Planning Care With Nursing Diagnosis
Learning Objectives
After reading the chapter, the following questions should be answered:
What are functional health patterns?
How are priority nursing diagnoses identified?
What is the difference between goals for nursing diagnoses and collaborative problems?
How is evaluation different for nursing diagnoses and collaborative problems?
What are standardized care plans?
Because individuals require nursing care 7 days a week and 24 hours a day, nurses must rely on each other and nonlicensed nursing personnel to help individuals achieve outcomes of care. Clearly, some system of communication is necessary. For more than 30 years, this system consisted of handwritten care plans or verbal reports, neither of which was very useful. This chapter addresses the various methods that nurses use today to communicate an individual’s care to other caregivers.
Assessment: Data Collection Formats
Data collection usually consists of two formats: the nursing baseline or screening assessment and the focus or ongoing assessment. The nurse can use each alone or together. As discussed in Chapter 4, nurses encounter, diagnose, and treat two types of response: nursing diagnoses and collaborative problems. Each type requires a different assessment focus.
Initial, Baseline, or Screening Assessment
An initial, baseline, or screening assessment involves collecting a predetermined set of data during initial contact with the individual (e.g., on admission, first home visit). This assessment serves as a tool for “narrowing the universe of possibilities” (Gordon, 1994). During this assessment, the nurse interprets data as significant or insignificant. This process is explored later in this chapter.
The nurse should have an assessment tool that permits the initial assessment to be systematic and efficient. Appendix B illustrates an assessment form with checking or circling options, which can be in an electronic medical record. The nurse always can elaborate with additional questions and comments. Openended questions are better for assessment of certain functional areas, such as fear or anxiety. Nurses should view assessment formats as guides, not as mandates. Before requesting information from an individual, nurses should ask themselves, “What am I going to do with the data?” If certain information is useless or irrelevant for a particular individual, then its collection is unnecessary and potentially distressing for the individual. For example, asking a terminally ill individual how much he or she smokes is unnecessary unless the nurse has a specific goal. If an individual will be NPO, collecting data about eating habits is probably unnecessary at this time. Such assessment will be indicated if the individual resumes eating.
If an individual is extremely stressed, the nurse should collect only necessary data and defer the assessment of functional patterns to another time.
Functional Health Patterns
As discussed earlier, nursing assessment focuses on collecting data that validate nursing diagnoses. Gordon’s (1994) system of functional health patterns provides an excellent, relevant format for nursing data collection to determine an individual’s or group’s health status and functioning. For over 20 years, Functional Health Patterns have served to direct the nurse to assess for the effects of illness and disabilities on daily functioning of individuals and their significant others. After data collection is complete, the nurse and individual can determine positive functioning, altered functioning, or at risk for altered functioning. Altered functioning is defined as functioning that the client (individual or group) perceives as negative or undesirable. Refer to Box 5.1 for functional health patterns.
Box 5.1 FUNCTIONAL HEALTH PATTERNS
Health Perception-Health Management Pattern
Perceived pattern of health, well-being
Knowledge of lifestyle and relationship to health
Knowledge of preventive health practices
Adherence to medical, nursing prescriptions
Nutritional-Metabolic Pattern
Usual pattern of food and fluid intake
Types of food and fluid intake
Actual weight, weight loss or gain
Appetite, preferences
Elimination Pattern
Bowel elimination pattern, changes
Bladder elimination pattern, changes
Control problems
Use of assistive devices
Use of medications
Activity-Exercise Pattern
Pattern of exercise, activity, leisure, recreation
Ability to perform activities of daily living (self-care, home maintenance, work, eating, shopping, cooking)
Sleep-Rest Pattern
Patterns of sleep, rest
Perception of quality, quantity
Cognitive-Perceptual Pattern
Vision, learning, taste, touch, smell
Language adequacy
Memory
Decision-making ability, patterns
Complaints of discomforts
Self-Perception-Self-Concept Pattern
Attitudes about self, sense of worth
Perception of abilities
Emotional patterns
Body image, identity
Role-Relationship Patterns
Patterns of relationships
Role responsibilities
Satisfaction with relationships and responsibilities
Sexuality-Reproductive Pattern
Menstrual, reproductive history
Satisfaction with sexual relationships, sexual identity
Premenopausal or postmenopausal problems
Accuracy of sex education
Coping-Stress Tolerance Patterns
Ability to manage stress
Knowledge of stress tolerance
Sources of support
Number of stressful life events in last year
Value-Belief Pattern
Values, goals, beliefs
Spiritual practices
Perceived conflicts in values
Refer to Appendix A for a sample initial assessment organized according to functional health patterns. It is designed to assist the nurse in gathering subjective and objective data. Should questions arise concerning a pattern, the nurse would gather more data about the diagnosis using the focus assessment under the diagnosis.
