Critical Thinking in Nursing Practice

Critical Thinking in Nursing Practice
Chapter 15 Critical Thinking in Nursing Practice •Critical thinking is acquired through experience, commitment, and active curiosity. •Critical thinking is not a simple step-by-step linear process that is learned in a short period of time. •You will soon learn that critical thinking and the nursing process are interwoven. One does not exist without the other. •You will find that throughout the clinical chapters of your textbook, the components of critical thinking are emphasized to help you better understand their relationship to the nursing process. •When caring for patients and their family members, nurses need to “think smart” to make sensible judgments, so the patient can receive appropriate nursing care.

Critical Thinking Defined
Critical thinking is: A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions •Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant (Heffner and Rudy, 2008). •Critical thinking encompasses the following: Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions (Settersten and Lauer, 2004). •Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, simple solutions. •Thinking and learning are related processes. •Nurses will use observations and judgments to make choices. •You will always want to ask “why” and “how” when caring for patients. •The use of evidence-based knowledge (see Chapter 5) helps you become a critical thinker.

Case Study Carla is a third year nursing student assigned to a surgical nursing unit. Mr. Javier Ramirez is a 55-year-old construction worker, admitted to the unit after falling off scaffolding on a construction site. His x-ray films revealed a right fractured femur and right wrist fracture. An abdominal computed tomography (CT) scan shows bruising of the liver. Mr. Ramirez has not been hospitalized in the past. When he first meets Carla, he is very quiet and asks few questions. [This case study will be presented in several sections throughout this presentation. To initiate a discussion, you might ask the following questions: •What do we know so far about the patient in this case study? •What reasons might there be for Mr. Ramirez to be so quiet and ask so few questions? •What kinds of responsibilities might Carla have when caring for Mr. Ramirez?’ •Do you think that because Mr. Ramirez is “very quiet and asks few questions,” he will be easy for Carla to care for?]

Clinical Decisions in Nursing Practice
Clinical decision making requires critical thinking. Clinical decision-making skills separate professional nurses from technical and ancillary staff. Patients often have problems for which no textbook answers exist. Nurses need to seek knowledge, act quickly, and make sound clinical decisions. •Clinical decision making is judgment that includes critical and reflective thinking and action and application of scientific and practical logic. •Critical thinking challenges you to think creatively, search for the answer, collect data, make inferences, and draw conclusions. [The critical thinking skills presented in Table 15-1 on text p. 193 are covered in the next slide.]

Critical Thinking Skills
Interpretation Analysis Inference Evaluation Explanation Self-regulation •Table 15-1 (on text p. 193) presents the critical thinking skills that you will employ in your nursing career. •These skills are: •Interpretation: Be orderly in data collection. Look for patterns to categorize data (e.g., nursing diagnoses [see Chapter 17]). Clarify any data you are uncertain about. •Analysis: Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? •Inference: Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists? •Evaluation: Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior. •Explanation: Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. •Self-regulation: Reflect on your experiences. Identify ways that you can improve your own performance. What will make you believe that you have been successful?

Thinking and Learning Learning is a lifelong process.
Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgments. The science of nursing continues to grow. Nurses need to be flexible and open to new information. •In Chapter 1, we talked about the attributes of a profession. One of them was having a knowledge base. •As you have more clinical experiences and apply the knowledge you acquire, you will become better at forming assumptions, presenting ideas, and making valid conclusions. •When you care for a patient, always think ahead. •The following questions are questions a nurse should ask when caring for a patient: •What is the patient’s status now? •How might it change and why? •Which physiological and emotional responses do I anticipate? •What do I know to improve the patient’s condition? •In which way will specific therapies affect the patient? •What should be my first action? •Do not let your thinking become routine or standardized. Instead, learn to look beyond the obvious in any clinical situation, explore the patient’s unique responses to health alterations, and recognize which actions are needed to benefit the patient.

Case Study (cont’d) Mr. Ramirez’s leg is in skeletal traction, and his right arm is in a soft cast. Carla decides that she needs to begin her care by assessing Mr. Ramirez and determining his health status. She begins by reviewing his medical history. She learns that he has a history of smoking and was diagnosed with type 2 diabetes just 5 years ago. •Here we find out a little more about the patient, Mr. Ramirez, and how Carla will care for him. [On our last slide, we covered the questions that a nurse should ask when caring for a patient. Let’s review them now: •What is the patient’s status now? •How might it change and why? •Which physiological and emotional responses do I anticipate? •What do I know to improve the patient’s condition? •In which way will specific therapies affect the patient? •What should be my first action? •Note that Carla decides that she will begin caring for Mr. Ramirez by assessing his health status. Do you think Carla is making the right decision? (Discuss.)]

Concepts for a Critical Thinker
Truth seeking Open-mindedness Analytic approach Systematic approach Self-confidence Inquisitiveness Maturity [See Table 15-2 on text p. 194.] •Truth seeking: Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions. •Open-mindedness: Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions. •Analytic approach: Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge. •Systematic approach: Be organized and focused; work hard in any inquiry. •Self-confidence: Trust in your own reasoning processes. •Inquisitiveness: Be eager to acquire knowledge and learn explanations, even when applications of knowledge are not immediately clear. Value learning for learning’s sake. •Maturity: Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity.

Critical Thinking Competencies
Scientific method Problem solving Decision making Diagnostic reasoning and inference Clinical decision making Nursing process as a competency •Critical thinking competencies are cognitive processes. •Critical thinking processes are not unique to nursing but are used in everyday life in many situations. •Critical thinking processes include scientific method, problem solving, and decision making. •Specifically in nursing, we use diagnostic reasoning and inference, clinical decision making, and nursing processes. •In diagnostic reasoning, a nurse collects patient data and analyzes them to determine the patient’s problems. •In clinical decision making, a nurse identifies a patient’s problem and selects a nursing intervention. •The nursing process is a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation.

