Planning Care With Nursing Diagnosis

Planning Care With Nursing Diagnosis

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.

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.

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

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.

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.

Dec 6, 2019 | Posted by in NURSING | Comments Off on Planning Care With Nursing Diagnosis
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