Nursing Diagnosis for Acute Pain

NANDA Nursing Diagnosis for Acute Pain Related factors R/T trauma, injuring agents (biological, chemical, physical, psychological) 

Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months. If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain. 

Definition Nursing Diagnosis for Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months 

Nursing Outcomes Client Will: Report pain is relieved / controlled. Follow prescribed pharmacological regimen. Verbalize methods that provide relief. Demonstrate use of relaxation skills and diversion activities as indicated for individual situation. 

Nursing Priority Nursing Diagnosis for Acute Pain To assess etiology/precipitating contributory factors: evaluate client’s response to pain: assist client to explore methods for alleviation/control of pain 

Sample Clinical Applications using Nursing Diagnosis for Acute Pain: Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia

Continue

Nursing Assessment

Nursing health Assessment part of nursing process: Assessment, Nursing diagnosis, Planning, Implementation, Evaluation. Nursing health Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The Nursing assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Nursing Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient 

The purpose of Nursing health assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems 

Data from nursing assessment can be classified as subjective and objective. 

Subjective data not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. patients health history is an example of subjective data. 

Objective data are overt and measurable. Objective data are referred to as signs. Nursing physical examination and diagnostic studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources come from anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective. 

Assessment Process, Nursing health Assessment is an ongoing process. Every patient encounter provides you with an opportunity for assessment. 

Types of Assessment Nursing Assessments can be comprehensive or focused. A comprehensive assessment is usually the initial assessment. It is very thorough and includes a detailed health history and physical examination: 

comprehensive assessment examines the patient’s overall health status. 

focused assessment is problem oriented and may be the initial assessment or an ongoing assessment. focused assessment is frequently performed on an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments. Even when a focused assessment is performed, it is important to look at the entire picture. A problem in one system will affect or be affected by every other system so scan your patient from head to toe and note any changes in other systems. Look for clues or pertinent data that will help you formulate your diagnosis.

Nursing Assessment and Medical Assessment 

Medical and nursing assessments should not contradict, each other in promoting the patient’s health and wellness. Often, data obtained through the nursing assessment contribute to the identification of medical problems. By working together in a collaborative relationship, nursing and medicine ensure the best possible care for patients 

Health Assessment is not unique to nursing. It is also an integral part of medical practice. The assessment process Could be same for nursing and medical practice, but the outcomes different. The goal of medical practice is to diagnose and treat disease. and The goal of nursing process is to diagnose and treat human responses to actual or potential health problems. Nursing assessment focuses on physiological and psychological responses and the psychosocial, cultural, developmental, and spiritual dimensions. It identifies patients’ responses to health problems as well as their strengths. Optimal level of wellness is the Nursing’s aim.

Methods of Collecting Data 

• Interviews 
• Observation 
• Physical Assessment

Continue

Nursing Assessment Video

Nursing Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnosis, and develop a Nursing Care Plans. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient. 

The purpose of assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems

Continue

Nursing Diagnosis and 11 Gordon's Functional Health Patterns

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function: 

11 Gordon’s Functional Health Patterns 

1. Health Perception Health Management Pattern 
2. Nutritional Metabolic Pattern 
3. Elimination Pattern 
4. Activity Exercise Pattern 
5. Sleep Rest Pattern 
6. Cognitive-Perceptual Pattern 
7. Self-Perception-Self-Concept Pattern 
8. Role-Relationship Pattern 
9. Sexuality-Reproductive 
10. Coping-Stress Tolerance Pattern 
11. Value-Belief Pattern 

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use. 

• Contamination
• Disturbed energy field 
• Effective therapeutic regimen management
• Health-seeking behaviors (specify) 
• Ineffective community therapeutic regimen management 
• Ineffective family therapeutic regimen management 
• Ineffective health maintenance 
• Ineffective protection 
• Ineffective therapeutic regimen management 
• Noncompliance (ineffective Adherence) 
• Readiness for enhanced immunization status 
• Readiness for enhanced therapeutic regimen management 
• Risk for contamination 
• Risk for infection 
• Risk for injury 
• Risk for perioperative positioning injury 
• Risk for poisoning 
• Risk for sudden infant death syndrome 
• Risk for suffocation 
• Risk for trauma 
• Risk-prone health behavior 

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. 