•Let’s look at a critical thinking model for nursing judgment
•Let’s look at a critical thinking model for nursing judgment. [This is Fig from text p The model’s levels of critical thinking in the pyramid at the top of the model are discussed on this slide. The components of critical thinking, at the bottom of the model, are discussed on the next slide.] •This model presents three levels of critical thinking: •Level 1 is Basic: At the basic level, nurses think concretely on the basis of a set of rules or principles, following a step-by-step process without deviation from the plan. Following a procedure step by step without adjusting to a patient’s unique needs is an example of basic critical thinking. •Level 2 is Complex: Complex critical thinking analyzes and examines choices independently. Nurses learn to think beyond and synthesize knowledge. In complex critical thinking, a nurse learns that alternative and perhaps conflicting solutions exist. •Level 3 is Commitment: Commitment is the third level of critical thinking. Nurses anticipate needs and make choices without assistance from others.

Five Components of Critical Thinking
Knowledge base Experience Nursing process competencies Attitudes Standards •The nursing process is a blueprint for patient care that involves both general and specific critical thinking competencies in a way that focuses on a particular patient’s unique needs. •The critical thinking model also includes five components of critical thinking, which combine a nurse’s knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care. •Let’s review what the five components of critical thinking are and what meaning they have for nurses: •A nurse’s knowledge base is drawn from nursing school education, as well as from knowledge obtained from basic sciences, humanities, and behavioral science. •Experience is obtained from clinical situations in actually working with patients and their families. •The nursing process is a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation. We will discuss this further on the next slide. [Note that the nursing process is also discussed in greater detail in the following chapters: Chapter 16: Nursing Assessment; Chapter 17: Nursing Diagnosis; Chapter 18: Planning Nursing Care; Chapter 19: Implementing Nursing Care; and Chapter 20: Evaluation.] •A new nurse needs 11 attitudes when thinking critically. We will review these after we learn a little more about our case study. [Slides 14 and 15 cover the 11 attitudes a nurse needs, from Table 15-3 on text p. 200.] •Two standards should be considered when thinking critically: intellectual and professional. •An intellectual standard is a guideline or principle for rational thought. The use of intellectual standards during assessment ensures that you obtain a complete database of information. •Professional standards refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility. Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility.

Nursing Process Assessment Diagnosis
The nursing process is a five-step clinical decision-making approach: Assessment Diagnosis Planning Implementation Evaluation •Nursing process is a scientific method with five specific steps. •Nursing process is essentially the process of applying the scientific method to caring for a patient. The scientific method has five steps: 1. Identifying the problem 2. Collecting data 3. Formulating a question or hypothesis 4. Testing the question or hypothesis 5. Evaluating results of the test or study [Discuss with students how the five steps of nursing process relate to the five steps of the scientific method.]

Case Study (cont’d) Carla knows that Mr. Ramirez is likely to be in pain because he is reluctant to move and take part in any activity. Her options include conducting a thorough pain assessment and learning how Mr. Ramirez feels about his pain. She must also be culturally sensitive and consider how Mr. Ramirez’s Hispanic heritage may influence his response to pain. Carla will then take what she learns and use pain control therapies that Mr. Ramirez will be likely to accept. •We just covered the nursing process, a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation. •Do you think Carla is following this process? [Discuss.]

Attitudes a Nurse Needs
Confidence Independence Fairness Responsibility Risk taking Discipline •Critical thinking attitudes help you to know when more information is necessary and when it is misleading and to recognize your own knowledge limits. •A nurse needs 11 attitudes when thinking critically. [The 11 attitudes a nurse needs are presented in Table 15-3 on text p. 200.] These attitudes include confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humility. Let’s discuss the first six attitudes. [The remaining five are covered in the next slide.] •To acquire and show confidence, learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions. •To develop independence, read the nursing literature, especially when different views on the same subject are presented. Talk with other nurses and share ideas about nursing interventions. •To practice and extend fairness, listen to both sides in any discussion. If a patient or a family member complains about a coworker, listen to the story and then speak with the coworker. If a staff member labels a patient as uncooperative, assume the care of that patient with openness and a desire to meet that patient’s needs. •To take on responsibility and authority, ask for help if you are uncertain about how to perform a nursing skill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care. •To become comfortable with risk taking , if your knowledge causes you to question a health care provider’s order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients. •To develop discipline, be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take the time to be thorough and manage your time effectively.

Attitudes a Nurse Needs
Perseverance Creativity Curiosity Integrity Humility [The five remaining attitudes a nurse needs are covered here.] •To develop perseverance, be cautious of an easy answer. If coworkers give you information about a patient and some fact seems to be missing, clarify the information or talk to the patient directly. If problems of the same type continue to occur on a nursing division, bring coworkers together, look for a pattern, and find a solution. •To employ creativity, look for different approaches if interventions are not working for a patient. For example, a patient in pain may need a different positioning or distraction technique. When appropriate, involve the patient’s family in adapting your approaches to care methods used at home. •To show curiosity, always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments. •To develop integrity, recognize when your opinions conflict with those of a patient; review your position, and decide how best to proceed to reach outcomes that will satisfy everyone. Do not compromise nursing standards or honesty in delivering nursing care. •To show humility, recognize when you need more information to make a decision. When you are new to a clinical division, ask for an orientation to the area. Ask registered nurses (RNs) regularly assigned to the area for assistance with approaches to care.

