimes on presumptions. This type of problem solving is more linear compared with the cyclic and ongoing nature of the nursing process. Nurses using the nursing process method of problem solving actively engage in taking deliberate steps and use critical thought to identify and solve problems.

17. 3-17 Decision Making Based on scientific theories Results from nurse�s ability to think critically Perceptual and intellectual skills used

18. 3-18 Maslow�s Hierarchy of Needs

19. 3-19 Benefits of the Nursing Process Improved quality of care Continuity of care Promotes client participation in care Delivery of care is organized, continuous, and systematic Efficient use of time and resources Expectations of client and standards of care are met Holds nurses accountable and responsible Examples of benefits of the nursing process include: Quality of care is improved Promotes continuity of care Promotes high level of client participation Delivery of care and problem solving are organized, continuous, and systematic Time and resources are utilized more efficiently Promotes delivery of care meeting expectations of both the health care consumer and standards of the nursing profession Holds all nurses accountable and responsible for assessment, diagnosis, planning, implementation, and evaluation of client careExamples of benefits of the nursing process include: Quality of care is improved Promotes continuity of care Promotes high level of client participation Delivery of care and problem solving are organized, continuous, and systematic Time and resources are utilized more efficiently Promotes delivery of care meeting expectations of both the health care consumer and standards of the nursing profession Holds all nurses accountable and responsible for assessment, diagnosis, planning, implementation, and evaluation of client care

20. 3-20 Five Steps of the Nursing Process Assessment Diagnosis Planning and outcome identification Implementation Evaluation The nursing process consists of five steps: assessment, diagnosis, planning and outcome identification, implementation, and evaluation.The nursing process consists of five steps: assessment, diagnosis, planning and outcome identification, implementation, and evaluation.

21. 3-21 Scope and Standards of Practice Assessment: Nurse collects data Diagnosis: Nurse analyzes data in determining diagnoses Outcome identification: Nurse identifiesexpected outcomes Planning: Nurse develops a plan of care Implementation: Nurse implementsinterventions identified in plan Evaluation: Nurse evaluates client�s progress From American Nurses Association. (1991). Standards of clinical nursing practice. Washington DC: Author. Scope and Standards of Practice Assessment: The nurse collects client health data. Diagnosis: The nurse analyzes the assessment data in determining diagnoses. Outcome Identification: The nurse identifies expected outcomes individualized to the client. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. Implementation: The nurse implements the interventions identified in the plan of care. Evaluation: The nurse evaluates the client�s progress toward attainment of outcomes.Scope and Standards of Practice Assessment: The nurse collects client health data. Diagnosis: The nurse analyzes the assessment data in determining diagnoses. Outcome Identification: The nurse identifies expected outcomes individualized to the client. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. Implementation: The nurse implements the interventions identified in the plan of care. Evaluation: The nurse evaluates the client�s progress toward attainment of outcomes.

22. 3-22 Questions Critical Thinkers Ask... What actual problems were identified during assessment? What are possible causes? Is client at risk for developing other problems? What are the factors involved? Did the client indicate a desire to function at a higher level of wellness? The nurse uses critical-thinking and decision-making skills in developing nursing diagnoses, a process facilitated by asking questions. The nurse uses critical-thinking and decision-making skills in developing nursing diagnoses, a process facilitated by asking questions.

23. 3-23 Questions Critical Thinkers Ask... What are the client�s strengths? What additional data might be needed to answer these questions? What are possible sources of data collection? Is collaboration needed at this time? What data are pertinent to collect before contacting the physician?

24. 3-24 Assessment Gathering data Organizing Verifying accuracy Documenting data Assessment is the first step in the nursing process. It involves the act of gathering data about the health status of a client (individual, resident, group of individuals). Information is collected using a systematic approach, then organized, interpreted, verified, and validated to ensure its accuracy. Finally, data are documented. The care plan will be developed from assessment activities, such as the client interview and physical assessment. Assessment is the first step in the nursing process. It involves the act of gathering data about the health status of a client (individual, resident, group of individuals). Information is collected using a systematic approach, then organized, interpreted, verified, and validated to ensure its accuracy. Finally, data are documented. The care plan will be developed from assessment activities, such as the client interview and physical assessment.

