Unit 5 Clinical Judgement and the Nursing Process

functional health patterns

Method for organizing assessment data based on the level of patient function in specific areas (e.g., mobility).

nursing process

Systematic problem-solving method by which nurses individualize care for each patient. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

review of systems (ROS)

a systematic approach for collecting subjective information from patients about the presence or absence of health-related issues in each body system. For example, the review of the skin, hair, and nails includes assessment of whether a patient has noticed any rash or skin lesions or has itching or abnormal nail or hair growth.

scientific rationale

the reason that you chose a specific nursing action, based on supporting evidence

Collaborative interventions

therapies that require the combined knowledge, skill, and expertise of multiple health care providers

subjective data

Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference.

independent nursing interventions

Nurse-initiated interventions or actions that a nurse initiates without supervision or direction from others. Examples include positioning patients to prevent pressure ulcer formation, instructing patients in side effects of medications, or providing skin care to an ostomy site.

Clinical decision making

Problem-solving approach that nurses use to define patient problems and select appropriate treatment

standing order

a preprinted document containing orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. A standing order directs patient care in a specific clinical setting.

inference

(1) Judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows.

Patient-Centered Goal/Outcome

A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions. • A correct goal statement: "Patient will ambulate independently in 3 days." • A correct outcome statement: "Patient ambulates in the hall 3 times a day by 4/22." • A common error is to write an intervention: "Ambulate patient in the hall 3 times a day."

Build your ability to make clinical decisions by fostering knowing your patients.

Follow these tips: • Spend more time during initial patient assessments to observe patient behavior and measure physical findings as a way to improve knowledge of your patients. Determine what is important to them and make an emotional connection. Patients perceive meaningful time as that involving personal rather than task-oriented conversation. • When talking with patients, listen to their accounts of their experiences with illness, watch them, and come to understand how they typically respond (Tanner, 2006). • Consistently check on patients to assess and monitor problems to help you identify how clinical changes develop over time. • Ask to have the same patient assigned to you over consecutive days. Researchers have noted that a nurse-patient relationship develops from getting to know a patient and building a foundation for connecting on the first day of care, to deepening understanding of the patient and sustaining a connection by the second day, to being comfortable with the patient by the third day (Lotzkar and Bottorff, 2010). • Social conversation and continuity are important for developing knowing and nurse-patient relationships

closed-ended question

Form of question that limits a respondent's answer to one or two words.

cue

Information that a nurse acquires through hearing, visual observations, touch, and smell.

Objective data

Information that can be observed by others; free of feelings, perceptions, prejudices.

evidence-based knowledge

Knowledge that is derived from the integration of best research, clinical expertise, and patient values

NANDA-I

North American Nursing Diagnosis Association -International

nursing-sensitive patient outcome

a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions; Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient's symptoms, functional status, safety, psychological distress, or costs.

related factor

an etiological or causative factor for the diagnosis (i.e., the data that appear to show some type of patterned relationship with a nursing diagnosis)

short-term goal

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week

long-term goal

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (e.g., "Patient will be tobacco free within 60 days")

critical thinking

Active, purposeful, organized, cognitive process used to carefully examine one's thinking and the thinking of other individuals

validation

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan. For example, you observe a patient crying and logically infer that it is related to hospitalization or a medical diagnosis. Making such an initial inference is not wrong, but problems result if you do not validate the inference with the patient. Instead ask, "I notice that you have been crying. Can you tell me about it?" By validating you discover the real reason for the patient's crying behavior.

concept map

Care-planning tool that assists in critical thinking and forming associations between a patient's nursing diagnoses and interventions

data cluster

Set of signs or symptoms that are grouped together in logical order. Each cue is an objective or subjective sign, symptom, or risk factor that, when analyzed with other cues, begins to lead to diagnostic conclusions.

goal

a broad statement that describes a desired change in a patient's condition, perceptions, or behavior

Evaluation

crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed.

interdisciplinary care plans

plans representing the contributions of all disciplines caring for a patient

patient-centered goal

reflects a patient's highest possible level of wellness and independence in function