Case Study (cont’d) When Carla notices that Mr. Ramirez is slow to respond to her questions, grimaces when shifting weight on his back, and is reluctant to have a bed bath, her critical thinking leads to the inference that Mr. Ramirez is in pain. Carla decides to assess the situation more thoroughly by asking Mr. Ramirez specific questions about his comfort, such as, “Tell me if you are hurting,” “Show me where the pain is located,” and “Is this pain you have felt before?” [You might encourage a discussion of this portion of the case study by asking the following questions.] •What does Carla notice about Mr. Ramirez in this case study? •What does Carla infer from Mr. Ramirez’s behavior? •How does Carla’s decision to ask Mr. Ramirez specific questions fit in with your understanding of clinical decision making? •Which of the 11 attitudes that we have covered would you say Carla is exhibiting?

Case Study (cont’d) Before Carla begins her questions, she repositions Mr. Ramirez to make him more comfortable. As she does so, she observes an area of redness over his left heel. Redness could be due to inflammation or pressure on the skin. Carla palpates the area, noting that it is tender to touch and warm. She asks Mr. Ramirez if he has been moving his leg much, and he says, “No, I haven’t. I am afraid I will hurt my other leg.” These initial findings imply that excess pressure is being applied to the heel. [Encourage discussion of this portion of the case study.] •What discovery does Carla make as she is helping to reposition Mr. Ramirez? •What knowledge does Carla possess that helps her in this part of the assessment? •We know that every patient a nurse cares for will not have the exact same health status and needs. How does a nurse prepare to meet the challenge of each new patient’s care needs?

Quick Quiz! 1. The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done A. Logically. B. Haphazardly. C. Independently. D. In a vacuum. Answer: B [Discuss.]

Case Study (cont’d) Carla gently applies pressure to the area with her finger and notes that after pressure is released, the area does not blanch or turn white, a key sign of excess pressure. She thinks about what she knows about normal skin integrity, the effect of immobility, and the effects of pressure on the skin. The information she collects leads her to determine that Mr. Ramirez has an early-stage pressure ulcer. The nursing diagnosis would be “Impaired skin integrity.” [You might choose to review the five steps of the nursing process clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation; and/or the 11 attitudes that a nurse will need: confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humility. Then continue to encourage discussion of the case study. ] •How would you rate Carla as to her competencies at each step of the nursing process? •Carla is clearly showing curiosity. What other attitudes and competencies is Carla displaying or employing?

Case Study (cont’d) Carla continues to gently encourage Mr. Ramirez to describe any symptoms or sensations that he is experiencing. He tells Carla that he does have pain in his stomach. Carla asks him to place his hand over the area of discomfort. Mr. Ramirez places his hand over the lower right quadrant of his abdomen. On a scale of 0 to 10, Mr. Ramirez rates his pain at 7. Carla inspects the area more closely and palpates gently over the abdomen for the presence of tenderness. She notes that the abdomen feels very tight. [Encourage discussion of the case study.] •Do you think Carla anticipated this latest information from Mr. Ramirez? •How important do you think it is for a nurse to be adaptable? •What do you think Carla will do next?

Developing Critical Thinking Skills
Reflective Journaling: A tool used to clarify concepts through reflection by thinking back or recalling situations Concept Mapping: A visual representation of patient problems and interventions that illustrates an interrelationship •When you use critical thinking, you need to connect knowledge and theory. This can be done through reflective journaling and concept mapping. •Reflective journaling: •Reflective journal writing is a tool for developing critical thought and reflection by clarifying concepts. •Reflective writing gives you the opportunity to define and express the clinical experience in your own words (Di Vito-Thomas, 2005). •By keeping a journal of each of your clinical experiences, you are able to explore personal perceptions or understanding of each experience and develop the ability to apply theory in practice. •The use of a journal improves your observation and descriptive skills. •Writing skills improve through the development of conceptual clarity. •Concept mapping: •The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures (Hill, 2006). •Through drawing a concept map, you learn to organize or connect information in a unique way so the diverse information that you have about a patient begins to form meaningful patterns and concepts. •You begin to see a more holistic view of a patient. •When you see the relationship between the various patient diagnoses and the data that support them, you better understand a patient’s clinical situation. •Concept maps become more detailed, integrated, and comprehensive as you learn more about the care of a patient and the care you provide similar patients (Ferrario, 2004).

Critical Thinking and Delegation
Effective communication is needed between registered nurses (RNs) and nursing assistive personnel (NAP) for giving feedback and clarifying tasks and patient status. When patients’ clinical conditions change, warranting attention by RNs, clear directions are necessary to avoid missed care. Applying critical thinking can help an RN make the decision about when to appropriately delegate care. [This slide covers the content of Box 15-1 on text p. 197: Critical Thinking and Delegation, which is drawn from the results of two separate studies in which nurses were asked to describe the process of delegation in their clinical practice.] •Nurses synthesize large amounts of information and think through complex and often emergent clinical situations to make decisions about patient care, including delegation. •An important delegation issue is the right circumstances. Registered nurses (RNs) are responsible for making clinical decisions when patients’ conditions change, including determining what and when to delegate. •When an RN makes the clinical decision to delegate care, it is expected that nursing assistive personnel (NAP) must report significant findings, and that the RN must follow up on tasks that have been delegated. •Delegation is ineffective if RNs fail to carry out proper supervision and evaluation of care. When delegation is ineffective, often activities such as ambulation, feedings, and turning are missed by NAP. •Successful delegation depends on good communication, developing a trusting and respectful relationship, and showing initiative.