25. 3-25 Characteristics of Assessment Systematic, ongoing, and continuous Process of collecting data Identification of problems Data yield information regarding health status Assessment is the initial step. It is systematic, ongoing, and continuous. Assessment is the process of collecting data (information) to identify actual or potential health problems and strengths of the client. The data provide a sense of the client�s overall health status. Data collection may include physical, psychological, social, cultural, spiritual, and cognitive areas, as well as developmental level, economic status, functional abilities, and lifestyle, depending on the tool used during data collection. Assessment is the initial step. It is systematic, ongoing, and continuous. Assessment is the process of collecting data (information) to identify actual or potential health problems and strengths of the client. The data provide a sense of the client�s overall health status. Data collection may include physical, psychological, social, cultural, spiritual, and cognitive areas, as well as developmental level, economic status, functional abilities, and lifestyle, depending on the tool used during data collection.

26. 3-26 Types of Data Subjective Objective Complements, clarifies, supports Data may be separated into two categories, subjective and objective data. Subjective data, also known as symptoms, are statements, feelings, perceptions, or concerns communicated by a client. For example, �I�m tired� or �I�m having pain� or �I feel so afraid.� Objective data, also referred to as signs, can be observed, measured, or felt by someone other than the person experiencing them. It is recommended for a novice to separate collected data into subjective and objective data. Each category will complement and clarify the other. Data may be separated into two categories, subjective and objective data. Subjective data, also known as symptoms, are statements, feelings, perceptions, or concerns communicated by a client. For example, �I�m tired� or �I�m having pain� or �I feel so afraid.� Objective data, also referred to as signs, can be observed, measured, or felt by someone other than the person experiencing them. It is recommended for a novice to separate collected data into subjective and objective data. Each category will complement and clarify the other.

27. 3-27 Baseline Data Initial data becomes foundation Accurate data collection is critical Used for comparison of future data Initial data collected become the foundation of the client database and are termed baseline data. Thorough and accurate data collection is an important element in planning effective client care. The professional nurse uses deliberate thought processes, judgment, and problem-solving skills as data are collected, analyzed, verified, organized, and interpreted. Data accumulated after the initial assessment are frequently compared to baseline data to determine the client�s progress or improvement or to discover trends reflecting deterioration of the client�s health status. For example, Mr. Gomez, a fifty-eight-year-old Hispanic male, has been seen for his annual physical exam consecutively over the last several years. His first visit at the clinic was six years ago. At that time, baseline data were collected, including physical assessment, blood chemistry, and vital signs, of which all were within the normal range: blood pressure 128/82, pulse eighty-four, respirations eighteen. Today, Mr. Gomez�s blood pressure measurement was 154/96. This value was compared to the previous blood pressure readings beginning with the initial baseline values and those obtained subsequently. The nurse discovered Mr. Gomez�s blood pressure had progressively elevated over the years. The nurse brought this fact to the physician�s attention. Further assessment, evaluation, and medical treatment will focus on minimizing and preventing the adverse effects of hypertension. Initial data collected become the foundation of the client database and are termed baseline data. Thorough and accurate data collection is an important element in planning effective client care. The professional nurse uses deliberate thought processes, judgment, and problem-solving skills as data are collected, analyzed, verified, organized, and interpreted. Data accumulated after the initial assessment are frequently compared to baseline data to determine the client�s progress or improvement or to discover trends reflecting deterioration of the client�s health status. For example, Mr. Gomez, a fifty-eight-year-old Hispanic male, has been seen for his annual physical exam consecutively over the last several years. His first visit at the clinic was six years ago. At that time, baseline data were collected, including physical assessment, blood chemistry, and vital signs, of which all were within the normal range: blood pressure 128/82, pulse eighty-four, respirations eighteen. Today, Mr. Gomez�s blood pressure measurement was 154/96. This value was compared to the previous blood pressure readings beginning with the initial baseline values and those obtained subsequently. The nurse discovered Mr. Gomez�s blood pressure had progressively elevated over the years. The nurse brought this fact to the physician�s attention. Further assessment, evaluation, and medical treatment will focus on minimizing and preventing the adverse effects of hypertension.

