Five-Step Nursing Process Model

Critical Thinking Synthesis

Chapter 16Nursing Assessment

Five-Step Nursing Process

Nursing ProcessThe nursing process is a variation of scientific reasoning. Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way. You learn to make inferences about the meaning of a patients response to a health problem or generalize about the patients functional state of health. Through assessment, a pattern begins to form.

Case StudyMs. Carla Thompkins is being admitted to the medical-surgical unit as a postop patient. Ms. Thompkins, a 52-year-old schoolteacher, is recovering from a below-the-knee amputation (BKA) secondary to complications of type 2 diabetes. Ms. Thompkins is admitted to the unit not only so her recovery from the BKA may be monitored, but also because Ms. Thompkins is going to receive preliminary occupational and physical therapy to help her adapt to the amputation.

Cues and Inferences

Comprehensive Assessment ApproachesUse of a structured database format, based on an accepted theoretical framework or practice standardExample: Gordons model of functional health patternsProblem-oriented approachAssessment moves from general to specific.

Process of AssessmentCollect data.Cluster cues, make inferences, and identify patterns and problem areas.Critically anticipate.Be sure to have supporting cues before making an inference.Knowing how to probe and frame questions is a skill that grows with experience.

Interview TechniquesOpen-ended vs. closed-ended questionsBack-channelingProbing-------------------------------------------Because a patients report includes subjective information, validate data from the interview later with objective data.Obtain information (as appropriate) about a patients physical, developmental, emotional, intellectual, social, and spiritual dimensions.

Case Study (contd)During the assessment, Ms. Thompkins complains of pain at the incision site.Ms. Thompkins report of pain is an example of what type of data?

Cultural ConsiderationsTo conduct an accurate and complete assessment, you need to consider a patients cultural background. When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patients uniqueness. If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion.

Nursing Health History

Next Assessment StepsPhysical examination = An investigation of the body to determine its state of healthObservation of patient behavior (verbal vs. nonverbal)Diagnostic and laboratory dataInterpreting and validating assessment data. Validation of assessment data consists of comparison of data with another source to determine accuracy of the data.

Concept Mapping

A visual representation that allows nurses to graphically illustrate the connections between a patients health problems

Allows nurses to obtain a holistic perspective of health care needs

Chapter 17Nursing Diagnosis

Nursing Diagnosis

History of Nursing DiagnosisFirst introduced in 1950In 1953, Fry proposed the formulation of a nursing diagnosis.In 1973, the first national conference was held.In 1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its publication Nursing: a Social Policy Statement.In 1982, NANDA was founded.

Case StudyJohn is a first semester nursing student who is particularly interested in the cardiac system and specifically heart disease since his father died of a heart attack at age 48. John decided to go into nursing because of his fathers death, which prompted him to select a career that improves peoples lives.John is studying nursing diagnoses in his nursing fundamentals course and is learning the steps of the nursing diagnostic process. He knows this information will help him care for cardiac patients in the future.

Nursing Diagnostic Process

Assessment of patients health status: Patient, family, and health care resources constitute database. Nurse clarifies inconsistent or unclear information. Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database.Validate data with other sources.Are additional data needed? If so, reassess. If not, continue

Nursing Diagnostic Process (contd)

If no additional data are needed, proceed:Interpret and analyze meaning of dataData clustering Group signs and symptoms. Classify and organize.Look for defining characteristicsand related factors.Identify patient needs.Formulate nursing diagnosesand collaborative problems.

Data ClusteringA data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way. Data clusters are patterns of data that contain defining characteristicsclinical criteria that are observable and verifiable. Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.

Case Study (contd)Because of Johns interest in cardiac nursing, he is familiar with the clinical criteria for heart disease. Which of the following is an example of a clinical criterion? (Select all that apply.)HypertensionFatigueFood preferenceHigh cholesterol

Types of Nursing Diagnoses

Components of a Nursing Diagnosis

Case Study (contd)John learns the four types of nursing diagnoses. Which of the following are the four types of nursing diagnoses? (Select all that apply.)Actual diagnosesRisk diagnosesWellness diagnosesHealth promotion diagnosesDisease prevention diagnoses

Cultural Relevance of Nursing DiagnosesConsider patients cultural diversity when selecting a nursing diagnosis. Ask questions such as:How has this health problem affected you and your family?What do you believe will help or fix the problem?What worries you most about the problem?Which practices within your culture are important to you?Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses.

Case Study (contd)John knows that a ______________ diagnosis is applied to vulnerable populations.

Concept Mapping Nursing Diagnosis

A visual representation of a patients nursing diagnoses and their relationships with one anotherConcept maps promote problem solving and critical thinking skills by organizing complex patient data, analyzing concept relationships, and identifying interventions.

Diagnostic Statement Guidelines

1. Identify the patients response, not the medical diagnosis.2. Identify a NANDA-I diagnostic statement rather than the symptom.3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention.4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.5. Identify the patient response to the equipment rather than the equipment itself.

Diagnostic Statement Guidelines (contd)

6. Identify the patients problems rather than your problems with nursing care. 7. Identify the patient problem rather than the nursing intervention.8. Identify the patient problem rather than the goal of care.9. Make professional rather than prejudicial judgments.10. Avoid legally inadvisable statements.11. Identify the problem and its cause to avoid a circular statement.12. Identify only one patient problem in the diagnostic statement.

Nursing Diagnosis: Application to Care PlanningBy learning to make accurate nursing diagnoses, your care plan will help communicate the patients health care problems to other professionals.A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.

Chapter 19Implementing Nursing Care

Nursing InterventionA nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.

Case StudyMiranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52 y/o Asian male admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels.Mr. Bagleys current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagleys plan of care to determine which interventions are to be implemented first.

Critical Thinking in ImplementationReview the set of all possible nursing interventions.Review all possible consequences associated with each possible nursing action.Determine the probability of all possible consequences.Make a judgment of the value of that consequence to the patient.

Standard Nursing InterventionsClinical practice guidelines and protocolsStanding ordersNIC interventionsANA Standards of Professional Practice

Protocols and Standing Orders

Guidelines and ProtocolsStanding OrdersSystematically developedset of statements that helps nurses, physicians, and other health care providers make decisions about appropriate healthcare for specific clinical situationsA preprinted document containing orders forthe conduct of routine therapies, monitoring guidelines, and/ordiagnostic procedures for specific patients with identified clinicalproblems

Implementation Process

Anticipate and Prevent ComplicationsIdentify risks to the patient.Adapt interventions to the situation.Evaluate the relative benefit of a treatment vs. the risk.Initiate risk prevention measures.