Key Points for Critical Thinking in Nursing Practice

• Clinical decision making involves judgment that includes critical and reflective thinking and action and application of scientific and practical logic. • Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, single solutions. • Reflection involves purposeful thinking back or recalling a situation to discover its purpose or meaning. • Following a procedure step by step without adjusting to a patient's unique needs is an example of basic critical thinking. • In complex critical thinking a nurse learns that alternative and perhaps conflicting solutions exist. • In diagnostic reasoning you collect patient data and analyze them to determine the patient's problems. • The critical thinking model combines a nurse's knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care. • Clinical learning experiences are necessary for you to acquire clinical decision-making skills. • Critical thinking attitudes help you know when more information is necessary and when it is misleading and to recognize your own knowledge limits. • The use of intellectual standards during assessment ensures that you obtain a complete database of information. • Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility. • Meeting regularly with colleagues allows you to discuss anticipated and unanticipated outcomes in any clinical situation to continually learn and develop your expertise. • Stress over a prolonged period or when extreme can cause distress, leading to poor work productivity and impaired decision making and communication.

Why to use NANDA-I terminology in a medical record entry!!

• NANDA-I diagnoses have a broad literature base, with many diagnoses being evidence based. Patient safety requires accurate documentation of health problems. • NANDA-I classifications are the most comprehensive. • NANDA-I diagnoses are under continual refinement and development by professional nurses.

steps to objectively evaluate the degree of success in achieving outcomes of care

1. Examine the outcome criteria to identify the exact desired patient behavior or response. 2. Evaluate a patient's actual behavior or response. 3. Compare the established outcome criteria with the actual behavior or response. 4. Judge the degree of agreement between outcome criteria and the actual behavior or response. 5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?

back-channeling

Active listening technique that prompts a respondent to continue telling a story or describing a situation. Involves use of phrases such as "Go on," "Uh huh," and "Tell me more."

Open-ended question

Form of question that prompts a respondent to answer in more than one or two words.

medical diagnosis

Formal statement of the disease entity or illness made by the physician or health care provider

dependent nursing interventions

Health care provider-initiated interventions or actions that require an order from a health care provider.

Implementation

Initiation and completion of the nursing actions necessary to help the patient achieve health care goals

standard of care

Minimum level of care accepted to ensure high-quality care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs.

Reviewing and Revising the Existing Nursing Care Plan

Modification of an existing written care plan includes four steps: 1. Revise data in the assessment column to reflect the patient's current status. Date any new data to inform other members of the health care team of the time that the change occurred. 2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient's goals, outcomes, and priorities. Date any revisions. 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient's present status. 4. Choose the method of evaluation for determining whether the patient achieved his or her outcomes.

consultation

Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs.

planning

Process of designing interventions to achieve the goals and outcomes of health care delivery.

Five-Column Student Care Plan format

Starting from left to right, the five columns include: (1) assessment data relevant to corresponding diagnosis, (2) goals/outcomes identified for the patient, (3) implementation (selected interventions) for the plan of care, (4) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence), and (5) a section to evaluate your care. The following questions help you design a plan: • What is the intervention, and is it evidence based? • When should each intervention be implemented? • How should the intervention be performed for this specific patient? • Who should be involved in each aspect of intervention?

Identifying Areas of Assistance

When you are asked to administer a new medication, operate a new piece of equipment, or administer a procedure with which you are unfamiliar, follow these steps. 1. Seek the information you need to be informed about a procedure. Check the scientific literature for evidence-based information, review resource manuals and the procedure book of the agency, or consult with experts (e.g., pharmacists, clinical nurse specialists). 2. Collect all equipment necessary for the procedure. 3. Have another nurse (e.g., staff nurse, faculty, clinical nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance. Requesting assistance occurs frequently in all types of nursing practice. It is a learning process that continues throughout educational experiences and into professional development. One tip is to verbalize with an instructor or staff nurse the steps you will take before actually performing the procedure to improve your confidence and ensure accuracy.