28. 3-28 Data Collection Interview, physical exam, diagnostic exams Communicated and documented Begins when client enters health care system Continues as long as there is a need Data are gathered during an interview, physical examination, and review of diagnostic studies. Information is analyzed and validated, and facts are clustered into groups of information to identify patterns of health or illness. Assessment data are accessible to other health care team members through communication and documentation. Data collection begins when the client enters the health care system. The nurse may begin collection prior to initial contact with the client through review of medical records and history. Collection continues during interview, observations, and examination. Data collection continues as long as there is a need for health care.Data are gathered during an interview, physical examination, and review of diagnostic studies. Information is analyzed and validated, and facts are clustered into groups of information to identify patterns of health or illness. Assessment data are accessible to other health care team members through communication and documentation. Data collection begins when the client enters the health care system. The nurse may begin collection prior to initial contact with the client through review of medical records and history. Collection continues during interview, observations, and examination. Data collection continues as long as there is a need for health care.

29. 3-29 Validating & Clarifying Data Subjective Data: �I feel like my heart is racing� Objective Data: Pulse 150 beats per minute, regular, strong Objective data support the subjective data. What the nurse observes and measures confirms what the client is feeling and experiencing. However, this may not always be true. There may be times when objective data will conflict or seem different from what the client is stating. Objective data support the subjective data. What the nurse observes and measures confirms what the client is feeling and experiencing. However, this may not always be true. There may be times when objective data will conflict or seem different from what the client is stating.

30. 3-30 Sources of Data Client Family or significant other Nursing records Medical records Consultations Health care team members Diagnostic results Relevant literature Gathering data should involve every possible source. The client should be the primary source of information, when possible. Family or significant others may provide useful or additional information about the client. Data may be obtained from nursing records, medical records, and verbal and written consultations. Other members of the health care team working with the client may provide valuable information. Additional sources include diagnostic results (past and present) and relevant literature, for example, accepted standards (which indicate normal functioning, such as the accepted range of a normal pulse rate). Gathering data should involve every possible source. The client should be the primary source of information, when possible. Family or significant others may provide useful or additional information about the client. Data may be obtained from nursing records, medical records, and verbal and written consultations. Other members of the health care team working with the client may provide valuable information. Additional sources include diagnostic results (past and present) and relevant literature, for example, accepted standards (which indicate normal functioning, such as the accepted range of a normal pulse rate).

31. 3-31 Data Collection Tools Organization Documentation Nursing models Holistic The assessment database should include all aspects of the client�s health status. Assessment tools are designed to help nurses remember what data to collect and to organize the information obtained. Health care facilities develop preprinted documents, which serve as a guide for collecting and recording necessary information. Most health care facilities use assessment tools based on nursing models considered holistic. This term means all aspects of the client�s physical, emotional, social, spiritual, and economic well-being are collected and considered. Otherwise, important information relating to how the client lives his or her daily life may be omitted or missed. Some tools are organized based on problems commonly encountered on a particular nursing unit. For example, pediatric and geriatric data collection tools have additional questions pertaining to these age groups. Any format is acceptable, as long as it is thorough and comprehensive and considers the client�s developmental age. Educator Note Emphasize that it is not necessary to memorize actual tools, but to realize that the tools used in health care settings have a theoretical base. Discuss human needs and/or expectations based on frameworks such as Maslow�s hierarchy, Erik Erikson�s developmental stages, and possibly, theories specific to the educator�s institution (NANDA�s Human Response, Gordon�s Functional Health Patterns, etc.). The assessment database should include all aspects of the client�s health status. Assessment tools are designed to help nurses remember what data to collect and to organize the information obtained. Health care facilities develop preprinted documents, which serve as a guide for collecting and recording necessary information. Most health care facilities use assessment tools based on nursing models considered holistic. This term means all aspects of the client�s physical, emotional, social, spiritual, and economic well-being are collected and considered. Otherwise, important information relating to how the client lives his or her daily life may be omitted or missed. Some tools are organized based on problems commonly encountered on a particular nursing unit. For example, pediatric and geriatric data collection tools have additional questions pertaining to these age groups. Any format is acceptable, as long as it is thorough and comprehensive and considers the client�s developmental age. Educator Note Emphasize that it is not necessary to memorize actual tools, but to realize that the tools used in health care settings have a theoretical base. Discuss human needs and/or expectations based on frameworks such as Maslow�s hierarchy, Erik Erikson�s developmental stages, and possibly, theories specific to the educator�s institution (NANDA�s Human Response, Gordon�s Functional Health Patterns, etc.).