Modification of an Existing Written Care PlanRevise data assessment.Revise the nursing diagnoses.Revise specific interventions.Determine how to evaluate whether you have achieved outcomes.

Quick Quiz!1.Nurse-initiated interventions are A. Determined by state Nurse Practice Acts.B. Supervised by the entire health care team.C. Made in concert with the plan of care initiated by the physician.D. Developed after interventions for the recent medical diagnoses are evaluated.

Implementation SkillsCognitive skillsApplication of critical thinking in the nursing processInterpersonal skillsDeveloping a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her familyPsychomotor skillsIntegration of cognitive and motor activities

Direct Care vs. Indirect Care

Direct CareIndirect CareTreatments performed through interactions with patients

Examples:-Medication administration-Insertion of an intravenous (IV) infusion-Counseling during a time of griefTreatments performed away from the patient but on behalf of thepatient or group of patients

-Managing the patients environment (e.g., safety and infection control)-Documentation-Interdisciplinary collaboration

Direct Care

Direct Care (contd)

CounselingTeachingControlling for adverse reactions

Preventive measures

Case Study (contd)Mr. Bagleys plan of care calls for oxygen therapy to improve his respiratory status.A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a __________ _____________.

Quick Quiz!2. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals.B. The nursing assistant will set the patient up for a bath every day.C. The patient will have improved airway clearance by June 5.D. The patient will identify the need to increase dietary intake of fiber by June 5.

Indirect CareCommunicating nursing interventionsWritten or oralDelegating, supervising, and evaluating the work of other health care team members

Case Study (contd)Mr. Bagley is placed on Isolation Precautions.Isolation Precautions as a treatment intervention are an example of which type of care?A. DirectB. IndirectC. PreventionD. Safety

Achieving Patient GoalsNurses implement care to meet patient goals.At times, multiple interventions may be needed.Priorities help nurses to anticipate and sequence nursing interventions.Patient adherence means that patients and families invest time in carrying out required treatments.

Chapter 18Planning Nursing Care

Establishing PrioritiesOrdering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. Helps nurses anticipate and sequence nursing interventions Classification of priorities:HighEmergentIntermediateLowAffect patients future well-being

Establishing Priorities (contd)The order of priorities changes as a patients condition changes.Priority setting begins at a holistic level when you identify and prioritize a patients main diagnoses or problems. Patient-centered care requires you to know a patients preferences, values, and expressed needs. Ethical care is a part of priority setting.

Priorities in Practice

Case StudyFulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35 y/o American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer and weakness and fatigue resulting from the anemia.Fulmala develops Ms. Skyfalls plan of care, which addresses pain, weakness, and fatigue. Fulmala includes nutrition and patient safety as part of the plan of care.

Critical Thinking in Setting Goals and Expected OutcomesGoalA broad statement that describes the desired change in a patients condition or behaviorAn aim, intent, or endExpected outcomeMeasurable criteria to evaluate goal achievement

Goals of Care

Patient-centered goal:A specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in functionShort-term goal:An objective behavior or response expected within hours to a weekLong-term goal:An objective behavior or response expected within days, weeks, or months

Goals of Care (contd)

Always partner with patients when setting their individualized goals. For patients to participate in goal setting, they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making. Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse.

Expected OutcomesAn objective criterion for goal achievementA specific, measurable change in a patients status that you expect in response to nursing careDirect nursing careDetermine when a specific, patient-centered goal has been metAre written sequentially, with time framesUsually, several are developed for each nursing diagnosis and goal.

Nursing Outcomes ClassificationA nursing-sensitive patient outcome is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions. The Iowa Intervention Project published the Nursing Outcomes Classification (NOC) and linked the outcomes to NANDA International nursing diagnoses.NOC outcomes provide a common nursing language for continuity of care and measuring the success of nursing interventions.

Seven Guidelines for Writing Goals

Quick Quiz!1.A patient is suffering from shortness of breath. The correct goal statement would be written as A. The patient will be comfortable by the morning.B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.C. The patient will not complain of breathing problems within the next 8 hours.D. The patient will have a respiratory rate of 14 to 18 breaths per minute.

Critical Thinking in Planning CareNursing interventions are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes.Nurses need to: Know the scientific rationale for the interventionPossess the necessary psychomotor and interpersonal skillsBe able to function within a setting to use health care resources effectively

Types of InterventionsNurse initiatedIndependentActions that a nurse initiatesPhysician initiatedDependentRequire an order from a physician or other health care professionalCollaborative InterdependentRequire combined knowledge, skill, and expertise of multiple health care professionals

Clarifying an OrderWhen preparing for physician-initiated or collaborative interventions, do not automatically implement the therapy, but determine whether it is appropriate for the patient. The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures.

Selection of InterventionsSix factors to consider:

Characteristics of nursing diagnosisGoals and expected outcomesEvidence base for interventionsFeasibility of the interventionsAcceptability to the patientNurses competency

Nursing Interventions Classification (NIC)The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes.The NIC model includes three levels: domains, classes, and interventions for ease of use. NIC interventions are linked with NANDA International nursing diagnoses.

Systems for Planning Nursing CareNursing care plan = Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patients clinical needs and situationReduces the risk for incomplete, incorrect, or inaccurate careChanges as the patients problems and status changeInterdisciplinary care plan = Contributions from all disciplines involved in patient care.

Change of ShiftA critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventionsChange-of-shift report: Communicates information from offgoing to oncoming patient care personnel = Nurse handoffFocus your reports on the nursing care, treatments, and expected outcomes documented in the care plans.

Student Care PlansA student care plan Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situationIs more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning carePlanning care for patients in community-based settings involves Educating the patient/family about careGuiding them to assume more of the care over time

Critical PathwaysCritical pathways are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially. The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient.

Concept MapsProvide a visually graphic way to show the relationship between patients nursing diagnoses and interventionsGroup and categorize nursing concepts to give you a holistic view of your patients health care needs and help you make better clinical decisions in planning careHelp you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information

Case Study (contd)What are some examples of independent nursing interventions that Fulmala may develop for Ms. Skyfall? (Select all that apply.)A. Medication administrationB. Medication teachingC. Patient positioningD. Family teaching

Consulting Other Health Care ProfessionalsPlanning involves consultation with members of the health care team. Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies.Consultation occurs at any step in the nursing process, most often during planning and implementation.