Reflective Journaling
The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice. The Circle of Meaning model uses a series of questions to help you through a clinical experience and to find meaning. [The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice (Bilinski, 2002).] •The series of questions that the Circle of Meaning Model uses are as follows: 1. Which experience, situation, or information in your clinical experience seems confusing, difficult, or interesting? 2. What is the meaning of the experience? What feelings did you have? What feelings did your patient have? What influenced the experience? Which guesses or questions developed with the first connection in question 1? Give examples. 3. Do the feelings, guesses, or questions remind you of any experience from the past or present or something that you think is a desirable future experience? How does it relate? What are the implications/significance? 4. What are the connections between what is being described and what you have learned about nursing science, research, and theory? What are some possible solutions? Which approach or solution would you choose and why? How is this approach effective?

Caring for Groups of Patients
Identify the nursing diagnoses and collaborative problems of each patient. Decide which are most urgent. Consider the time it will take to care for those patients. Consider the resources that you have to manage each problem. Consider how to involve the patients as participants in care. Decide how to combine activities. Decide which nursing care procedures to delegate. Discuss complex cases with the health care team. •Box 15-2 (on text p. 197) covers the important issues of clinical decision making for groups of patients. •Identify the nursing diagnoses and collaborative problems of each patient (see Chapter 17). •Analyze patients’ diagnoses/problems and decide which are most urgent on the basis of basic needs, the patients’ changing or unstable status, and problem complexity (see Chapter 18). •Consider the time it will take to care for patients whose problems are of high priority (e.g., do you have the time to restart a critical intravenous [IV] line when medication is due for a different patient?). •Consider the resources you have to manage each problem, nursing assistive personnel assigned with you, other health care providers, and patients’ family members. •Consider how to involve the patients as decision makers and participants in care. •Decide how to combine activities to resolve more than one patient problem at a time. •Decide which, if any, nursing care procedures to delegate to assistive personnel so you are able to spend your time on activities requiring professional nursing knowledge. •Discuss complex cases with other members of the health care team to ensure a smooth transition in care requirements.

Meeting With Colleagues
When nurses have a formal means to discuss their experiences such as a staff meeting or a unit practice council, the dialogue allows for questions, differing viewpoints, and sharing of experiences. When nurses are able to discuss their practices, the process validates good practice and offers challenges and constructive criticism. •Meeting with colleagues gives you the chance to discuss and examine work experiences. •Discussing anticipated and unanticipated outcomes in any clinical situation allows you to continually learn and develop your expertise and knowledge (Cirocco, 2007). •Much can be learned by drawing from others’ experiences and perspectives to promote reflective critical thinking.

Five-Step Nursing Process Model
[Fig 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 patient’s 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 patient’s unique needs. •Within each step of the nursing process, you apply critical thinking to provide the very best professional care to your patients.

Components of Critical Thinking in Nursing
I. Specific knowledge base in nursing II. Experience III. Critical thinking competencies IV. Attitudes for critical thinking V. Standards for critical thinking A. Intellectual standards B. Professional standards [Review Box 15-3 on text p. 199: Components of Critical Thinking in Nursing.] I. Specific knowledge base in nursing II. Experience III. Critical thinking competencies A. General critical thinking B. Specific critical thinking C. Specific critical thinking in nursing: nursing process IV. Attitudes for critical thinking Confidence, Independence, Fairness, Responsibility, Risk taking, Discipline, Perseverance, Creativity, Curiosity, Integrity, Humility V. Standards for critical thinking A. Intellectual standards Clear, Precise, Specific, Accurate, Relevant, Plausible, Consistent, Logical, Deep, Broad, Complete, Significant, Adequate (for purpose), Fair B. Professional standards 1. Ethical criteria for nursing judgment 2. Criteria for evaluation 3. Professional responsibility

Quick Quiz! 2. The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and A. Decision making. B. Problem solving. C. Intellectual standards. D. Critical thinking skills. Answer: D [Discuss.]

Synthesis of Critical Thinking With the Nursing Process Competency
[This is Fig from text p. 203, a synthesis of critical thinking with the nursing process competency, or the five steps of the nursing process.] •As a beginning nurse, it is important to learn the steps of the nursing process and incorporate the elements of critical thinking. •Critical thinking is a reasoning process by which you reflect on and analyze your own thoughts, actions, and knowledge. •To be a good critical thinker requires dedication and a desire to grow intellectually. •The two processes, dedication and the desire to grow intellectually, go hand in hand in making quality decisions about patient care. [Discuss the QSEN Box on text p. XXX: Building Competency in Quality Improvement.]

Case Study (cont’d) Carla does what she can to position Mr. Ramirez more comfortably and makes sure his leg discomfort is under control. She knows that the increased pain and tightness he is experiencing suggest that something is causing pressure in the abdomen. It could mean the patient is having bleeding from his bruised liver. Carla decides to call Mr. Ramirez’s physician immediately. [Encourage discussion of the conclusion of the case study with the following questions: Ask the class: Carla's thought that Mr. Ramirez has pressure developing in his abdomen is an example of what critical thinking competency? Explain. Ask the class to describe the intellectual standards that Carla applied when asking Mr. Ramirez to rate his pain. Ask the class: What knowledge did Carla apply in this clinical situation? Do you think Carla made the right decision? Why?]

Critical Thinking Synthesis
A reasoning process used to reflect on and analyze thoughts, actions, and knowledge Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions •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.

Chapter 16 Nursing Assessment
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.