32. 3-32 Methods of Data Collection Observation Interview Physical assessment The nurse collects data through the following methods: observation, interview, and physical examination. The nurse collects data through the following methods: observation, interview, and physical examination.

33. 3-33 Promoting Data Collection Use communication techniques paraphrasing clarifying focusing summarizing open-ended questions Data collection is facilitated by various communication techniques. During the interview, nurses ask questions to elicit a particular response. How questions are asked will determine client responses. Open-ended questions are stated in a manner that encourages the client to elaborate about a particular concern or problem. For example, �What types of food do you usually eat during a twenty-four-hour period?� or �What led to your coming here today?� Each of these questions encourages the client to respond with information. Closed questions can be answered with brief yes-or-no answers. This type of questioning may be appropriate in certain situations, for example, in an emergency: �Did she respond to you when you entered her room?� or �How many pounds has she lost over the last month?� Data collection is facilitated by various communication techniques. During the interview, nurses ask questions to elicit a particular response. How questions are asked will determine client responses. Open-ended questions are stated in a manner that encourages the client to elaborate about a particular concern or problem. For example, �What types of food do you usually eat during a twenty-four-hour period?� or �What led to your coming here today?� Each of these questions encourages the client to respond with information. Closed questions can be answered with brief yes-or-no answers. This type of questioning may be appropriate in certain situations, for example, in an emergency: �Did she respond to you when you entered her room?� or �How many pounds has she lost over the last month?�

34. 3-34 Data Clustering Determines relation Finds patterns Data clustering is used to determine the relatedness of facts, to find patterns, and to determine if further data are needed. Example: Situation: Sharon O�Reilly, a thirty-eight-year-old female, was diagnosed with rheumatoid arthritis at the age of twenty. She states that at first, joints in her wrists and fingers were stiff and sometimes painfully swollen, but would resolve without intervention. She thought the symptoms were related to her active lifestyle. Over time, other joints became involved. Bilateral knees, right ankle and right hand and fingers are painful, reddened, and edematous. She states she has difficulty performing even the simplest activities, such as brushing her hair or teeth or ambulating to the bathroom. The client was observed having difficulty brushing her hair and putting on her gown. She experiences almost constant pain, which she rates as �six� on a scale of one to ten. The nurse observes Ms. O�Reilly�s face is masked with pain. She guards her knees, so that no one touches them. She asked for her walker as she attempted to ambulate to a chair. The nurse observes that she walks with a limp. She states she began to use a walker �about a year ago.� Data clustering is used to determine the relatedness of facts, to find patterns, and to determine if further data are needed. Example: Situation: Sharon O�Reilly, a thirty-eight-year-old female, was diagnosed with rheumatoid arthritis at the age of twenty. She states that at first, joints in her wrists and fingers were stiff and sometimes painfully swollen, but would resolve without intervention. She thought the symptoms were related to her active lifestyle. Over time, other joints became involved. Bilateral knees, right ankle and right hand and fingers are painful, reddened, and edematous. She states she has difficulty performing even the simplest activities, such as brushing her hair or teeth or ambulating to the bathroom. The client was observed having difficulty brushing her hair and putting on her gown. She experiences almost constant pain, which she rates as �six� on a scale of one to ten. The nurse observes Ms. O�Reilly�s face is masked with pain. She guards her knees, so that no one touches them. She asked for her walker as she attempted to ambulate to a chair. The nurse observes that she walks with a limp. She states she began to use a walker �about a year ago.�

35. 3-35 Diagnosis Analysis Problem identification Nursing diagnosis Diagnosis is the second phase of the nursing process. It involves the classification of a disease, condition, or human response based upon scientific evaluation of signs, symptoms, history, and diagnostic studies. Diagnosis is also referred to as analysis, problem identification, or nursing diagnosis, corresponding terms that are used interchangeably. During the assessment phase, nurses use critical thinking skills and judgment to analyze, organize, and interpret assessment data. Problems, potential problems, and strengths of the client are identified. In the diagnosis phase problems, potential problems, and strengths are labeled with an appropriate nursing diagnosis. Once labeled, the nursing diagnosis communicates specific health care needs about the client to other members of the health care team involved in care. Educator Note Stress the importance of reading the definition of each nursing diagnosis to determine if applicable to client�s condition. Diagnosis is the second phase of the nursing process. It involves the classification of a disease, condition, or human response based upon scientific evaluation of signs, symptoms, history, and diagnostic studies. Diagnosis is also referred to as analysis, problem identification, or nursing diagnosis, corresponding terms that are used interchangeably. During the assessment phase, nurses use critical thinking skills and judgment to analyze, organize, and interpret assessment data. Problems, potential problems, and strengths of the client are identified. In the diagnosis phase problems, potential problems, and strengths are labeled with an appropriate nursing diagnosis. Once labeled, the nursing diagnosis communicates specific health care needs about the client to other members of the health care team involved in care. Educator Note Stress the importance of reading the definition of each nursing diagnosis to determine if applicable to client�s condition.

36. 3-36 Nursing vs. Medical Diagnoses Nursing Diagnosis Determined by the nurse Clinical judgment about the client Human responses to disease or treatment May change Medical Diagnosis Determined by physician Indicates disease, illness Doesn�t change Nursing diagnoses are problems identified and determined by the professional nurse. According to NANDA, a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. In 1980, the ANA defined nursing process as the diagnosis and treatment of human responses to actual or potential health problems of disease and medical treatment. This means that nurses are not responsible for diagnosing and ordering treatment for disorders such as cancer. Professional nurses diagnose and treat the client�s response to cancer, such as inadequate nutrition, nausea, altered self-esteem, anxiety, and pain. After assessment, a list of nursing diagnoses is formulated and presented to the client or family (when client is unable to participate) for confirmation. Finally, the list of nursing diagnoses is recorded and the remainder of the client�s care plan completed. The client continues to be monitored; their response to treatment may involve improvement, or the condition may worsen. Nursing diagnoses included in the care plan reflect the changing needs of the client. Educator Note Emphasize the initial nursing diagnoses list is not static, but a dynamic list; that is, nursing diagnoses change when the client�s health status improves or additional problems are discovered. Clients receive both medical and nursing diagnoses. Nursing diagnoses should not be confused with medical diagnoses. Medical diagnoses are determined by the physician indicating a disease or disorder identified or to be ruled out, e.g. pneumonia, renal failure, sepsis, or diabetes mellitus.Nursing diagnoses are problems identified and determined by the professional nurse. According to NANDA, a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. In 1980, the ANA defined nursing process as the diagnosis and treatment of human responses to actual or potential health problems of disease and medical treatment. This means that nurses are not responsible for diagnosing and ordering treatment for disorders such as cancer. Professional nurses diagnose and treat the client�s response to cancer, such as inadequate nutrition, nausea, altered self-esteem, anxiety, and pain. After assessment, a list of nursing diagnoses is formulated and presented to the client or family (when client is unable to participate) for confirmation. Finally, the list of nursing diagnoses is recorded and the remainder of the client�s care plan completed. The client continues to be monitored; their response to treatment may involve improvement, or the condition may worsen. Nursing diagnoses included in the care plan reflect the changing needs of the client. Educator Note Emphasize the initial nursing diagnoses list is not static, but a dynamic list; that is, nursing diagnoses change when the client�s health status improves or additional problems are discovered. Clients receive both medical and nursing diagnoses. Nursing diagnoses should not be confused with medical diagnoses. Medical diagnoses are determined by the physician indicating a disease or disorder identified or to be ruled out, e.g. pneumonia, renal failure, sepsis, or diabetes mellitus.