When and How to ConsultWhen: The exact problem remains unclear

How: Begin with your understanding of the patients clinical problem.Direct the consultation to the right professional.Provide the consultant with relevant information about the problem area: Summary, methods used to date, and outcomesDo not influence consultants.Be available to discuss the consultants findings.Incorporate the suggestions.

Case Study (contd)Fumala works with the nutritionist to develop a meal plan for Ms. Skyfall.True or False: Collaborative interventions are therapies that involve multiple health care professionals.

[Fig. 15-2 from text p. 198 is a model of the five-step nursing process.]This model of the five-step nursing process illustrates that the critical thinking and clinical decision making that you will engage in as nurses are not part of a simple, linear process. Each step of the process is affected by the step before and will affect the steps that follow.The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems (American Nurses Association, 2010). Human responses include patient symptoms and physiological reactions to treatment, the need for knowledge when health care providers make a new diagnosis or treatment plan, and a patients ability to cope with loss. Use of the process allows nurses to help patients meet agreed-on outcomes for better health.The nursing process requires a nurse to use the general and specific critical thinking competencies that we have reviewed to focus on a particular patients unique needs.Within each step of the nursing process, you apply critical thinking to provide the very best professional care to your patients.**Critical thinking is a reasoning process used to reflect on and analyze thoughts, actions, and knowledge.Critical thinking requires a desire to grow intellectually.Critical thinking requires the use of nursing process to make nursing care decisions.Critical thinking and the nursing process are inseparable. As a new nurse, you will rely on the nursing process to guide your practice. The next five chapters thoroughly discuss nursing process and application to patient care.*The nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and to promoting human functions and responses to health and illness. Assessment is the first step in the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.The process is continuous and dynamic, so that you may move back and forth among the steps. Nursing assessment helps nurses to form a clear definition of the patient's problems, which in turn provides the foundation for planning and implementing nursing interventions and evaluating the outcomes of care. The nursing process is also a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care.The nursing process is central to your ability to provide timely and appropriate care to your patients. It begins with the first step, assessment, the gathering and analysis of information about the patients health status.You then make clinical judgments from the assessment to identify the patients response to health problems in the form of nursing diagnoses. Once you define appropriate nursing diagnoses, you create a plan of care. Planning includes setting goals and expected outcomes for your care and selecting interventions (nursing and collaborative) individualized to each of the patients nursing diagnoses. The next step, implementation, involves performing the planned interventions. After performing interventions, you evaluate the patients response and determine whether the interventions were effective. [This is Fig. 16-1 from text p. 207.]*Assessment is the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns.Clearly defining your patients problems provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care.*Yolanda is the student nurse who has been assigned to admit Ms. Thompkins. Yolanda enters Ms. Thompkins room, introduces herself, and begins the admission health history and physical assessment.

*[This figure, Observational overview using cues and forming inferences, is on text p. 209.]Once a patient provides subjective data, explore findings further by collecting objective data.*When you first meet a patient, perform a quick screening.After your observational screening, focus on the assessment cues and patterns of information that suggest problem areas. [See Box 16-1 on text p. 209 Typology of 11 Functional Health Patterns.]Ultimately, your assessment identifies functional patterns (patient strengths) and dysfunctional patterns (nursing diagnoses) that help you develop the nursing care plan.Table 16-1 (on text p. 209) presents an example of a problem-focused patient assessment.

*Once you ask a patient a question or make an observation, patterns form, and the information branches to an additional series of questions or observations. [See Fig. 16-4 on branching logic (on text page 210).]You learn to decide which questions are relevant to a situation and to attend to accurate interpretations of data.During assessment, critically anticipate and use an appropriate branching set of questions or observations to collect data and to cluster cues of assessment information to identify emerging patterns and problems.*[Review each technique with the class. Ask the class for examples of each. Open-ended questions cannot be answered with yes or no, whereas closed-ended ones can be answered with one or two words. Back-channeling, such as uh-huh or go on, reinforces the patient.][Examples of closed-ended and open-ended questions are shown in Box 16-3 on text p. 213.]How you conduct the interview is just as important as the questions you ask.A skillful interviewer adapts interview strategies based on the patients responses.During the interview, you are responsible for directing the flow of the discussion so your patient has the opportunity to freely contribute stories about his or her health problems to enable you to get as much detailed information as possible.Always clarify or validate any information about which you are unclear.During an assessment interview, encourage patients to tell their stories about their illnesses or health care problems.*Answer: Subjective dataRationale: Subjective data refers to the patients verbal description of his or her health problems. Objective data are observations by another person of a patients health status.