Types of Assessments

You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. For example, when you bathe a patient or change a dressing, you are always using your skills of observation and physical examination to gather data about him or her.

health promotion nursing diagnosis

a clinical judgment concerning a patient's motivation and desire to increase well-being and actualize human health potential; a health promotion is activities such as routine exercise and good nutrition that help patients maintain or enhance their present level of health and reduce their risk of developing certain diseases.

Counseling

a direct care method that helps patients use problem-solving processes to recognize and manage stress and facilitate interpersonal relationships. As a nurse you counsel patients to accept actual or impending changes resulting from stress. Examples include patients who are facing terminal illness or chronic disease.

adverse reaction

a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention

lifesaving measure

a physical care technique that you use when a patient's physiological or psychological state is threatened. The purpose of lifesaving measures is to restore physiological or psychological homeostasis. Such measures include administering emergency medications, instituting cardiopulmonary resuscitation, intervening to protect a confused or violent patient, and obtaining immediate counseling from a crisis center for a severely anxious 265patient.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

a standardized survey used across the country by hospitals to measure patients' perspectives on hospital care

clinical practice guideline

a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

Delegation

allows you to use your time more wisely and to have NAP assist by performing noninvasive and frequently repetitive interventions such as skin care, ambulation, vital signs on stable patients, and hygiene measures. When you delegate tasks to NAP, you are responsible for ensuring that you assign each task appropriately and that the NAP completes each task according to the standard of care. You must be sure that any delegated action was completed correctly, documented, and evaluated. You only delegate direct care interventions to personnel who are competent.

Activities of daily living (ADLs)

ambulation, eating, dressing, bathing, and grooming

nursing intervention

any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

evaluative measures

assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, patient interview)

problem-focused nursing diagnosis

describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community

Patient adherence

patients and families invest time in carrying out required treatments

Preventive nursing actions

promote health and prevent illness to avoid the need for acute or rehabilitative health care; Nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care.

Instrumental activities of daily living (IADLs)

skills such as shopping, preparing meals, housecleaning, writing checks, and taking medications

expected outcome

the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal

diagnostic label

the name of the nursing diagnosis as approved by NANDA-I

Indirect care interventions

treatments performed away from a patient but on behalf of the patient or group of patients (e.g., managing a patient's environment [e.g., safety and infection control]), documentation, and interdisciplinary collaboration

Direct care interventions

treatments performed through interactions with patients . For example, a patient receives direct intervention in the form of medication administration, insertion of a urinary catheter, discharge instruction, or counseling during a time of grief

Key Points for Planning Nursing Care

• After identifying a patient's nursing diagnoses and collaborative problems, establish a plan of care that prioritizes the diagnoses and establishes nursing interventions, patient-centered goals, and expected outcomes. • Planning involves individualizing a plan of care for a patient's unique needs. • Priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing actions. • Priorities help you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems. • A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions. • The use of goals and outcomes in patient care is designed to focus the efforts of all health care team members on a common purpose. • Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient's health problems. • When writing goals and outcomes, use the SMART acronym: Specific, Measurable, Attainable, Realistic, and Timed. 254 • During planning select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes. • Independent nursing interventions are actions that a nurse initiates without supervision or direction from others, are autonomous based on scientific rationale, and do not require an order from another health care provider. • Health care provider-initiated interventions require specific nursing responsibilities and technical nursing knowledge. • Care plans increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another. • A nurse hand-off transfers essential information (along with responsibility and authority) from one nurse to the next during transitions in care and allows you to ask questions, clarify, and confirm important details. • A concept map is a visual representation of a patient's nursing diagnoses with links to nursing interventions, helping you learn to make better clinical decisions. • The NIC taxonomy provides a standardization to help nurses select suitable interventions for patients' problems. • Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.

