Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales 10th edition Doenges eBook

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  • Published: 2006
  • ISBN-10: 0803614802
  • ISBN-13: 978-0803614802

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nurse’s pocket guide 10th edition eBook

CHAPTER 1 The Nursing Process

Nursing is both a science and an art concerned with the physical,

psychological, sociological, cultural, and spiritual concerns

of the individual. The science of nursing is based on a broad

theoretical framework; its art depends on the caring skills and

abilities of the individual nurse. In its early developmental years,

nursing did not seek or have the means to control its own practice.

In more recent times, the nursing profession has struggled

to define what makes nursing unique and has identified a body

of professional knowledge unique to nursing practice. In 1980,

the American Nurses Association (ANA) developed the first

Social Policy Statement defining nursing as “the diagnosis and

treatment of human responses to actual or potential health

problems.” Along with the definition of nursing came the need

to explain the method used to provide nursing care.

Thus, years ago, nursing leaders developed a problem-solving

process consisting of three steps—assessment, planning, and

evaluation—patterned after the scientific method of observing,

measuring, gathering data, and analyzing findings. This

method, introduced in the 1950s, was called nursing process.

Shore (1988) described the nursing process as “combining the

most desirable elements of the art of nursing with the most relevant

elements of systems theory, using the scientific method.”

This process incorporates an interactive/interpersonal approach

with a problem-solving and decision-making process (Peplau,

1952; King, 1971; Yura & Walsh, 1988).

Over time, the nursing process expanded to five steps and has

gained widespread acceptance as the basis for providing effective

nursing care. Nursing process is now included in the conceptual

framework of all nursing curricula, is accepted in the

legal definition of nursing in the Nurse Practice Acts of most

states, and is included in the ANA Standards of Clinical Nursing

Practice.

The five steps of the nursing process consist of the following:

1. Assessment is an organized dynamic process involving three

basic activities: a) systematically gathering data, b) sorting

and organizing the collected data, and c) documenting

the data in a retrievable fashion. Subjective and objective

data are collected from various sources, such as the client

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interview and physical assessment. Subjective data are what

the client or significant others report, believe, or feel, and

objective data are what can be observed or obtained from

other sources, such as laboratory and diagnostic studies,

old medical records, or other healthcare providers. Using

a number of techniques, the nurse focuses on eliciting a

profile of the client that supplies a sense of the client’s overall

health status, providing a picture of the client’s physical,

psychological, sociocultural, spiritual, cognitive, and developmental

levels; economic status; functional abilities; and

lifestyle. The profile is known as the client database.

2. Diagnosis/need identification involves the analysis of

collected data to identify the client’s needs or problems,

also known as the nursing diagnosis. The purpose of this step

is to draw conclusions regarding the client’s specific needs or

human responses of concern so that effective care can be

planned and delivered. This process of data analysis uses

diagnostic reasoning (a form of clinical judgment)

in which conclusions are reached about the meaning of the

collected data to determine whether or not nursing intervention

is indicated. The end product is the client diagnostic

statement that combines the specific client need with the

related factors or risk factors (etiology), and defining characteristics

(or cues) as appropriate. The status of the client’s

needs are categorized as actual or currently existing diagnoses

and potential or risk diagnoses that could develop due

to specific vulnerabilities of the client. Ongoing changes in

healthcare delivery and computerization of the client record

require a commonality of communication to ensure continuity

of care for the client moving from one setting/level of

healthcare to another. The use of standardized terminology

or NANDA International nursing diagnosis labels provides

nurses with a common language for identifying client needs.

Furthermore, the use of standardized nursing diagnosis

labels also promotes identification of appropriate goals,

provides acuity information, is useful in creating standards

for nursing practice, provides a base for quality

improvement, and facilitates research supporting

evidence-based nursing practices.