*As a professional nurse, it is important to conduct all assessments with cultural competence. This involves not imposing your own attitudes and beliefs. Avoid making stereotypes; draw on knowledge from your assessment, and ask questions in a constructive and probing way to allow you to truly know who the patient is. You must be sure that you grasp exactly what a patient means and know exactly what a patient thinks you mean in words and actions. Do not make assumptions about a patients cultural beliefs and behaviors without validation from the patient.Communication and culture are interrelated in the way feelings are expressed verbally and nonverbally. If you learn the variations in how people of different cultures communicate, you will gather more accurate information from patients. Using the right approach with eye contact shows respect for your patient and likely results in the patient sharing more information. It is easier to explore cultural differences if you allow time for thoughtful answers and ask your questions in a comfortable order.**Nursing health history = Data about the patients current level of wellness. When collecting a complete nursing history, let the patients story guide you in fully exploring the components related to his or her problems.[Ask students to discuss what type of data each collects.]Biographical information: Age, address, occupations, marital status, health care insurance.Patient expectations: Find out what patients expect to happen to them while seeking treatments for their health.Reason for seeking health care: You learn the patients chief concerns or problems.Present illness or heath concerns: Determine when the problems began, how severe, intensity, quality, what makes them worse, and what makes them better.Concomitant symptomsDoes the patient experience other symptoms along with the primary symptom?Health history: Provides you with information regarding the patients past history. Has there been a hospitalization? A procedure? Medication uses? Prescription, over the counter, herbal, natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns? Exercise habits? Nutritional habits? Family history: Blood relative health issues? Recent losses? Religious influences? Relationships? Environmental history: Home environment? Workplace environment? Exposure to pollutants?Psychosocial history: Support system? Spouse? Children? Friends? Family members? Coping mechanisms?Spiritual health: Religion? Religious habits? Review of systems: A method for collecting data on body systems. Documentation: Each health care facility has forms to use. Refer to your specific health care facilitys documentation forms. [See also Fig. 16-5 Dimensions for gathering data for a health history on text p. 215.] *You will learn more about physical assessments when we get to Chapter 30, Health Assessment and Physical Examination.A physical examination involves the techniques of inspection, palpation, percussion, auscultation, and smell. A complete examination includes a patients height, weight, and vital signs, and a head-to-toe examination of all body systems. The data from a hands-on physical assessment allow you to collect valuable objective information needed to form accurate diagnostic conclusions. Always conduct an examination competently using a caring and culturally sensitive approach.To accompany the results you obtain from the physical assessment, data can be obtained from other sources.By observing patients, you will be able to get an idea of whether their nonverbal behavior matches what they are saying. Observations direct you to gather additional objective information to form accurate conclusions about the patients condition.An important aspect of observation consists of a patients level of function: physical, developmental, psychological, and social aspects of everyday living.Diagnostic and laboratory data will provide you with information needed to develop a plan of care. Interpreting and validating assessment data will help you when selecting a nursing diagnosis.Data analysis involves recognizing patterns or trends in the clustered data and then comparing them with standards. [See Box 16-6 for assistance; see also Box 16-4 on text p. 217 Recognizing Data Clusters.]Successful interpretation and validation of assessment data ensure that you have collected a complete database.*Concept mapping can be used to help understand relationships between patients past and present medical problems. A concept map allows us to organize and link information about a patient. At times, patients will have multiple nursing diagnoses. The concept map allows students to plan interventions that are therapeutic. The map allows students to think critically and promotes clinical decision making. [See also Fig. 16-6 on text p. 218 Concept map for Mr. Jacobs: Assessment, and Box 16-5 Evidence-Based Practice Using Concept Maps as a Learning Strategy on text p. 218.] Through concept mapping, you obtain a holistic perspective of your patients health care needs, which ultimately allows you to make better clinical decisions.

*After you assess a patient, the next step in the process is to form a diagnostic conclusion. Some conclusions can be used to select a nursing diagnosis. The diagnostic process includes critical analysis and interpretation of assessment data that reveal a patients response to health problems with the goal of identifying patient needs and formulating nursing diagnoses.

*A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms, the patients medical history, and the results of diagnostic tests and procedures.A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. What makes the nursing diagnostic process unique from medical diagnoses is having patients involved, when possible, in the process.Selection of a nursing diagnosis provides the basis for choosing nursing interventions. Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions.Nursing diagnoses are listed according to the North American Nursing Diagnosis Association (NANDA). Selecting the correct nursing diagnosis on the basis of an assessment involves diagnostic expertise.

*Nursing diagnoses have been around for more than 60 years! Nursing diagnoses allow nurses to practice independently, especially in the areas of patient education and symptom relief. NANDA, the North American Nursing Diagnosis Association, was established in 1982. The purpose of this organization was to develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses. NANDA has changed its name to NANDA International (NANDA-I). Research in diagnosis continues to grow. [See Box 17-1 on text p. 224 Evidence-Based Practice Nursing Diagnosis: Impact on Nursing Practice.]One purpose of nursing diagnosis to provide a precise definition of a patients problem that gives nurses and other members of the health care team a common language for understanding the patients needs.[Ask the class: Do you have a situation in your life that caused you to consider nursing? How will it affect your ability to provide nursing care?]*NANDA-I continually develops and adds new diagnostic labels to the NANDA International listing through the process outlined in Fig. 17-2 (on text p. 224, the beginning of which is shown here). *[This is the remainder of Fig. 17-2 from text p. 224.]Most state Nurse Practice Acts include nursing diagnosis as part of the domain of nursing practice.[See text pp. 225-226 for a list of Nanda International Nursing Diagnoses as provided in Box 17-2.]*Each NANDA-Iapproved nursing diagnosis has an identified set of defining characteristics that support identification of a nursing diagnosis. You learn to recognize patterns of defining characteristics from your patient assessments and then readily select the corresponding diagnosis. Working with similar patients over a period of time helps you recognize clusters of defining characteristics, but remember that each patient is unique and requires an individualized diagnostic approach. Defining characteristics are subjective and objective clinical criteria that form clusters, leading to a diagnostic conclusion.Box 17-3 (Examples of NANDA InternationalApproved Nursing Diagnoses with Defining Characteristics) (on text p. 227) shows two examples of approved nursing diagnoses and their associated defining characteristics. When an assessment reveals defining characteristics that apply to more than one nursing diagnosis, gather more information to clarify your interpretation.

*Answers: Hypertension, fatigue, and high cholesterolRationale: Clinical criteria consist of objective or subjective signs and symptoms or risk factors that lead to a diagnostic conclusion. Hypertension, fatigue, and high cholesterol are all clinical criteria for heart disease, whereas food preference is not.

**NANDA-I (2012) identifies three types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses. An actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. The selection of an actual diagnosis indicates that assessment data are sufficient to establish the nursing diagnosis. Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patients condition.A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. These diagnoses do not have defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors: environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. Risk factors are diagnostic-related factors that help in planning preventive health care measures. A health promotion nursing diagnosis is a clinical judgment of a persons, familys, or communitys motivation, desire, and readiness to enhance well-being and actualize human health potential as expressed in their readiness to focus on specific health behaviors such as nutrition and exercise. Health promotion diagnoses can be used in any health state and do not require current levels of wellness. A persons readiness is supported by defining characteristics. *A common method of developing a nursing diagnosis is to assign a diagnostic label and then note the related or causative factor. Table 17-1 (on text p. 229), NANDA International Two-Part Nursing Diagnosis Format, presents examples. [You will want to individualize this format to the format used at your college/university/agency.] The diagnostic label is the name of the nursing diagnosis as approved by NANDA International.All NANDA-I approved diagnoses also have a definition, which describes the characteristics of the human response identified.The related factor is identified from the patients assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patients actual or potential response to the health problem and can change by using specific nursing interventions.Inclusion of the related to phrase requires you to use critical thinking to individualize the nursing diagnosis and then select nursing interventions. [See Table 17-2 (on text p. 229) Comparison of Interventions for Nursing Diagnoses with Different Related Factors.][See also Fig. 17-4 Relationship between a diagnostic label and related factor (etiology) on text p. 229.]In the case of a risk nursing diagnosis, a risk factor is the related factor. Table 17-3 (on text p. 230), Developing a Two-part Nursing Diagnosis Label, demonstrates the association between a nurses assessment of a patient, the clustering of defining characteristics, and the formulation of nursing diagnoses.The diagnostic process results in the formation of a total diagnostic label that allows you to develop an appropriate, patient-centered plan of care.Some agencies prefer a three-part nursing diagnostic label: the NANDA-I label, the related factor, and the defining characteristics. A three-part nursing diagnosis, using a PES format, includes a diagnostic label, etiological statement, and symptoms or defining characteristics.Answer: The four types of nursing diagnoses are actual diagnoses, risk diagnoses, wellness diagnoses, and health promotion diagnoses.

