How to Use the Nursing Diagnosis Handbook: A Guide to Planning Care Betty Ackley, RN, MSN, EdS Marina Martinez-Kratz MS, RN, CNE Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 1

Objective Explain how to use this text to write a nursing care plan.

This text is designed to make the nursing process understandable. Learning the nursing process can be overwhelming at times for nursing students. Our text is designed to make the nursing process easier to understand and use. 3

Steps of the Nursing Process Assess. Diagnose (nursing diagnosis). Determine outcomes. Plan interventions. Give nursing care. Evaluate nursing care. These are defined steps of the nursing process, a systematic, organized, purposeful, and dynamic method which is the core framework for nursing practice. 4

Assess Assess the client: Collect data Use the format provided by the clinical setting. Collect data Include the client’s symptoms, clinical state, and known medical or psychiatric diagnoses. Assessment is continuous throughout the nursing process. The nursing process always begins with assessment to determine the present reality of the client. 5

Diagnose Turn to Section II, “Guide to Nursing Diagnoses.” Locate the symptoms, diagnosis, and clinical states found in your client. The 2nd step of the nursing process is to make a nursing diagnosis. Here the nurse analyzes the assessment data and develops one or more nursing diagnoses. 6

Nursing Diagnosis—Cont’d Section II includes client’s symptoms, clinical state, medical or psychiatric diagnoses, and anticipated or prescribed diagnostic studies or surgical interventions (listed in alphabetical order). Section II of this text supports the nursing student in making a diagnosis, by giving suggested nursing diagnoses for common diseases, symptoms, and clinical states. 7

Nursing Diagnosis—Cont’d Section II is like a differential diagnosis text for physicians making a medical diagnosis. Using a differential diagnosis text, the physician can look up a symptom and find possible relevant medical diagnoses. Using the Nursing Diagnosis Handbook, a nursing student can look up a symptom, medical diagnosis, or clinical state and find possible relevant nursing diagnoses. 8

Nursing Diagnosis—Cont’d Note suggestions for appropriate nursing diagnoses in Section II. These are suggested nursing diagnoses only; they must be validated for the client and relevant to the client needs. These suggested nursing diagnoses may or may not be relevant to the client. 9

Diagnostic Reasoning Critical Thinking The process of determining the appropriate nursing diagnoses The process of making nursing diagnoses is called diagnostic reasoning and uses critical thinking. 10

Nursing Diagnosis Use Section III, “Guide to Planning Care,” to evaluate the suggested nursing diagnoses and “related to” etiology statement. 11

Nursing Diagnosis—Cont’d Section III is a listing of care plans according to North American Nursing Diagnosis Association (NANDA); they are arranged alphabetically by diagnostic concept for each nursing diagnosis referred to in Section II. Determine the appropriateness of each nursing diagnosis by comparing the defining characteristics or risk factors in Section III with the client data collected. Use Section III of this text to validate a nursing diagnosis to determine if it fits the nursing diagnosis definition and the defining characteristics. 12

Determine Outcomes Older terms Newer term: Client outcomes Objectives Goals Newer term: Client outcomes Statements of accomplishments Physical health Improvement or lack of improvement in the client Outcomes must be measurable Years ago nurses used goals and objectives to set a direction and measurable outcome for nursing care. Now the term outcome is used. Outcomes are what the nurse wants to accomplish with nursing care. 13

Determining Outcomes—Cont’d Use Section III, “Guide to Planning Care,” to find suggested outcomes for the client. Suggested outcomes are listed in Section III, but of course the student must evaluate if they are appropriate and modify them as needed. 14

Determining Outcomes—Cont’d Use either the Nursing Outcomes Classification (NOC) outcomes with the associated rating scales or client outcomes. Use of NOC outcomes is recommended if accepted by the nursing school or health care facility. 15

Nursing Outcomes Classification (NOC) Is the standardized nursing language designed to increase nursing accountability and make nursing visible. NOC outcomes are part of the standardized nursing language. 16

Plan Interventions Nursing interventions Guidelines on how to give nursing care Nursing interventions are prescriptive guidelines on how to give nursing care to the client. 17

Use Section III, “Guide to Planning Care,” to find appropriate interventions for the client. In Section III there is a listing of defined interventions that are useful for clients with a defined nursing diagnosis. The student will need to choose those interventions that are relevant to the client. There may be additional interventions that are relevant to the client also. 18

Nursing Interventions Use either Nursing Interventions Classification (NIC) interventions or nursing interventions as found in that section. The NIC text contains several sample NIC activities. To use the NIC interventions more effectively, the nursing student will need access to the Nursing Intervention Classification text. Only 2 example NIC interventions are given in the Nursing Diagnosis Handbook. 19

Nursing Interventions—Cont’d NIC is the standardized nursing language that is interventions designed to increase nursing accountability and make nursing visible. There are 542 NIC interventions that cover all aspects of nursing practice. 20

Nursing Interventions—Cont’d Evidence-based rationales are included in this text for nursing interventions to help validate the interventions. Ideally all nursing interventions would be evidence-based. Unfortunately there is not enough research available yet for this to be possible. Nursing is progressing on this journey to excellence. 21

Printed Care Plan Use the “Care Plan Constructor” on the Evolve website to get a printed version of the developed care plan. Use the Evolve website associated with the Ackley/Ladwig text. 22

Give Nursing Care The nurse administers nursing care, following the plan of care based on the interventions. 23

Document and Evaluation As the nursing care plan is developed, it should be documented so that all nurses caring for the client have access to the plan. The client’s progression toward meeting the outcomes should be evaluated and documented at intervals, and also when the patient is discharged from the facility or health care service. Documentation is also recorded information on the client’s condition and response to nursing care. This documentation is called charting. 24

Happy Care Planning! Use this text to plan care and give the best nursing care possible! 25