3. Planning includes setting priorities, establishing goals, identifying

desired client outcomes, and determining specific

nursing interventions. These actions are documented as the

plan of care. This process requires input from the client/

significant others to reach agreement regarding the plan to

facilitate the client taking responsibility for his or her own

care and the achievement of the desired outcomes and goals.

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Setting priorities for client care is a complex and dynamic

challenge that helps ensure that the nurse’s attention and

subsequent actions are properly focused. What is perceived

today to be the number one client care need or appropriate

nursing intervention could change tomorrow, or, for that

matter, within minutes, based on changes in the client’s

condition or situation. Once client needs are prioritized,

goals for treatment and discharge are established that indicate

the general direction in which the client is expected to

progress in response to treatment. The goals may be shortterm—

those that usually must be met before the client is

discharged or moved to a lesser level of care—and/or longterm,

which may continue even after discharge. From these

goals, desired outcomes are determined to measure the

client’s progress toward achieving the goals of treatment or

the discharge criteria. To be more specific, outcomes are

client responses that are achievable and desired by the client

that can be attained within a defined period, given the situation

and resources. Next, nursing interventions are chosen

that are based on the client’s nursing diagnosis, the established

goals and desired outcomes, the ability of the nurse to

successfully implement the intervention, and the ability and

the willingness of the client to undergo or participate in the

intervention, and they reflect the client’s age/situation and

individual strengths, when possible. Nursing interventions

are direct-care activities or prescriptions for behaviors, treatments,

activities, or actions that assist the client in achieving

the measurable outcomes. Nursing interventions, like nursing

diagnoses, are key elements of the knowledge of nursing

and continue to grow as research supports the connection

between actions and outcomes (McCloskey & Bulechek,

2000). Recording the planning step in a written or computerized

plan of care provides for continuity of care, enhances

communication, assists with determining agency or unit

staffing needs, documents the nursing process, serves as a

teaching tool, and coordinates provision of care among disciplines.

A valid plan of care demonstrates individualized

client care by reflecting the concerns of the client and significant

others, as well as the client’s physical, psychosocial, and

cultural needs and capabilities.

4. Implementation occurs when the plan of care is put into

action, and the nurse performs the planned interventions.

Regardless of how well a plan of care has been constructed, it

cannot predict everything that will occur with a particular

client on a daily basis. Individual knowledge and expertise

and agency routines allow the flexibility that is necessary to

THE NURSING PROCESS 3

adapt to the changing needs of the client. Legal and ethical

concerns related to interventions also must be considered.

For example, the wishes of the client and family/significant

others regarding interventions and treatments must be

discussed and respected. Before implementing the interventions

in the plan of care, the nurse needs to understand

the reason for doing each intervention, its expected effect,

and any potential hazards that can occur. The nurse must also

be sure that the interventions are a) consistent with the established

plan of care, b) implemented in a safe and appropriate

manner, c) evaluated for effectiveness, and d) documented in

a timely manner.

5. Evaluation is accomplished by determining the client’s

progress toward attaining the identified outcomes and by

monitoring the client’s response to/effectiveness of the

selected nursing interventions for the purpose of altering the

plan as indicated. This is done by direct observation

of the client, interviewing the client/significant other, and/or

reviewing the client’s healthcare record. Although the

process of evaluation seems similar to the activity of assessment,

there are important differences. Evaluation

is an ongoing process, a constant measuring and monitoring

of the client status to determine: a) appropriateness

of nursing actions, b) the need to revise interventions, c)

development of new client needs, d) the need for referral

to other resources, and e) the need to rearrange priorities

to meet changing demands of care. Comparing overall

outcomes and noting the effectiveness of specific interventions

are the clinical components of evaluation that

can become the basis for research for validating the

nursing process and supporting evidenced-based practice.

The external evaluation process is the key for refining

standards of care and determining the protocols, policies,

and procedures necessary for the provision of quality nursing

care for a specific situation or setting.