*It is important to consider your own cultural competence so you are more sensitive to a patients health care problems and the implications.Additional examples of questions that contribute to making culturally competent nursing diagnoses are: What do you expect from us, your nurses, to help maintain some of your cultural practices? What cultural practices do you do to keep yourself and your family well?When you ask questions such as these, you use a patient-centered care approach that allows you to see the patients health situation through his or her eyes. When making a diagnosis, be sure to also consider how culture influences the related factor for your diagnostic statement. Your own culture potentially influences the cues and defining characteristics that you select from your assessment. *Answer: risk nursingRationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.

**A concept map places the central focus on the patient rather than on the patients disease or health alteration. This encourages nursing students to concentrate on patients specific health problems and nursing diagnoses. The focus also promotes patient participation with the eventual plan of care.A concept map diagrams the critical thinking associated with making accurate diagnoses. A concept map promotes critical thinking because you identify, graphically display, and link key concepts by organizing and analyzing information Patients seldom have only one health problem. Your holistic view of a patient heightens the challenge of thinking about all patient needs and problems. Therefore a picture of each patient usually consists of several interconnections between sets of data, all associated with identified patient problems. Data sources include physical, psychological, and sociocultural domains. Concept mapping helps students to display knowledge in a visual format. [See Figure 17-5 on text p. 231.]For each diagnosis, you list defining characteristics and begin to see the connections or associations among different diagnostic statements.

Be sure that the etiology portion of the diagnostic statement is within the scope of nursing to diagnose and treat.[Discuss each guideline.]Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.Identify nursing diagnoses from a cluster of defining characteristics, not just from a single symptom. An accurate etiology allows you to select nursing interventions directed toward correcting the cause of the problem or minimizing the patients risk.Patients experience many responses to diagnostic tests and medical treatments.Patients often are unfamiliar with medical technology.

*[Discuss each.]Nursing diagnoses are always patient centered and form the basis for goal-directed care. You plan nursing interventions after identifying a nursing diagnosis.Goals based on accurate identification of a patients problems serve as a basis for determining problem resolution.Base nursing diagnoses on subjective and objective patient data, and do not include your personal beliefs and values. Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. Circular statements are vague and give no direction to nursing care.It is permissible to include multiple causes that may be contributing to one patient problem.**Nursing diagnosis is a mechanism for identifying the domain of nursing. Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients. Just as the medical diagnosis of diabetes leads a physician to prescribe a low-carbohydrate diet and medication for blood glucose control, the nursing diagnosis of Impaired skin integrity directs a nurse to apply certain support surfaces to a patients bed and to initiate a turning schedule. In Chapter 18, you will learn how unifying the languages of NANDA-I with the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) facilitates the process of matching nursing diagnoses with accurate and appropriate interventions and outcomes (Dochterman and Jones, 2003). The care plan (see Chapter 18) is a map for nursing care, and it demonstrates your accountability for patient care. When you make accurate nursing diagnoses, your subsequent care plan communicates to other professionals the patients health care problems and ensures that you select relevant and appropriate nursing interventions.*Implementation constitutes the fourth step of the nursing process. After the nursing diagnoses have been identified, nurses initiate the nursing interventions most likely to achieve the goals and expected outcomes that support or improve the patients health status. Nursing interventions can be direct or indirect. Ideally, nursing interventions should be evidence based and should use the most up-to-date approaches to solving patient problems. Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.Direct care interventions are treatments performed through interactions with patients. Indirect care interventions are treatments performed away from the patient but on behalf of the patient or a group of patients. [These are discussed further in a later slide.][See Box 19-1 Domains of Nursing Practice on text p. 253.] *Throughout the lesson, we will give examples of implementing nursing care with respect to Mr. Bagleys case. Keep him in mind as we discuss the process.**Given the complexity of interventions, critical thinking is necessary in choosing which of a number of alternative approaches to use in the time available to act. The critical thinking model described in Chapter 15 provides a framework for how to make decisions when implementing nursing care.Before nurses proceed with an intervention, they need to consider what they know about the purpose of the interventions, the steps in performing the interventions correctly, and the medical condition of the patient and the patients expected response.[See also Fig. 19-1 on text p. 255 Critical thinking and the process of implementing care.]

*Standards of nursing practice offer guidelines for the selection of interventions. Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care.A nursing care plan is unique to the patient. Therefore, interventions are individualized. However, patients do have common health care problems, and standardized interventions for those health problems make it quicker and easier for you to intervene. These interventions are evidence based.NIC interventions offer a level of standardization to enhance communication of nursing care across settings. If your college/university uses NIC and NOC, please spend time explaining how students use this in their plan of care.[See also Box 19-2 on text p. 256 Purposes of the Nursing Interventions Classification.]The ANA Standards of Professional Nursing Practice are to be used as evidence of the standard of care that registered nurses provide their patients.A guideline guides interventions for specific health care problems or conditions such as low back pain, dizziness, or deep vein thrombosis.The guideline is developed on the basis of an authoritative examination of current scientific evidence.[Ask students what types of standing orders they can think of. ANSWERS may include medications for cardiac dysrhythmias or diabetic emergencies.]