When collecting data according to the functional health patterns, the nurse questions, observes, and evaluates the individual or family. For example, under the Cognitive-Perceptual Pattern, the nurse asks the individual whether he or she has difficulty hearing, observes whether the individual is wearing a hearing aid, and evaluates whether the individual understands English.
Physical Assessment
In addition to functional health pattern assessment, the nurse also collects data related to body system functioning. Physical assessment, the collection of objective data concerning the individual’s physical status, incorporates head-to-toe examination with a focus on the body systems. The techniques that can be used include inspection, palpation, percussion, and auscultation.
Appendix B lists those areas of physical assessment in which nurse generalists should be proficient. Physical assessment by nurses should be clearly “nursing” in focus. By examining their philosophy and definition of nursing, nurses should seek to develop expertise in those areas that will enhance their nursing practice.
Keeping in mind that separation of functional health patterns from physical assessment is done for organizational purposes only. No useful nursing assessment framework can restrict actual data collection in such a manner. Because humans are open systems, a problem in one functional health pattern invariably influences body system functioning or functioning in another functional health pattern. Anxiety can affect appetite; sleep problems can increase coping difficulties.
Focus Assessment
Focus assessment is the acquisition of selected or specific data as determined by the individual’s condition or by the nurse and the individual or family (Carpenito, 1986). The nurse who assesses the vital signs, surgical
site, bowel function/sounds, hydration, comfort of a new postoperative individual, for example, is performing a focus assessment. These assessments are ongoing during the hospitalization.
site, bowel function/sounds, hydration, comfort of a new postoperative individual, for example, is performing a focus assessment. These assessments are ongoing during the hospitalization.
INTERACTIVE EXERCISE 5.1 Mr. Gene, 61, is admitted for neurologic surgery. He has a history of peripheral vascular disease and Parkinson’s disease. The nurse’s initial assessment reveals the following under the functional health pattern Activity-Exercise and physical assessment of musculoskeletal function:ACTIVITY-EXERCISE PATTERN
SELF-CARE ABILITY:
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ASSISTIVE DEVICES: _____ None _____ Crutches _____ bedside commode [check mark] Walker X _____ Cane _____ Splint/brace _____ Wheelchair _____ Other _____
PHYSICAL ASSESSMENT
MUSCULAR-SKELETAL
Range of motion: [check mark] Full _____ Other __________________________________________
Balance and gait: _____ Steady [check mark] Unsteady
Hand grasps: [check mark] Equal [check mark] Strong _____ Weakness/paralysis (_____ Right _____ Left)
Leg muscles: _____ Equal _____ Strong [check mark] Weakness/paralysis ([check mark] Right X Left)
Examine the above assessment data. What data are significant?
The nurse can also perform a focus assessment during the initial interview if collected data suggest a possible problem that the nurse must validate or rule out. For example, during the baseline interview, the individual reports a problem with occasional constipation. The nurse then collects additional data (focus assessment) to confirm a problem or risk nursing diagnosis or rule out a constipation problem.
Planning: The Care Planning Process
Carp’s CuesCare plans serve a function, which is to communicate to the nurse who is caring for an individual the care needed to achieve positive outcomes and transition. If an individual has had a total hip replacement, this care can be predetermined in an electronic or paper care plan. It is unnecessary for a nurse to create a so called “individualized care plan.” What is necessary for the nurse to determine whether all the elements on the electronic or paper care plan are relevant to her or his individual. If the individual also has Diabetes Mellitus, then Risk for Complications of Hypo/Hyperglycemia must be added to the problem list.
Today, the methods used to communicate individual care between nurses and other caregivers vary. Critical pathways, electronic health systems, and preprinted standardized care plans have replaced handwritten care plans. Later in this chapter, types of care planning systems will be discussed.
Critical pathways, electronic health systems, and preprinted standardized care plans reflect the expected diagnoses and associated goals and interventions commonly related to an individual’s medical or surgical problem. This type of system frees nurses from the repetitive, unnecessary writing of routine care. The care outlined on the standardized plan or critical pathway should represent the responsible care to which the individual is entitled.
Before discussing the care planning process, the nurse must identify the type, as well as the duration, of needed care. People receiving nursing care for less than 8 hours, as in the emergency department, short-stay surgery, or recovery room, have a specific medical diagnosis or need a specific procedure. Nursing care is derived from standardized plans or protocols. In nonacute settings such as long-term care, community or home care, or assisted-living and rehabilitation units, nurses will supplement predetermined standardized plans with personalized care plans. The longer the nurse-individual relationship, the more data there is available to individualize the plan. Care plans represent the planning, not the delivery, of care. This planning phase of the nursing process has three components:
Establishing a priority set of diagnoses
Designating client goals and collaborative goals
Prescribing nursing interventions
Establishing a Priority Set of Diagnoses
Realistically, a nurse cannot address all, or even most, of the nursing diagnoses and collaborative problems that can apply to an individual, family, or community during an encounter or length of stay. By identifying a priority set—a group of nursing diagnoses and collaborative problems that take precedence over others—the nurse can best direct resources toward goal achievement. Differentiating priority diagnoses from nonpriority diagnoses is crucial.