Five-Step Nursing Process
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 patient’s health status. You then make clinical judgments from the assessment to identify the patient’s 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 patient’s nursing diagnoses. The next step, implementation, involves performing the planned interventions. After performing interventions, you evaluate the patient’s response and determine whether the interventions were effective. [This is Fig from text p. 207.]

Nursing Process The 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 patient’s response to a health problem or generalize about the patient’s functional state of health. Through assessment, a pattern begins to form. 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.

Critical Thinking Approach to Assessment
Assessment involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database. Two stages of assessment: Collection and verification of data Analysis of data Assessment has two stages: First, to collect and verify data from the patient (primary source) and from family, health care providers, and medical records (secondary source) Second, to analyze the data The data will be used to develop the nursing diagnosis, identify collaborative problems, and develop an individualized plan of care. You perform assessment to gather information needed to make an accurate judgment about a patient’s current condition. Experience, knowledge, standards, and attitudes all influence critical thinking in assessment.

Case Study Ms. 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. 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.

Database The purpose of assessment is to establish a database about the patient’s perceived needs, health problems, and responses to these problems. In addition, the data reveal related goals, experiences, health practices, values, and expectations about the health care system. Critical thinking skills help you to synthesize relevant information and use it in a purposeful way. Critical thinking is a vital part of assessment. It allows you to see the big picture when you form conclusions or make decisions about a patient’s health condition. Validation of any abnormal assessment findings and personal observation of assessments performed by skilled professionals help you become competent in assessment. You also learn to apply standards of practice and accepted standards of “normal” for physical assessment data when assessing patients. Use of critical thinking attitudes such as curiosity, perseverance, and confidence assists you in completing a comprehensive database. [See also Fig Critical thinking and the assessment process on text p. 208.]

Data Collection Sources of data Subjective vs. objective data
Patient (interview, observation, physical examination)—the best source of information Family and significant others (obtain patient’s agreement first) Health care team Medical records Scientific literature Nurse’s experience Subjective vs. objective data As you begin a patient assessment, think critically about what to assess for that specific patient. When beginning to assess your patients, you will use cues and inferences to help you deal with all of the data collected. A cue is information that you collect through the use of your senses. An inference is your judgment or interpretation of the cues you just gathered. [Note: You will want to discuss the assessment model or tool that you utilize at your college or university.] Remember, a patient does not always want you to question or involve the family. You must obtain a patient’s agreement to include family members or friends. Data can be subjective or objective. [Ask students if they can differentiate between these two. Subjective data: Patients’ verbal descriptions of their own health problems. Objective data: Observations or measurements that a health care provider obtains.]

Cues and Inferences [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.

Comprehensive Assessment Approaches
Use of a structured database format, based on an accepted theoretical framework or practice standard Example: Gordon’s model of functional health patterns Problem-oriented approach Assessment moves from general to specific. 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.

Process of Assessment Collect 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. 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 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.

Methods of Data Collection
Patient-centered interview = An organized conversation with the patient Set the stage (preparation, environment, greeting). Set an agenda/gather information about patient’s concerns. Collect the assessment or nursing health history; assure the patient of confidentiality. Terminate the interview (cue the end). The best clinical interview focuses on the patient, not on your own agenda. A successful interview requires preparation. Collect available information about the patient before starting the interview, prepare the interview environment, and time the interview to avoid interruptions. A good interview environment is free of distractions, unnecessary noise, and interruptions. Remove any barriers to privacy. [See Box 16-2 on text p. 211 Focus on Older Adults.] During the interview, you will conduct a nursing health history. The history collects information regarding patients’ current level of wellness, as well as a review of body systems, family history, sociocultural history, spiritual health, and mental and emotional reactions. [More discussion of the health history is provided on an upcoming slide.] Be sure to assure the patient that any information obtained remains confidential and is used only by health care professionals who provide his or her care. The Health Insurance Portability and Accountability Act (HIPAA) regulations require patients to sign an authorization before you collect personal health data. As you conclude the interview, you summarize your discussion with the patient and check for accuracy of the information collected. Give your patient a clue that the interview is coming to an end. This helps the patient maintain direct attention without being distracted by wondering when the interview will end and also gives the patient an opportunity to ask additional questions.

Interview Techniques Open-ended vs. closed-ended questions
Back-channeling Probing Because a patient’s report includes subjective information, validate data from the interview later with objective data. Obtain information (as appropriate) about a patient’s physical, developmental, emotional, intellectual, social, and spiritual dimensions. [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 patient’s 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.

Case Study (cont’d) 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? Answer: Subjective data Rationale: Subjective data refers to the patient’s verbal description of his or her health problems. Objective data are observations by another person of a patient’s health status.

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

Quick Quiz! 1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of A. Evaluation. B. Data collection. C. Problem identification. D. Testing a hypothesis. Answer: B

Nursing Health History
Biographical information Patient expectations Reason for seeking health care Present illness or health concerns Health history Family history Environmental history Psychosocial history Spiritual health Review of systems Documentation of findings Nursing health history = Data about the patient’s current level of wellness. When collecting a complete nursing history, let the patient’s 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 patient’s 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 symptoms—Does the patient experience other symptoms along with the primary symptom? Health history: Provides you with information regarding the patient’s 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 facility’s documentation forms. [See also Fig Dimensions for gathering data for a health history on text p. 215.]

Next Assessment Steps Physical examination = An investigation of the body to determine its state of health Observation of patient behavior (verbal vs. nonverbal) Diagnostic and laboratory data Interpreting and validating assessment data. Validation of assessment data consists of comparison of data with another source to determine accuracy of the data. 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 patient’s 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 patient’s condition. An important aspect of observation consists of a patient’s 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.