**You will need to prepare to implement your interventions to provide efficient, safe, and effective nursing care. When you reassess your patient, you collect additional data and identify any new patient needs. At this point, you may need to modify your plan of care. To organize resources and deliver care to your patient, you need to identify the facilitys resources and personnel. So, an orientation to the facilitys physical layout, equipment, and operations is a necessity. Creating a favorable environment for the patient to receive care is another part of organizing resources.It is necessary to anticipate and prevent complications that might occur while patients are hospitalized. Risks to patients come from both illness and treatment. Methods used to ensure that you administer physical care techniques appropriately include protecting yourself and the patient from injury, using proper infection control practices, staying organized, and following applicable practice guidelines.[Ask students to identify some complications we can help patients to avoid. ANSWERS may include coughing and deep breathing to prevent atelectasis; turning to prevent pressure ulcers; medicating to reduce pain; and promoting urine and bowel evacuation.][See also Fig. 19-2 on text p. 257 The concept map for the texts case study.]These four steps help you anticipate and prevent complications.[Ask the class to evaluate the relative benefit of a treatment versus the risk. Discuss.]*After you reassess your patient, review the care plan, compare assessment data to validate the nursing diagnoses, and determine whether the nursing interventions remain the most appropriate for the clinical situation. *Answer: A

**These three skills are needed to implement direct and indirect nursing interventions.No intervention should be automatic. Nurses need to think and anticipate how to individualize care for their patients.Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the patient and family. Psychomotor skills require the integration of cognitive and motor activities. Remember, it will take time and practice to acquire a psychomotor skill. So, make sure to take advantage of your time in the nursing skills labwith human patient simulation, with interactive technology and with each otherto hone your skills and confidence.Nurses provide a wide variety of direct care measures. All direct care measures require competent and therefore safe practice. Show a caring approach each time you provide direct care.Nurses spend much time in indirect and unit management activities. Communication of information about patients (e.g., change-of-shift report, consultation) is critical, ensuring that direct care activities are planned, coordinated, and performed with the proper resources.**To complete any nursing procedure, you need to know the procedure, its frequency, the steps, and the expected outcomes.Activities of daily living (ADLs) are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, and grooming.You will perform these activities of direct care as you carry out the nursing interventions you have selected for your patients.You will want to be cognitive of mobility, pain, confusion, and fatigue that patients may be experiencing.IADLs: These instrumental ADLs include the day-to-day activities a person performs such as shopping, preparing meals, writing checks to pay the bills, and taking medications. Physical care techniques are the activities that nurses perform while rendering care. These including turning, positioning, and administering care, as well as performing tasks such as Foley catheter insertion, NG tube insertion, IV insertion, and administering medications.Lifesaving measures are those activities you perform when a patients physiological or psychological state is threatened. They include CPR, administering emergency medications, and falls prevention. Note that when you delegate aspects of a patients care, you are responsible for ensuring that each task is assigned appropriately and is completed according to the standard of care.

Counseling involves providing emotional, intellectual, spiritual, and psychological support to your patients. [Box 19-3 (on text p. 260) presents examples of counseling strategies.]Teaching is a constant part of nursing. Teaching occurs formally and informally and involves patients and their family members. We will further discuss this in Chapter 25, Patient Education.An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. Before performing any skill or task, you need to know the possible adverse effects or reactions that can occur.Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the patients health potential, application of prescribed measures, health teaching, and identification of risk factors for illness and/or trauma. [Shown is Fig. 19-3 from text p. 261.]

*Answer: standing orderRationale: A standing order is a preprinted document that contains orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.*Answer: D

**These measures are actions that support the effectiveness of direct care interventions. Many of these measures may be managerial. Box 19-4 (on text p. 262) presents examples of indirect nursing interventions.Communication is imperative to ensure that direct care activities are planned, coordinated, and performed with the proper resources. Many health care agencies use interdisciplinary care plans. Most important, all interventions must be documented correctly and in the proper time sequence. In Chapter 26, documentation will be discussed more thoroughly.Staff in many institutions develop interdisciplinary care plansplans that represent the contributions of all disciplines caring for a patient. Oftentimes, nurses who develop the patients plan of care do not deliver the care. Some activities are performed by other members of the health care team. Chapter 21 will present the ten principles of delegation as delineated by the American Nurses Association and the National Council of State Boards of Nursing.

Answer: BRationale: Indirect care interventions are treatments performed away from the patient but on behalf of the patient or group of patients. Implementing Isolation Precautions is an example of providing indirect care by managing the patients environment.

**Another way to achieve patient goals is to help patients adhere to their treatment plan. When delivering care, it will be necessary for you to incorporate your patients health beliefs, culture, lifestyle patterns, and patterns of wellness. *Planning constitutes the third step of the nursing process. Planning will require the use of your critical thinking skills, in which decision-making and problem-solving techniques are incorporated. After you have identified your patients nursing diagnosis, planning appropriate care comes next. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. A plan of care is dynamic and will change as your patients needs change, or as you identify new needs.Planning requires working closely with patients, their families, and the health care team through communication and ongoing consultation. *No doubt, patients will have multiple nursing diagnoses and problems. To care for one patient and groups of patients, you will need to rank and deal with individual and aggregate nursing diagnoses so you can recognize those most important problems to organize your day. It will be important to classify priorities as high, intermediate, or low.By ranking a patients nursing diagnoses in order of importance, you attend to each patients most important needs and better organize ongoing care activities. Nursing diagnoses that, if untreated, result in harm to a patient or others have the highest priority and typically revolve around safety, adequate oxygenation, and circulation. However, you must always consider each patients unique situation. These priorities can be physiological, psychological, or related to other basic human needs. A task for an intermediate-priority diagnosis involves the nonemergent, nonlife threatening needs of the patient. The low-priority nursing diagnosis may not be related to a specific illness or prognosis but may call for an intervention that affects the patients future well-being. Many of these deal with the patient's long-term health care needs. Together with your patients, you select mutually agreed-on priorities based on the urgency of the problems, the patients safety and desires, the nature of the treatment indicated, and the relationship among the diagnoses.