37. 3-37 Definition: Nursing Diagnosis A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selecting interventions to achieve outcomes for which the nursing is accountable

38. 3-38 Types Nursing Diagnosis Actual Risk Possible Syndrome Wellness Collaborative

39. 3-39 Making a Nursing Diagnosis Know diagnoses Collect valid & pertinent data, cluster data, differentiate nursing diagnosis from collaborative problems, prioritize Defining the characteristics Major & Minor Related factors Pathophysiological Treatment Situational Maturational

40. 3-40 Actual ND Represents a problem that has been validated by the presence of major defining characteristics. Has four parts Label Definition Defining characteristics Related factors

41. 3-41 Risk ND Clinical judgment that an individual, family or community is vulnerable to develop the problem than others in the same or similar situation

42. 3-42 Possible ND Describes a suspected problem requiring additional data. This is where data is not complete or an evaluation has not been completed Not a NANDA ND because it is not classified, yet viable for the clinical nurse for further clarification of a problem

43. 3-43 Syndrome ND Clustering of predictable actual or high-risk NDs related to events or situations Complex clinical situation, use with care and stated as a one-part statement There should be a clustering of other NDs

44. 3-44 Wellness ND Clinical judgment about an individual, family or community transition from a specific level of wellness to a higher level Stated as a one-part

45. 3-45 Collaborative Problems Physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems with PCP-prescribed (dependent nursing functions) and Nursing-prescribed (independent nursing functions) to minimize complications

46. 3-46 Cultural, Ethical & Spiritual ND Cultural Needs Where is the cultural component? Belief system, knowledge, food, environment, powerlessness Ethical Issues What do you do with issues that are illegal, or different from your belief system? Spiritual Concerns Does, or how does the patient utilize spirituality in there health care?

47. 3-47 Components of a Nursing Diagnosis Stated as one, two or three parts

48. 3-48 Formulating Nursing Diagnosis

49. 3-49 Example of Actual Nursing Diagnoses Hyperthermia Client�s temperature is 104.6�F. Impaired Gas Exchange Client�s oxygen saturation in arterial blood is 92%.

50. 3-50 Example of Actual Nursing Diagnoses Pain Client states pain level �8� on scale of one to ten. Anxiety Client states he is experiencing anxiety. Self-care deficit Client is unable to perform ADLs.

51. 3-51 Components of Actual Nursing Diagnoses Problem Etiology Defining characteristics For actual nursing diagnoses, the problem statement consists of three components: problem, etiology, and defining characteristics. Each element has a specific purpose. For actual nursing diagnoses, the problem statement consists of three components: problem, etiology, and defining characteristics. Each element has a specific purpose.

52. 3-52 Problem Label Nursing diagnosis The problem is the identified label of a client�s health problem or response to the medical condition or therapy for which nursing may intervene. The problem is also known as the nursing diagnosis. The problem is the identified label of a client�s health problem or response to the medical condition or therapy for which nursing may intervene. The problem is also known as the nursing diagnosis.

53. 3-53 Etiology Related to (R/T) or related factor Involved in development of problem Becomes focus for interventions Cause component Gives direction to problem statement The etiology, written as related to or R/T, includes conditions most likely to be involved in the development of a problem. This factor becomes the focus for nursing interventions. The etiology or cause component of the nursing diagnosis identifies one or more probable causes of the abnormal response. The etiology gives direction to the problem statement. In view of this fact, the nurse is able to individualize care. NANDA uses the term Related Factor to describe the etiology or likely cause of the actual nursing diagnosis. The etiology, written as related to or R/T, includes conditions most likely to be involved in the development of a problem. This factor becomes the focus for nursing interventions. The etiology or cause component of the nursing diagnosis identifies one or more probable causes of the abnormal response. The etiology gives direction to the problem statement. In view of this fact, the nurse is able to individualize care. NANDA uses the term Related Factor to describe the etiology or likely cause of the actual nursing diagnosis.