Key Points for Evaluation

• Evaluation is a step of the nursing process that includes two components: an examination of a condition or situation and a judgment as to whether change has occurred. • During evaluation apply critical thinking to make clinical decisions and redirect nursing care to best meet patient needs. • Positive evaluations occur when your patient meets desired outcomes and goals. • Criterion-based standards for evaluation are the physiological, emotional, and behavioral responses that are a patient's goals and expected outcomes. • Evaluative measures are assessment skills or techniques that you use to collect data for determining if outcomes were met. • It sometimes becomes necessary to collect evaluative measures over time to determine if a pattern of change exists. • When interpreting findings, you compare a patient's behavioral responses and the physiological signs and symptoms that you expect to see with those actually seen from your evaluation and judge the degree of agreement. • Documentation of evaluative findings allows all members of the health care team to know whether or not a patient is progressing. • A patient's nursing diagnoses, priorities, and interventions sometimes change as a result of evaluation. • Evaluation examines two factors: the appropriateness of the interventions selected and the correct application of the intervention.

four indicators reflecting a nurse's ability to perform evaluation

• Examine the results according to clinical data collected. • Compare achieved effect with goals and expected outcomes. • Recognize errors. • Understand a patient situation, participate in self-reflection, and correct errors.

Examples of questions on the HCAHPS

• How often did nurses explain things in a way you could understand? • During this hospital stay did you get information in writing about which symptoms or health problems to look for after you left the hospital? • Before giving you new medicine, how often did staff describe possible side effects in a way you could understand?

Key Points for Implementing Nursing Care

• Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. The nurse then initiates interventions that are designed to achieve patient goals and expected outcomes. • A direct care intervention is a treatment performed through interactions with a patient that include nurse-initiated, health care provider-initiated and collaborative approaches. • Always think first and determine if an intervention is correct and appropriate and if you have the resources needed to implement it. • Clinical guidelines or protocols are evidence-based documents that guide decisions and interventions for specific health care problems. • Remaining competent and using good communication skills build your ability to participate in interdisciplinary practices. • A clinical practice guideline establishes evidence-based interventions for specific health care problems or conditions. • The implementation of nursing care often requires additional knowledge, nursing skills, and personnel resources. • Before performing an intervention, make sure that a patient is as physically and psychologically comfortable as possible. • Use good judgment during implementation to ensure that no nursing action is automatic. • Know the purpose of each intervention, the associated preassessment and postassessment risks, steps in performing the intervention correctly, the current medical condition of a patient, and his or her expected response so you can anticipate what to expect in a given clinical situation and how to modify your approach. • To anticipate and prevent complications, identify risks to a patient, adapt interventions to the situation, evaluate the relative benefit of a treatment versus the risk, and initiate risk-prevention measures. • When you administer physical care techniques, protect yourself and the patient from injury, use proper infection control practices, stay organized, and follow applicable practice guidelines. • When you delegate aspects of a patient's care, you are responsible for ensuring that each task is assigned appropriately and completed according to the standard of care.

Tips for Making Decisions During Implementation

• Review the set of all possible nursing interventions for a patient's problem (e.g., for Mr. Lawson's pain Tonya considered analgesic administration, positioning and splinting, progressive relaxation, and other nonpharmacological approaches). • Review all possible consequences associated with each possible nursing action (e.g., Tonya considers that the analgesic will relieve pain; have little or insufficient effect; or cause an adverse reaction, including sedating the patient and increasing the risk of falling). • Determine the probability of all possible consequences (e.g., if Mr. Lawson's pain continues to decrease with analgesia and positioning and there have been no side effects, it is unlikely that adverse reactions will occur, and the intervention will be successful; however, if the patient continues to remain highly anxious, his pain may not stay relieved, and Tonya needs to consider an alternative). • Judge the value of the consequence to the patient (e.g., if the administration of an analgesic is effective, Mr. Lawson will likely become less anxious and more responsive to postoperative instruction and counseling about his anxiety).

Three Approaches for Delegation

• Unit-based scenario—NAP serves the unit. The NAP works off a task list usually found in the job description and has minimal direction from or interaction with RNs. Limited 1 : 1 delegation occurs. Lack of communication can cause conflicts. • Pairing—One RN works with a licensed practical nurse (LPN) and/or a NAP for a shift. The RN and LPN and/or NAP are not intentionally scheduled to work the same shift each day. For a given shift they work together, or are paired, and care for the same group of patients. Delegation usually increases with pairing. • Partnering—Involves one RN and one LPN and/or NAP who are consistently scheduled to work together. The partners commit to healthy interpersonal relationships, trust in one another, and advance each other's knowledge. It is recognized that the RN has the authority to make the delegation decisions.