Each time you begin a sequence of care such as at the beginning of a hospital shift or a patients clinic visit, it is important to reorder priorities. You also need to prioritize the specific interventions or strategies that you will use.Involve patients in priority setting whenever possible. Consulting with the patient to learn the patients concerns does not relieve you of the responsibility to act in a patients best interests. Always assign priorities on the basis of good nursing judgment.When ethical issues make priorities less clear, it is important to have open dialogue with the patient, the family, and other health care providers

*This model for priority setting is Fig. 18-1 (from text p. 238 A model for priority setting). (Modified from Hendry C, Walker A: Priority setting in clinical nursing practice, J Adv Nurs 47:427, 2004.)Many factors within the health care environment affect your ability to set priorities. The same factors that influence your minute-by-minute ability to prioritize nursing actions affect your ability to prioritize nursing diagnoses for groups of patients. The nature of nursing work challenges your ability to cognitively attend to a given patients priorities when you care for more than one patient.Always work from your plan of care and use your patients priorities to organize the order for delivering interventions and documenting care.*[Ask the class: Why arent anemia and peptic ulcer part of the care plan? Then discuss. Remind the class that nursing care plans do not directly address the medical diagnosis.]**Once you identify nursing diagnoses for a patient, ask yourself, What is the best approach to address and resolve each problem? What do I plan to achieve? Goals and expected outcomes are specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem. Having goals and expected outcomes serves two purposes: It gives a clear direction for selecting and using nursing interventions and for evaluating the effectiveness of the interventions. [See Fig. 18-2 (on text p. 239) Critical thinking and the process of planning care.]Once an outcome is met, you know that a goal has been at least partially achieved. Selection of goals, expected outcomes, and interventions requires consideration of your previous experience with similar patient problems and any established standards for clinical problem management. Goals and outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited. You use critical thinking attitudes in selecting interventions with the greatest likelihood of success.*A patient-centered goal is realistic and is based on patient needs and resources. Patient-centered goals reflect a patients highest possible level of wellness and independence in function. A patient goal represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function.Each goal must be time limited, so that the health care team has a common time frame for problem resolution. The time frame depends on the nature of the problem, its causes, the patients overall condition, and the treatment setting.A short-term goal is what you expect the patient to achieve in a short period of time. Because hospital stays are shorter than before, these goals may last several hours to days. Long-term goals are expected to be achieved over a longer period of time. Table 18-1 (on text p. 240) shows the progression from nursing diagnoses to goals and expected outcomes and their relationship to nursing interventions.Mutual goal setting includes the patient and the family (when appropriate) in prioritizing the goals of care and developing a plan of action. Unless goals are mutually set and a clear plan of action is decided, patients fail to fully participate in the plan of care. When setting goals, act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible.

**Outcomes must be measurable. Expected outcomes direct nursing care because they are the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patients health problems. Expected outcomes should be written in a sequential time frame. The time frames give progressive steps in which a patient moves toward recovery and impose an order on nursing interventions. Time frames also set limits for problem resolution.A patients willingness and capability to reach an expected outcome improves his or her likelihood of achieving it. A list of the step-by-step expected outcomes gives you practical guidance in planning interventions.

Much attention in the health care environment is focused on measuring outcomes to gauge the quality of health care. If a chosen intervention repeatedly results in desired outcomes that benefit patients, it needs to become part of a standardized approach to a patient problem. Nursing plays an important role in monitoring and managing patient conditions and diagnosing problems that are amenable to nursing intervention. Thus it is important to identify and measure patient outcomes that are influenced by nursing care. For the nursing profession to become a full participant in clinical evaluation research, policy development, and interdisciplinary work, nurses need to identify and measure patient outcomes influenced by nursing interventions. For each NANDA International nursing diagnosis, there are multiple NOC-suggested outcomes. These outcomes have labels for describing the focus of nursing care and include indicators to use in evaluating the success of nursing interventions. Table 18-2 (on text p. 241) shows examples of NANDA International nursing diagnoses and suggested NOC linkages.Efforts to measure outcomes and capture changes in the status of patients over time allow nurses to improve patient care quality and add to nursing knowledge.The fourth edition of NOC is an excellent resource for use in developing care plans and concept maps. **A patient-centered goal is singular, observable, measurable, time limited, mutual, and realistic.Outcomes and goals reflect patient behaviors and responses expected as a result of nursing interventions. Write a goal or outcome to reflect a patients specific behavior, not to reflect your goals or interventions.A specific goal or outcome must be defined precisely before a patient response to a nursing action can be evaluated. Each goal or outcome addresses only one behavior or response. Observable changes occur in physiological findings and in the patients knowledge, perceptions, and behavior. You will learn how to write goals and expected outcomes that set standards against which to measure the patient's response to nursing care. Do not use vague terms or qualifiers such as normal, acceptable, or stable. Instead use terms that can be evaluated preciselyfor example, terms that describe quality, quantity, frequency, length, or weight. Time-limited time frames for each goal and expected outcomes indicate when nurses expect identified responses to occur. Time frames enable nurses to help patients meet goals and make progress at a reasonable rate.Mutual factors combine goals and expected outcomes to ensure that the patient and the nurse agree on the direction and time limits of care. By setting mutual goals and expected outcomes, nurses can increase the patients motivation and cooperation. For the patient to succeed, goals and outcomes must be attainable. Because lengths of stay are now much shorter, this can be problematic. When setting goals and outcomes, make sure to factor in the patients physiological, emotional, cognitive, and sociocultural potential, as well as the economic costs and resources required to reach these in a timely manner.Answer: B[Discuss how B addresses the seven guidelines for writing goals.]*Part of the planning process is to select nursing interventions to meet the patients goals and outcomes. Once nursing diagnoses have been identified and goals and outcomes selected, you choose interventions individualized for the patients situation.During planning, you 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. Actual implementation of these interventions occurs during the implementation phase of the nursing process.**Nurse-initiated interventions require no order and no supervision or direction from others. Nurse-initiated interventions are autonomous actions based on scientific rationale.According to the Nurse Practice Acts in a majority of states, independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. The NIC taxonomy provides standardization to help nurses select suitable interventions for patients problems.[Ask students to identify some independent nursing actions. ANSWERS can include elevating an extremity, providing patient education, showing how to splint.]Physician-initiated interventions require specific nursing responsibilities and technical nursing knowledge. These interventions are based on the physicians or the health care providers response to treat or manage a medical diagnosis. Each of these interventions requires nursing responsibilities and specific knowledge. Advanced practice nurses who work under collaborative agreements with physicians, or who are licensed independently by state practice acts, are able to write dependent interventions. Typically, when you plan care for a patient, you review the necessary interventions and determine whether the collaboration of other health care disciplines is necessary. In a patient care conference, the multidisciplinary health care team selects and assigns interdependent nursing interventions.Every nurse faces an inappropriate or incorrect order at some time. Clarifying an order is part of competent nursing practice, and it protects the patient and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the persons who wrote or transcribed the original order. You are legally responsible for any complications resulting from the error.