Case Study (cont’d) Which of the following statements or questions made by Yolanda to Ms. Thompkins addresses the nature of Ms. Thompkins’ pain? (Select all that apply.) A. “Describe your pain to me.” B. “Is the pain worse in the morning or in the evening?” C. “Place your hand over the area that is uncomfortable.” D. “Rate your pain on a scale of 0 to 10.” Answers: A and C Rationale: Asking the patient to describe or show the location of pain addresses the nature of pain. Asking the patient about pain during certain periods of the day or in association with movement addresses precipitating factors of pain. Severity of pain is addressed by a pain scale rating.

Data Documentation The last component of a complete assessment
Legal and professional responsibility Requires accurate and approved terminology and abbreviations The patient record is a legal document. It can be used in a court of law. It is reviewed by accreditation agencies. It is used by insurance companies to deny or approve patient charges and payments.

Quick Quiz! 2. The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and A. Decision making. B. Problem solving. C. Interview process. D. Intellectual standards. Answer: C

Case Study (cont’d) True or False: Yolanda knows that the best source of information regarding Ms. Thompkins’ care is the surgeon. Answer: False Rationale: The best source of information regarding the patient’s care is typically the patient, as long as the patient is conscious, alert, and able to accurately answer questions.

Allows nurses to obtain a holistic perspective of health care needs
Concept Mapping A visual representation that allows nurses to graphically illustrate the connections between a patient’s health problems Allows nurses to obtain a holistic perspective of health care needs 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 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 patient’s health care needs, which ultimately allows you to make better clinical decisions.

Chapter 17 Nursing Diagnosis
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 patient’s response to health problems with the goal of identifying patient needs and formulating nursing diagnoses.

Nursing Diagnosis 1. Medical diagnosis
Identification of a disease condition based on specific evaluation of signs and symptoms 2. Nursing diagnosis Clinical judgment about the patient in response to an actual or potential health problem 3. Collaborative problem Actual or potential physiological complication that nurses monitor to detect a change in patient status A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms, the patient’s 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.

History of Nursing Diagnosis
First introduced in 1950 In 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. 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 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 patient’s problem that gives nurses and other members of the health care team a common language for understanding the patient’s needs.

Case Study John 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 father’s death, which prompted him to select a career that improves people’s 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. [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?]

Nursing Diagnostic Process
Assessment of patient’s 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… NANDA-I continually develops and adds new diagnostic labels to the NANDA International listing through the process outlined in Fig (on text p. 224, the beginning of which is shown here).

Nursing Diagnostic Process (cont’d)
If no additional data are needed, proceed: Interpret and analyze meaning of data Data clustering • Group signs and symptoms. • Classify and organize. Look for defining characteristics and related factors. Identify patient needs. Formulate nursing diagnoses and collaborative problems. [This is the remainder of Fig from text p. 224.] Most state Nurse Practice Acts include nursing diagnosis as part of the domain of nursing practice. [See text pp for a list of Nanda International Nursing Diagnoses as provided in Box 17-2.]

Nursing Diagnostic Statements
Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding patients’ needs Allows nurses to communicate what they do among themselves and with other health care professionals and the public Distinguishes the nurse’s role from that of the physician or other health care provider Helps nurses focus on the scope of nursing practice Two additional purposes of nursing diagnosis are that they Foster the development of nursing knowledge Promote creation of practice guidelines that reflect the essence of nursing

Case Study (cont’d) John reviews the phases of the nursing process.
Rank in correct order the phases of the nursing process: Evaluation Planning Assessment Diagnosis Implementation Answer: The correct order of the phases of the nursing process is: Assessment, diagnosis, planning, implementation, and evaluation.

Critical Thinking and the Nursing Diagnostic Process
The diagnostic reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgment or a nursing diagnosis. Nursing diagnoses and definitions Defining characteristics = Clinical criteria or assessment findings Related factors pertinent to the diagnoses Interventions suited for treating the diagnoses The diagnostic process flows from the assessment process and includes decision-making steps: Data clustering, identifying patient health problems, and formulating the diagnosis or collaborative problem. Think back to the critical thinking chapter. You will use your critical thinking abilities to identify an appropriate nursing diagnosis to individualize patient care. In the practice of nursing, it is important for you to know nursing diagnoses, their definitions and defining characteristics for making diagnoses, related factors pertinent to the diagnoses, and interventions suited for treating the diagnoses. Sources of information about nursing diagnoses include faculty, advanced practice nurses, documentation systems, and, in some settings, practice guidelines or protocols. The application of critical thinking attitudes and standards helps you to be thorough, comprehensive, and accurate when identifying nursing diagnoses that apply to your patients. See Figure 17-1 (on text p. 223), which shows how critical thinking interacts with the nursing process. Each nursing diagnosis contains a specific set of defining characteristics to support it. When you focus on the defining characteristics, you also need to compare the patient’s pattern of data with normal or expected data. Data you will look at include laboratory and diagnostic values, professional standards, and normal anatomy and physiology.

Data Clustering A 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 characteristics—clinical 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. Each NANDA-I–approved 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 International–Approved 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.

Case Study (cont’d) Because of John’s 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.) Hypertension Fatigue Food preference High cholesterol Answers: Hypertension, fatigue, and high cholesterol Rationale: 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.