Nursing Outcomes Classification (NOC)

link outcomes to NANDA International (NANDA-I) nursing diagnoses; This resource is an option that you can use in selecting goals and outcomes for your patients. For each NANDA-I nursing diagnosis there are multiple NOC suggested outcomes. The outcomes have labels for describing the focus of nursing care and include indicators (expected outcomes) to use in evaluating the success with nursing interventions.

Nursing assessment

1. Collection of information from a primary source (a patient) and secondary sources (e.g., family or friends, health professionals, and the medical record) 2. The interpretation and validation of data to ensure a complete database First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.

Guidelines to Reduce Errors in the Diagnostic Statement part 1

1. Identify a patient's response, not the medical diagnosis . Because a medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Change the diagnosis Acute Pain related to colectomy to Acute Pain related to trauma of a surgical incision. 2. Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. One defining characteristic is insufficient for problem identification. For example, dyspnea alone does not definitively lead you to a diagnosis. However, the pattern of dyspnea, reduced chest excursion, and rapid respiratory rate are defining characteristics that lead you to the diagnosis of Ineffective Breathing Pattern. If a patient has severe chest pain resulting from a rib fracture, the final diagnosis will be Ineffective Breathing Pattern related to chest pain. 3. Identify a treatable related factor or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. An accurate related factor allows you to select nursing interventions directed toward correcting the etiology of the problem or minimizing a patient's risk. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A patient with fractured ribs likely has pain when inhaling; impaired chest excursion; and slower, shallow respirations. An x-ray film may show atelectasis (collapse of alveolar air sacs) in the area affected. The nursing diagnosis of Ineffective Breathing Pattern related to shallow respirations is an incorrect diagnostic statement. Ineffective Breathing Pattern related to chest pain from rib fracture is more accurate. 4. Identify a problem caused by the treatment or diagnostic study rather than the treatment or study itself. Patients experience many responses to diagnostic tests and medical treatments. These responses are the area of nursing concern. The patient who has angina and is scheduled for a cardiac catheterization possibly has a nursing diagnosis of Anxiety related to lack of knowledge about cardiac testing. An incorrect diagnosis is Anxiety related to cardiac catheterization. 5. Identify a patient response to the equipment rather than the equipment itself. Patients are often unfamiliar with medical technology and its use. The diagnosis of Deficient Knowledge regarding the need for cardiac monitoring is accurate compared with the statement Anxiety related to cardiac monitor. 6. Identify a patient's problems rather than your problems with nursing care. Nursing diagnoses are always patient centered and form the basis for goal-directed care. Consider a patient with a peripheral intravenous line. Potential Intravenous Complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis Risk for Infection properly centers attention on the patient's potential needs.

Guidelines to Reduce Errors in the Diagnostic Statement part 2

7. Identify a patient problem rather than a nursing intervention. You plan nursing interventions after identifying a nursing diagnosis. The intervention, "offer bedpan frequently because of altered elimination patterns," is not a diagnostic statement. Instead, with the proper assessment data the correct diagnostic statement would be Diarrhea related to food intolerance. This corrects the misstatement and allows proper implementation of the nursing process. More appropriate interventions are selected rather than a single intervention that alone will not solve the problem. 8. Identify a patient problem rather than the goal of care. You establish goals during the planning step of the nursing process. Goals based on accurate identification of a patient's problems serve as a basis to determine problem resolution. Change the goal-phrased statement, "Patient needs high-protein diet related to potential alteration in nutrition," to Imbalanced Nutrition: Less Than Body Requirements related to inadequate protein intake. 9. Make professional rather than prejudicial judgments. Base nursing diagnoses on subjective and objective patient data and do not include your personal beliefs and values. Remove your judgment from Impaired Skin Integrity related to poor hygiene habits by changing the nursing diagnosis to read Impaired Skin Integrity related to inadequate knowledge about perineal care. 10. Avoid legally inadvisable statements. Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. The statement, "Acute Pain related to insufficient medication," implies an inadequate prescription by a health care provider. Correct problem identification is Acute Pain related to poor adherence to analgesic schedule. 11. Identify the problem and etiology to avoid a circular statement. Circular statements are vague and give no direction to nursing care. Change the statement, "Impaired Breathing Pattern related to shallow breathing," to identify the real patient problem and cause, Ineffective Breathing Pattern related to incisional pain. 12. Identify only one patient problem in the diagnostic statement. Every problem has different specific expected outcomes. Confusion during the planning step occurs when you include multiple problems in a nursing diagnosis. For example, Pain and Anxiety related to difficulty in ambulating are two nursing diagnoses combined in one diagnostic statement. A more accurate statement would be two separate diagnoses: Impaired Physical Mobility related to pain in right knee and Anxiety related to difficulty in ambulating. It is permissible to include multiple etiologies contributing to one patient problem, as in Complicated Grieving related to diagnosed terminal illness and change in family role.