**When selecting interventions, review the patients needs, priorities, and previous health experiences. [See Box 18-1 (on text p. 243) Choosing Nursing Interventions.]Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.

[If your college or university uses the Nursing Interventions Classification (NIC), discuss how you incorporate NIC into your plan of care.]The domains are the highest level (level 1) of the model, and broad terms are used to organize the more specific classes and interventions. [See Table 18-3 (on text pp. 244-245) Nursing Interventions Classification (NIC) Taxonomy.]The second level of the model includes 30 classes, which offer useful clinical categories. The third level of the model includes 542 interventions, defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Each intervention includes a variety of nursing activities from which to choose and which a nurse commonly uses in a plan of care. [See Boxes 18-2 and 18-3 (on text p. 243) Example of Interventions for Physical Comfort Promotion and Example of an Intervention and Associated Nursing Activities.]You determine which interventions and activities best suit your patients individualized needs and situation.**In health care settings, nurses are responsible for providing a written nursing plan of care for all patients. The plan can take many forms, such as Kardex, standard care, or computerized plan. Increasingly, hospitals are adopting electronic health records (EHRs) and a documentation system that includes software programs for nursing care plans. Written care plans can be used for change-of-shift reports. The nursing care plan helps to ensure continuity of care by all nurses. The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. A care plan includes a patients long-term needs. Incorporating the goals of the care plan into discharge planning is important.

During a nursing handoff, nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.At the end of a shift, you discuss with the next caregivers your patients plans of care and their overall progress. Thus all nurses are able to discuss current and relevant information about each patients plan of care. No evidence has been found for one best nursing hand-off practice. [See Box 18-4 (on text p. 247) Evidence-Based Practice Nursing Hand-Offs.] In some agencies, the nursing handoff process occurs during walking rounds when nurses exchange information about patients at the bedside, giving patients the opportunity to also ask questions and confirm information. Written care plans organize information exchanged by nurses in change-of-shift reports.Avoid adding personal opinions about the patient because these are not relevant and could unnecessarily influence the oncoming nurses perception of him or her as an individual.

*Student care plans are useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care.The plan also helps you to apply theory you learned. Most commonly, a column format is used. [Discuss the format you use.]A six-column format includes (from left to right): (1) assessment data relevant to corresponding diagnosis, (2) goals, (3) outcomes identified for the patient, (4) implementation for the plan of care, (5) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence), and (6) a section to evaluate your care. In the implementation section, you select interventions appropriate for the patient. For care plans in community-based settings, you design a plan to (1) educate the patient/family about necessary care techniques and precautions, (2) teach the patient/family how to integrate care within family activities, and (3) guide the patient/family on how to assume a greater percentage of care over time. Finally, the plan includes nurses and the patients/familys evaluation of expected outcomes.[Review Table 18-4 (on text p. 247) Frequent Errors in Writing Nursing Interventions.]

*Care plans and critical pathways increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another.A critical pathway clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible. Critical pathways improve continuity of care because they clearly define the responsibility of each health care discipline. Well-developed pathways include evidence-based interventions and therapies.

*[If your program uses a concept map, lead a discussion on the use and format of concept maps in your nursing program.]When planning care for each nursing diagnosis, analyze the relationships among the diagnoses. Draw dotted lines between nursing diagnoses to indicate their relationship to one another. [See Fig. 18-3 on text p. 248 for an example of a concept map showing these relationships.] Because you care for patients who present with multiple health problems and related nursing diagnoses, it is often not realistic to have a written columnar plan developed for each nursing diagnosis. It is important for you to make meaningful associations between one concept and another. The links need to be accurate, meaningful, and complete so you can explain why nursing diagnoses are related. Critical thinkers learn by organizing and relating cognitive concepts. *Answers: Medication teaching, patient positioning, family teachingRationale: Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education. Administering medication requires an order from a physician or other health care professional.

*Consultation can occur at any step of the nursing process. Consultation increases your knowledge about a patients problem and helps in learning skills and obtaining the resources needed to solve the problem.When making a consultation, first identify the general problem, direct the consultation to the right professional, and provide the consultant with relevant information about the problem.[Ask students whom they might want to consult with when caring for patients in the hospital setting. ANSWERS may include dietitians, respiratory therapists, physical therapists, wound care specialists, diabetic educators, and case managers.]Do not be afraid to ask for a consultation. Consultations will increase your knowledge and will help you learn new skills and how to obtain additional resources. You consult most often during planning and implementation.During these times, you are more likely to identify a problem requiring additional knowledge, skills, or resources. This requires you to be aware of your strengths and limitations as a team member. Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies. The consultation process is important, so all health care providers are focused on common patient goals. Always be prepared before you make a consult. Consultation is based on the problem-solving approach, and the consultant is the stimulus for change. Often, an experienced nurse is a valuable consultant when you face an unfamiliar patient care situation such as a new procedure or a patient presenting a set of symptoms that you cannot identify.In clinical nursing, consultation helps to solve problems in delivery of nursing care. For example, a nursing student consults a clinical specialist for wound care techniques or an educator for useful teaching resources. Nurses are consulted for their clinical expertise, patient education skills, or staff education skills. Nurses also consult with other members of the health care team such as physical therapists, nutritionists, and social workers. Again, the consultation focuses on problems in providing nursing care.

*[See Box 18-5, Tips for Making Phone Consultations.]Consultation occurs when you identify a problem that you are unable to solve using personal knowledge, skills, and resources. The process requires good intrapersonal and interprofessional collaboration.Consultation with other care providers increases your knowledge about the patients problems and helps you learn skills and obtain resources. An objective consultant enters a clinical situation and more clearly assesses and identifies the nature of a problem, whether it is patient, personnel, or equipment oriented. Share information from the patients medical record, conversations with other nurses, and the patients family.Consultants are in the clinical setting to help identify and resolve a nursing problem, and biasing or prejudicing them blocks problem resolution.Avoid bias by not overloading consultants with subjective and emotional conclusions about the patient and the problem.When you request a consultation, provide a private, comfortable atmosphere for the consultant and the patient to meet. A common mistake is turning the whole problem over to the consultant. The consultant is not there to take over the problem but to help you resolve it. When possible, request the consultation for a time when both you and the consultant are able to discuss the patients situation with minimal interruptions or distractions. The success of the advice depends on the implementation of the problem-solving techniques. Always give the consultant feedback regarding the outcome of the recommendations.*Answer: TrueRationale: Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

*