Interpretation— Identifying Health Problems
It is critical to select the correct diagnostic label for a patient’s need. From assessment to diagnosis, move from general information to specific. Think of the problem identification phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem. The absence of certain defining characteristics suggests that you reject a diagnosis under consideration. While analyzing clusters of data, you begin to consider the patient’s health problems. Your interpretation of the information allows you to select among various diagnoses the ones that apply to your patient. Often a patient has defining characteristics that apply to more than one diagnosis. Knowing that there are similar diagnoses directs you to gather more information to clarify your interpretation. Always examine carefully the defining characteristics in your database to support or eliminate a nursing diagnosis. To be more accurate, review all characteristics, eliminate irrelevant ones, and confirm relevant ones.

Formulating a Nursing Diagnosis
A related factor is a condition, historical factor, or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis. A related factor allows you to individualize a nursing diagnosis for a specific patient. When you are ready to form a plan of care and select nursing interventions, a concise nursing diagnosis allows you to select suitable therapies. To individualize a nursing diagnosis further, you identify the associated related factor. Placing a diagnosis into the context of the patient’s situation clarifies the nature of the patient’s health problem. While focusing on patterns of defining characteristics, you compare a patient’s pattern of data with data that are consistent with normal, healthful patterns. Use accepted norms as the basis for comparison and judgment. This includes using laboratory and diagnostic test values, professional standards, and normal anatomical or physiological limits. When comparing patterns, judge whether the grouped signs and symptoms are expected for the patient, and whether they are within the range of healthful responses. Isolate any defining characteristics not within healthy norms to allow you to identify a specific problem. A nursing diagnosis focuses on a patient’s actual or potential response to a health problem rather than on the physiological event, complication, or disease. A nurse cannot independently treat a medical diagnosis. Critical thinking is necessary in identifying nursing diagnoses and collaborative problems, so you can appropriately individualize care for your patients. [See also Figure 17-3 on text p. 228 Differentiating nursing diagnoses from collaborative problems.]

Types of Nursing Diagnoses
Actual Nursing Diagnosis Describes human responses to health conditions or life processes Risk Nursing Diagnosis Describes human responses to health conditions/life processes that may develop Health Promotion Nursing Diagnosis A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential 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 patient’s 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 person’s, family’s, or community’s 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 person’s readiness is supported by defining characteristics.

Components of a Nursing Diagnosis
Diagnostic Label (NANDA-I) Definition Related Factors/Etiology: Treatment-related Pathophysiological (biological or psychological) Maturational Situational (environmental or personal) PES Format: Problem Etiology Symptoms (or 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 patient’s assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patient’s 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 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 nurse’s 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.

Case Study (cont’d) John learns the four types of nursing diagnoses.
Which of the following are the four types of nursing diagnoses? (Select all that apply.) Actual diagnoses Risk diagnoses Wellness diagnoses Health promotion diagnoses Disease prevention diagnoses Answer: The four types of nursing diagnoses are actual diagnoses, risk diagnoses, wellness diagnoses, and health promotion diagnoses.

Cultural Relevance of Nursing Diagnoses
Consider 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. It is important to consider your own cultural competence so you are more sensitive to a patient’s 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 patient’s 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.

Case Study (cont’d) John knows that a ______________ diagnosis is applied to vulnerable populations. Answer: risk nursing Rationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.

Concept Mapping Nursing Diagnosis
A visual representation of a patient’s nursing diagnoses and their relationships with one another Concept maps promote problem solving and critical thinking skills by organizing complex patient data, analyzing concept relationships, and identifying interventions. A concept map places the central focus on the patient rather than on the patient’s 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.

Sources of Diagnostic Error
Data collection Data clustering Interpretation and analysis of data Labeling the diagnosis/ the diagnostic statement Documentation and informatics Nursing diagnostic errors occur during data collection, clustering, interpretation, and labeling of the diagnosis. Box 17-4 (on text p. 232) lists Sources of Diagnostic Error. You should strive to avoid inaccurate or missing data and to collect data in an organized way. It is important to validate the measurable, objective physical findings that support subjective data. Errors in data collection occur when data are clustered prematurely, incorrectly, or not at all. Begin interpretation by identifying and organizing relevant assessment patterns to support the presence of patient problems. Be careful to consider conflicting cues, or decide whether cues are insufficient to form a diagnosis. To reduce errors, you will need to word the diagnostic statement in appropriate, concise, and precise language using NANDA-I terminology. Documentation is of paramount importance. Always date the diagnosis accurately. Refer to your clinical facility for the way to list nursing diagnoses.

Quick Quiz! 1. Concept mapping is one way to A. Connect concepts to a central subject. B. Relate ideas to patient health problems. C. Challenge a nurse’s thinking about patient needs and problems. D. Graphically display ideas by organizing data. E. All of the above Answer: E

Diagnostic Statement Guidelines
1. Identify the patient’s 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. 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 patient’s risk. Patients experience many responses to diagnostic tests and medical treatments. Patients often are unfamiliar with medical technology.

Diagnostic Statement Guidelines (cont’d)
6. Identify the patient’s 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. [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 patient’s 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.

Quick Quiz! 2. For a student to avoid a data collection error, the student should A. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. B. Review his or her own comfort level and competency with assessment skills. C. Ask another student to perform the assessment. D. Consider whether the diagnosis should be actual, potential, or risk. Answer: A

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

Chapter 18 Planning Nursing Care
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 patient’s 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 patient’s 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.

Establishing Priorities
Ordering 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: High—Emergent Intermediate Low—Affect patients’ future well-being 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 patient’s nursing diagnoses in order of importance, you attend to each patient’s 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 patient’s 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, non–life 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 patient’s 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 patient’s safety and desires, the nature of the treatment indicated, and the relationship among the diagnoses.