When a client enters the healthcare system, whether as an

acute care, clinic, or homecare client, the steps of the process

noted above are set in motion. Although these steps are

presented as separate or individual activities, the nursing

process is an interactive method of practicing nursing, with the

components fitting together in a continuous cycle of thought

and action.

To effectively use the nursing process, the nurse must possess,

and be able to apply, certain skills. Particularly important is a

thorough knowledge of science and theory, as applied not only

in nursing but also in other related disciplines, such as medicine

4 NURSE’S POCKET GUIDE

and psychology. A sense of caring, intelligence, and competent

technical skills are also essential. Creativity is needed in the

application of nursing knowledge as well as adaptability for

handling constant change in healthcare delivery and the many

unexpected happenings that occur in the everyday practice of

nursing.

Because decision making is crucial to each step of the process,

the following assumptions are important for the nurse to

consider:

• The client is a human being who has worth and dignity.

This entitles the client to participate in his/her own healthcare

decisions and delivery. It requires a sense of the

personal in each individual and the delivery of competent

healthcare.

• There are basic human needs that must be met, and when

they are not, problems arise that may require interventions

by others until and if the individual can resume responsibility

for self. This requires healthcare providers to anticipate

and initiate actions necessary to save another’s life or

to secure the client’s return to health and independence.

• The client has the right to quality health and nursing care

delivered with interest, compassion, competence, and a

focus on wellness and prevention of illness. The philosophy

of caring encompasses all of these qualities.

• The therapeutic nurse-client relationship is important in

this process, providing a milieu in which the client can feel

safe to disclose and talk about his/her deepest concerns.

The revised Nursing’s Social Policy Statement (ANA, 1995)

acknowledges that since the release of the original statement,

nursing has been influenced by many social and professional

changes as well as by the science of caring. Nursing has integrated

these changes with the 1980 definition to include treatment

of human responses to health and illness. The new

statement provides four essential features of today’s contemporary

nursing practice:

• Attention to the full range of human experiences and

responses to health and illness without restriction to a

problem-focused orientation (in short, clients may have

needs for wellness or personal growth that are not “problems”

to be corrected)

• Integration of objective data with knowledge gained from

an understanding of the client’s or group’s subjective experience

• Application of scientific knowledge to the process of diagnosis

and treatment

• Provision of a caring relationship that facilitates health and

healing

THE NURSING PROCESS 5

Whereas nursing actions were once based on variables such as

diagnostic tests and medical diagnoses, use of the nursing

process and nursing diagnoses provides a uniform method of

identifying and dealing with specific client needs/responses in

which the nurse can intervene. The nursing diagnosis is thus

helping to set standards for nursing practice and should lead to

improved care delivery.

Nursing and medicine are interrelated and have implications

for each other. This interrelationship includes the exchange of

data, the sharing of ideas/thinking, and the development of

plans of care that include all data pertinent to the individual

client as well as the family/significant others. Although nurses

work within medical and psychosocial domains, nursing’s

phenomena of concern are the patterns of human response, not

disease processes. Thus, the written plan of care should contain

more than just nursing actions in response to medical orders

and may reflect plans of care encompassing all involved disciplines

to provide holistic care for the individual/family.

Summary

Because the nursing process is the basis of all nursing actions,

it is the essence of nursing. It can be applied in any healthcare

or educational setting, in any theoretical or conceptual framework,

and within the context of any nursing philosophy. In

using nursing diagnosis labels as an integral part of the nursing

process, the nursing profession has identified a body of knowledge

that contributes to the prevention of illness as well as to the

maintenance/restoration of health (or relief of pain and

discomfort when a return to health is not possible).

Subsequent chapters help the nurse applying the nursing

processes to review the current NANDA list of nursing diagnoses,

their definitions, related/risk factors (etiology), and

defining characteristics. Aware of desired outcomes and the

most commonly used interventions, the nurse can write, implement,

and document an individualized plan of care.

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nurse’s pocket guide 10th edition eBook