concomitant symptoms

Also assess if the patient has concomitant symptoms. Does he or she experience other symptoms along with the primary symptom? For example, does nausea accompany pain?

Developing the Nurse-Patient Relationship for Data Collection

An assessment is necessary for you to gather information to make accurate judgments about a patient's current condition. Your information comes from: • The patient through interview, observations, and physical examination. • Family members or significant others' reports and response to interviews. • Other members of the health care team. • Medical record information (e.g., patient history, laboratory work, x-ray film results, multidisciplinary consultations). • Scientific and medical literature (evidence about disease conditions, assessment techniques, and standards).

knowing the patient

An in-depth knowledge of the patient's patterns of responses; fosters skilled clinical decision making.

Cultural Aspect of Nursing Diagnoses

Consider asking these questions to make culturally competent nursing diagnoses: • How has this health problem affected you and your family? • What do you believe will help or fix the problem? • What worries you the most about this problem? • What do you expect from us, your nurses, to help maintain some of your values or practices for staying healthy? • Which cultural practices do you observe to keep yourself and your family well?

nursing health history

Data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

problem solving

Methodical, systematic approach to explore conditions and develop solutions, including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem.

collaborative problem

Physiological complication that requires the nurse to use nursing- and health care provider-prescribed interventions to maximize patient outcomes; an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status

decision making

Process involving critical appraisal of information that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking.

reflection

Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking.

diagnostic reasoning

Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking.

defining characteristics

The observable assessment cues that cluster as manifestations of a problem focused or health promotion nursing diagnosis.

scientific method

The scientific method has five steps: 1. Identify the problem. 2. Collect data. 3. Formulate a question or hypothesis. 4. Test the question or hypothesis. 5. Evaluate results of the test or study.

Reflective Journaling

The use of a journal improves your observation and descriptive skills and ultimately your clinical decision making. Use these tips for reflecting on a clinical experience to explore its meaning: 1. Which experience, situation, or information in your clinical experience is confusing, difficult, or interesting? 2. What is the meaning of the experience? What feelings did you have? What feelings did your patient or family have? What influenced the experience? 3. Do the feelings, guesses, or questions remind you of any experiences from the past or something that you think is a desirable future experience? How does it relate? 4. What are the connections between what is being described and what you have learned about nursing science and theory? Meeting with Colleagues

Purpose of Standard Nursing Diagnostic Statements

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice: • Provides a precise definition of a patient's responses to health problems that gives nurses and other members of the health care team a common language for understanding a patient's needs • Allows nurses to communicate (e.g., written and electronic) what they do among themselves with other health care professionals and the public • Distinguishes the nurse's role from that of other health care providers • Helps nurses focus on the scope of nursing practice • Fosters the development of nursing knowledge • Promotes creation of practice guidelines that reflect the essence and science of nursing

nursing diagnosis

a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat; Formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step of the nursing process, during which the patient's actual and potential unhealthy responses to an illness or condition are identified.

risk nursing diagnosis

a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes

nursing care plan

includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation

three-part nursing diagnostic label

the diagnostic label consists of the NANDA-I label, the related factor, and the defining characteristics; To write a three-part nursing diagnosis, the acronym PES, which stands for problem, etiology, and symptoms, is helpful. • P (problem)—NANDA-I label—Example: Impaired Physical Mobility • E (etiology or related factor)—Example: incisional pain • S (symptoms or defining characteristics)—Briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning Full three-part diagnostic statement: Impaired Physical Mobility related to incisional pain as evidenced by restricted turning and positioning.