54. 3-54 Defining Characteristics As evidenced by (AEB) Clinical evidence How response is manifested Defining characteristics, written as evidenced by or AEB, are the clinical signs and symptoms, which confirm the problem exists. This component reflects how the diagnosis or problematic response is manifested. Defining characteristics, written as evidenced by or AEB, are the clinical signs and symptoms, which confirm the problem exists. This component reflects how the diagnosis or problematic response is manifested.

55. 3-55 Examples The examples that follow of actual nursing diagnoses include all components of the problem statement. The examples that follow of actual nursing diagnoses include all components of the problem statement.

56. 3-56 Scenario One: The nurse is caring for a client who was involved in a motor vehicle accident and sustained superficial skin trauma. The client�s epidermal layer of skin on the right knee, forearm, and hand is excoriated, reddened, and bleeding as the result of sliding across a cement pavement. Educator Note Instruct students to locate the nursing diagnosis, Impaired Skin Integrity, in Appendix A. Instruct students to read the definition and then determine the etiology and defining characteristics. Emphasize the related to criteria as contributing factors involved in the development of the problem and the as evidenced by criteria as the clinical signs and symptoms of how the nursing diagnosis is manifested. Answer on next slide. Educator Note Instruct students to locate the nursing diagnosis, Impaired Skin Integrity, in Appendix A. Instruct students to read the definition and then determine the etiology and defining characteristics. Emphasize the related to criteria as contributing factors involved in the development of the problem and the as evidenced by criteria as the clinical signs and symptoms of how the nursing diagnosis is manifested. Answer on next slide.

57. 3-57 Answer: Impaired Skin Integrity R/T: mechanical factors, shearing forces AEB: disruption of skin surface, destruction of skin, layers, traumatized skin excoriated, reddened, bleeding

58. 3-58 Scenario Two The client you are caring for has been medically diagnosed with a right cerebral vascular accident (stroke). He experiences partial paralysis on the left side of his body. He is unable to turn over while in bed without assistance and has demonstrated decreased muscle strength and control in the left extremities. Educator Note Instruct the students to locate the nursing diagnosis Impaired Physical Mobility in their text. Identify the etiology and defining characteristics. Answer is on following slide. Educator Note Instruct the students to locate the nursing diagnosis Impaired Physical Mobility in their text. Identify the etiology and defining characteristics. Answer is on following slide.

59. 3-59 Answer: Impaired Physical Mobility R/T: neuromuscular impairment AEB: inability to purposefully move within the environment, decreased muscle strength, control, left-sided partial paralysis

60. 3-60 Components of Risk Nursing Diagnoses Potential problem Risk factor No evidence Problem does not exist Risk nursing diagnoses are identified when the client is at risk for developing a problem. The problem statement consists of two components, the problem and risk factor. The term risk factor is used to describe the etiology of risk nursing diagnoses, because there are no subjective or objective data present. The actual problem does not exist at the time of assessment. However, due to clinical circumstances, the client is at risk for developing this specific problem or complication. Risk nursing diagnoses are identified when the client is at risk for developing a problem. The problem statement consists of two components, the problem and risk factor. The term risk factor is used to describe the etiology of risk nursing diagnoses, because there are no subjective or objective data present. The actual problem does not exist at the time of assessment. However, due to clinical circumstances, the client is at risk for developing this specific problem or complication.

61. 3-61 Risk Nursing Diagnoses Examples Cancer patient, Risk for Infection Risk Factors (R/T): inadequate secondary defenses, immunosuppression Client with surgical incision, Risk for Infection Risk Factors (R/T): inadequate primary defenses, invasive procedure

62. 3-62 Risk Nursing Diagnoses Examples Client who is semi-conscious, vomiting, Risk for Aspiration Risk Factors (R/T): reduced level of consciousness, vomiting Neonate unable to maintain his body temperature, parent does not keep the child covered, Risk for Hypothermia Risk Factors (R/T): extremes of age, inadequate clothing