Establishing Priorities (cont’d)
The order of priorities changes as a patient’s condition changes. Priority setting begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems. Patient-centered care requires you to know a patient’s preferences, values, and expressed needs. Ethical care is a part of priority setting. Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient’s 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 patient’s concerns does not relieve you of the responsibility to act in a patient’s 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

Priorities in Practice
This model for priority setting is Fig (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 patient’s 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.

Case Study Fulmala 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. Skyfall’s plan of care, which addresses pain, weakness, and fatigue. Fulmala includes nutrition and patient safety as part of the plan of care. [Ask the class: Why aren’t 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.]

Critical Thinking in Setting Goals and Expected Outcomes
A broad statement that describes the desired change in a patient’s condition or behavior An aim, intent, or end Expected outcome Measurable criteria to evaluate goal achievement 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 (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.

Goals of Care Patient-centered goal:
A specific and measurable behavior or response that reflects a patient’s highest possible level of wellness and independence in function Short-term goal: An objective behavior or response expected within hours to a week Long-term goal: An objective behavior or response expected within days, weeks, or months A patient-centered goal is realistic and is based on patient needs and resources. Patient-centered goals reflect a patient’s 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 patient’s 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.

Always partner with patients when setting their individualized goals.
Goals of Care (cont’d) 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. 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.

Expected Outcomes An objective criterion for goal achievement
A specific, measurable change in a patient’s status that you expect in response to nursing care Direct nursing care Determine when a specific, patient-centered goal has been met Are written sequentially, with time frames Usually, several are developed for each nursing diagnosis and goal. 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 patient’s 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 patient’s 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.

Nursing Outcomes Classification
A 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. 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.

Seven Guidelines for Writing Goals
Patient centered Singular goal or outcome Observable Measurable Time limited Mutual factors Realistic 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 patient’s 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 patient’s 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 precisely—for 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 patient’s 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 patient’s physiological, emotional, cognitive, and sociocultural potential, as well as the economic costs and resources required to reach these in a timely manner.

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. Answer: B [Discuss how B addresses the seven guidelines for writing goals.]

Critical Thinking in Planning Care
Nursing 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 intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively Part of the planning process is to select nursing interventions to meet the patient’s goals and outcomes. Once nursing diagnoses have been identified and goals and outcomes selected, you choose interventions individualized for the patient’s 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.

Types of Interventions
Nurse initiated Independent—Actions that a nurse initiates Physician initiated Dependent—Require an order from a physician or other health care professional Collaborative Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals 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 physician’s or the health care provider’s 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.

Clarifying an Order When 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. 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 person’s who wrote or transcribed the original order. You are legally responsible for any complications resulting from the error.

Case Study (cont’d) Fulmala develops Ms. Skyfall’s plan of care, including writing the goals and expected outcomes. Fulmala knows that the guidelines for writing goals and expected outcomes include which of the following? (Select all that apply.) A. Measurable B. Time-limited C. Observable D. Diagnostic E. Realistic Answers: Measurable, time-limited, observable, realistic Rationale: The seven guidelines for writing goals and expected outcomes are patient-centered, singular goals or outcomes; they are observable, measurable, and time-limited with mutual factors, and they are realistic.

Selection of Interventions
Six factors to consider: Characteristics of nursing diagnosis Goals and expected outcomes Evidence base for interventions Feasibility of the interventions Acceptability to the patient Nurse’s competency When selecting interventions, review the patient’s 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.

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. [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 ) 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 patient’s individualized needs and situation.

Case Study (cont’d) Fulmala knows that _________________ interventions require an order from a physician or another health care professional. Answer: dependent nursing Rationale: Dependent nursing interventions are actions that require an order from a physician or other health care professional.

Systems for Planning Nursing Care
Nursing 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 patient’s clinical needs and situation Reduces the risk for incomplete, incorrect, or inaccurate care Changes as the patient’s problems and status change Interdisciplinary care plan = Contributions from all disciplines involved in patient care. 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 patient’s long-term needs. Incorporating the goals of the care plan into discharge planning is important.

Change of Shift A 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 interventions Change-of-shift report: Communicates information from offgoing to oncoming patient care personnel = “Nurse handoff” Focus your reports on the nursing care, treatments, and expected outcomes documented in the care plans. 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 patient’s 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 nurse’s perception of him or her as an individual.

Student Care Plans A student care plan
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care Planning care for patients in community-based settings involves Educating the patient/family about care Guiding them to assume more of the care over time 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 patient’s/family’s evaluation of expected outcomes. [Review Table 18-4 (on text p. 247) Frequent Errors in Writing Nursing Interventions.]

Critical Pathways Critical 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. 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.

Concept Maps Provide a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help you make better clinical decisions in planning care Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information [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 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.

Case Study (cont’d) What are some examples of independent nursing interventions that Fulmala may develop for Ms. Skyfall? (Select all that apply.) A. Medication administration B. Medication teaching C. Patient positioning D. Family teaching Answers: Medication teaching, patient positioning, family teaching Rationale: 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.

Quick Quiz! 2. When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a A. Critical pathway. B. Nursing care plan. C. Concept map. D. Diagnostic label. Answer: C

Consulting Other Health Care Professionals
Planning 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. Consultation can occur at any step of the nursing process. Consultation increases your knowledge about a patient’s 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.

When and How to Consult When: The exact problem remains unclear
How: Begin with your understanding of the patient’s 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 outcomes Do not influence consultants. Be available to discuss the consultant’s findings. Incorporate the suggestions. [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 patient’s 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 patient’s medical record, conversations with other nurses, and the patient’s 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 patient’s 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.

Case Study (cont’d) 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. Answer: True Rationale: Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Quick Quiz! 3. Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation Answer: C

Critical Thinking in Nursing Practice

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