Priority setting

the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions. Priority setting is not the ordering of a list of care tasks, but an organization of a vision of desired outcomes for a patient.

PQRST to guide an assessment

• P—Provokes (e.g., precipitating and relieving factors): What causes symptom? What makes it better or worse? Are there activities (e.g., exercise) that affect it? • Q—Quality: What does the symptom feel like? If patient cannot describe, offer probes such as "Is it sharp? Dull? Burning?" • R—Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have patient be as precise as possible. • S—Severity: Ask a patient to rate the severity of a symptom on a scale of 0 to 10. This gives you a baseline with which to compare in follow-up assessments. • T—Time: Assesses onset and duration of symptom. When did it start? Does it come and go? If so, how often and for how long? What time of day or day of the week?

Key Points for Nursing Diagnosis

• The diagnostic process is a clinical judgment that involves reviewing assessment information, recognizing cues, clustering cues into patterns of data, and identifying a patient's specific health care problems. • Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems). • Nurses manage collaborative problems by using medical, nursing, and allied health interventions. • The use of standard formal nursing diagnostic statements provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding a patient's needs. • Data analysis and interpretation involve recognizing patterns in clustered data, comparing them with standards such as the NANDA-I classification of nursing diagnoses and defining characteristics, and coming to a reasoned conclusion about a patient's response to a health problem. • Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions. • Defining characteristics are the subjective and objective clinical cues that a nurse gathers intentionally and unintentionally, clusters, and uses to form a diagnostic conclusion. • When an assessment reveals defining characteristics that apply to more than one nursing diagnosis, gather more information to clarify your interpretation. • Absence of defining characteristics suggests that you reject a proposed diagnosis. • A problem-focused nursing diagnosis is usually written in a two-part format, including a diagnostic label and an etiological or related factor. • A three-part diagnostic statement includes defining characteristics that apply to a patient's condition. • Assessing the cultural differences that affect how patients define health and illness and want or choose to be treated will assist in making correct diagnostic conclusions. • The "related to" factor of a diagnostic statement helps you to individualize problem-focused and health promotion nursing diagnoses and provides direction for your selection of appropriate interventions. • Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patient's condition. • A concept map is a visual representation of a patient's nursing diagnoses and their relationship with one another. • Nursing diagnostic errors occur by errors in data collection, interpretation and analysis of data, clustering of data, or the diagnostic statement.

Key Points for Nursing Assessment

• The nursing process is a variation of scientific reasoning that involves five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. • Assessment is an important first step of the nursing process for learning as much as you can about each patient by partnering together in a therapeutic relationship. • Assessment involves collecting information from a patient and secondary sources (e.g., health care providers, family members) along with interpreting and validating the information to form a complete database. • Establishing a nurse-patient therapeutic relationship allows you to know a patient as a person. • There are two approaches to gathering a comprehensive assessment: use of a structured database format and use of a problem-focused approach. • Effectively communicating with patients during an assessment interview requires communication skills built on courtesy, comfort, connection, and confirmation. • Once a patient provides subjective data, explore the findings further by collecting objective data. • During assessment critically anticipate and use an appropriate branching set of questions or observations to collect data and cluster cues of assessment information to identify emerging patterns and problems. • In a patient-centered interview an organized conversation with a patient allows the patient to set the initial focus and initiate discussion about his or her health problems. • An initial patient-centered interview involves: (1) setting the stage, (2) gathering information about the patient's problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview. • When literacy assessment tools are not available, a review of general cognitive ability and educational and/or occupational levels needs to be part of nursing assessment. 222 • An assessment needs to adapt to the unique needs of patients of backgrounds and cultures different from your own. • When collecting a complete nursing history, let the patient's story guide you in fully exploring the components related to his or her problems. • Successful interpretation and validation of assessment data ensure that you have collected a complete database.