Priority diagnoses are those nursing diagnoses or collaborative problems that, if not managed now, will deter progress to achieve outcomes or will negatively affect functional status.
Nonpriority diagnoses are those nursing diagnoses or collaborative problems for which treatment can be delayed without compromising present functional status.
Carp’s CuesNumbering the diagnoses on a problem list does not indicate priority; rather, it shows the order in which the nurse entered them on the list. Assigning absolute priority to nursing diagnoses or collaborative problems can create the false assumption that number one is automatically the first priority. In the clinical setting, priorities can shift rapidly as the individual’s condition changes. For this reason, the nurse must view the entire problem list as the priority set, with priorities shifting within the list periodically.
Priority Diagnoses
In an acute care setting, the individual enters the hospital for a specific purpose, such as surgery or other treatments for acute illness. In such a situation, certain nursing diagnoses or collaborative problems requiring specific nursing interventions often apply, which can be found on the standardized plan (electronic, paper). Carpenito (1995) uses the term diagnostic cluster to describe such a group; this cluster can appear in a critical pathway or standardized plan of care. For example, Box 5.2 is a diagnostic cluster for a person having abdominal surgery.
All of these diagnoses in the diagnostic cluster are priority diagnoses. When should additional diagnoses (other than in the diagnostic cluster) be added to the problem list or care plan?
Are there additional collaborative problems associated with coexisting medical conditions that require monitoring (e.g., hypoglycemia)?
Are there additional nursing diagnoses that, if not managed or prevented now, will deter recovery or affect the individual’s functional status (e.g., High Risk for Constipation)?
What problems does the individual perceive as priority?
Additional nursing diagnoses and/or collaborative problems can be added to an electronic care plan or written on the problem/care plan.
Box 5.2 DIAGNOSTIC CLUSTER
Preoperative
Nursing Diagnosis
Anxiety/Fear related to surgical experience, loss of control, unpredictable outcome, and insufficient knowledge of preoperative routines, postoperative exercises and activities, and postoperative changes and sensations
Postoperative
Collaborative Problems
RC of Hemorrhage
RC of Hypovolemia/Shock
RC of Evisceration/Dehiscence
RC of Paralytic Ileus
RC of Infection (Peritonitis)
RC of Urinary Retention
RC of Thrombophlebitis
Nursing Diagnoses
Risk for Ineffective Respiratory Function related to immobility secondary to post anesthesia sedation and pain
Risk for Infection related to a site for organism invasion secondary to surgery
Acute Pain related to surgical interruption of body structures, flatus, and immobility
Risk for Imbalanced Nutrition: Less Than Body Requirements related to increased protein and vitamin requirements for wound healing and decreased intake secondary to pain, nausea, vomiting, and diet restrictions
Risk for Constipation related to decreased peristalsis secondary to immobility and the effects of anesthesia and opioids
Activity Intolerance related to pain and weakness secondary to anesthesia, tissue hypoxia, and insufficient fluid and nutrient intake
Risk for Self-Health Management related to insufficient knowledge of care of operative site, restrictions (diet, activity), medications, signs and symptoms of complications, and follow-up care.
INTERACTIVE EXERCISE 5.2 Mr. Stanley, 76, is admitted for emergency gastric surgery for repair of a bleeding ulcer. He also has diabetes mellitus and peripheral vascular disease. After completing a functional assessment, the nurse identifies the following:
Compromised gait
Occasional incontinence when walking to the bathroom
Wife complaining of many caregiver responsibilities and an unmotivated husband
Examine the data above and begin to formulate nursing diagnoses and collaborative problems that need nursing interventions. Refer to the three questions above to assist with this analysis and to determine whether Mr. Stanley and his family have other diagnoses that require nursing interventions. Mr. Stanley’s priority list (diagnostic cluster) follows.
From Postoperative Standard of Care (Diagnostic Cluster):
RC of Urinary Retention
RC of Hemorrhage
RC of Hypovolemia/Shock
RC of Pneumonia (stasis)
RC of Peritonitis
RC of Thrombophlebitis
RC of Paralytic ileus
Risk for Infection related to destruction of first line of defense against bacterial invasion
Risk for Impaired Respiratory Function related to postanesthesia state, postoperative immobility, and pain
Impaired Physical Mobility related to pain and weakness secondary to anesthesia, tissue hypoxia, and insufficient fluids/nutrients
Risk for Imbalanced Nutrition: Less Than Body Requirements related to increased protein/vitamin requirements for wound healing and decreased intake secondary to pain, nausea, vomiting, and diet restrictions
Risk for Compromised Human Dignity related to multiple factors associated with hospitalization (standard to all hospitalized persons)
Risk for Ineffective Self-Health Management related to insufficient knowledge of home care, incisional care, signs and symptoms of complications, activity restriction, and follow-up care
From Medical History of Diabetes Mellitus:
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