• Adult failure to thrive 
• Deficient fluid volume: [isotonic] 
• Deficient fluid volume: hyper/hypotonic 
• Effective breastfeeding [Learning Need] 
• Excess fluid volume 
• Hyperthermia 
• Hypothermia 
• Imbalanced nutrition: more than body requirements 
• Imbalanced nutrition: less than body requirements 
• Imbalanced nutrition: risk for more than body requirements 
• Impaired dentition 
• Impaired oral mucous membrane 
• Impaired skin integrity 
• Impaired swallowing 
• Impaired tissue integrity 
• Ineffective breastfeeding 
• Ineffective infant feeding pattern 
• Ineffective thermoregulation 
• Interrupted breastfeeding 
• Latex allergy response 
• Nausea 
• Readiness for enhanced fluid balance 
• Readiness for enhanced nutrition 
• Risk for aspiration 
• Risk for deficient fluid volume 
• Risk for imbalanced fluid volume 
• Risk for imbalanced body temperature 
• Risk for impaired liver function 
• Risk for impaired skin integrity 
• Risk for latex allergy response 
• Risk for unstable blood glucose 

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin). 

• Bowel incontinence 
• Constipation 
• Diarrhea 
• Functional urinary incontinence 
• Impaired urinary elimination 
• Overflow urinary incontinence 
• Perceived constipation 
• Readiness for enhanced urinary elimination
• Reflex urinary incontinence 
• Risk for constipation 
• Risk for urge urinary incontinence 
• Stress urinary incontinence 
• Total urinary incontinence 
• Urge urinary incontinence 
• [acute/chronic] Urinary retention 

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. 

• Activity intolerance 
• Autonomic dysreflexia 
• Decreased cardiac output 
• Decreased intracranial adaptive capacity 
• Deficient diversonal activity 
• Delayed growth and development 
• Delayed surgical recovery 
• Disorganized infant behavior 
• Dysfunctional ventilatory weaning response 
• Fatigue 
• Impaired spontaneous ventilation 
• Impaired bed mobility 
• Impaired gas exchange 
• Impaired home maintenance 
• Impaired physical mobility 
• Impaired transfer ability 
• Impaired walking 
• Impaired wheelchair mobility 
• Ineffective airway clearance 
• Ineffective breathing pattern 
• Ineffective tissue perfusion 
• Readiness for enhanced organized infant behavior 
• Readiness for enhanced self care 
• Risk for delayed development 
• Risk for disorganized infant behavior 
• Risk for disproportionate growth 
• Risk for activity intolerance 
• Risk for autonomic dysreflexia 
• Risk for disuse syndrome 
• Sedentary lifestyle 
• Self-care deficit 
• Wandering 

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input. 

• Acute confusion 
• Acute pain 
• Chronic confusion 
• Chronic pain 
• Decisional conflict 
• Deficient knowledge 
• Disturbed sensory perception 
• Disturbed thought processes 
• Impaired environmental interpretation syndrome 
• Impaired memory 
• Readiness for enhanced comfort 
• Readiness for enhanced decision making 
• Readiness for enhanced knowledge 
• Risk for acute confusion 
• Unilateral neglect 

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation. 

• Insomnia 
• Readiness for enhanced sleep 
• Sleep deprivation 

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth. 

• Anxiety 
• disturbed Body image 
• Chronic low self-esteem 
• Death anxiety 
• Disturbed personal identity 
• Fear 
• Hopelessness 
• Powerlessness 
• Readiness for enhanced hope 
• Readiness for enhanced power 
• Readiness for enhanced self-concept 
• Risk for compromised human dignity 
• Risk for loneliness 
• Risk for powerlessness 
• Risk for situational low self-esteem 
• Risk for [/actual] other-directed violence Risk for [actual/] self-directed violence 
• Situational low self-esteem 

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships. 

• Caregiver role strain 
• Chronic sorrow 
• Complicated grieving 
• Dysfunctional family processes: alcoholism (substance abuse) 
• Grieving 
• Impaired social interaction 
• Impaired verbal communication 
• Ineffective role performance 
• Interrupted family processes 
• Parental role conflict 
• Readiness for enhanced communication 
• Readiness for enhanced family processes 
• Readiness for enhanced parenting 
• Relocation stress syndrome 
• Risk for caregiver role strain 
• Risk for complicated grieving 
• Risk for impaired parent/infant/child attachment 
• Risk for relocation stress syndrome 
• Social isolation 

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions. 

• Ineffective sexuality patterns 
• Rape-trauma syndrome 
• Sexual dysfunction 

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies. 

• Compromised family coping 
• Defensive coping 
• Disabled family coping 
• Impaired adjustment 
• Ineffective community coping 
• Ineffective coping 
• Ineffective denial Post-trauma syndrome 
• Readiness for enhanced community coping 
• Readiness for enhanced coping 
• Readiness for enhanced family coping 
• Risk for self-mutilation 
• Risk for suicide 
• Risk for post-trauma syndrome 
• Self-mutilation 
• Stress overload 

Value-Belief Pattern it’s focused on the person’s values and beliefs. 

• Impaired religiosity 
• Moral distress 
• Readiness for enhanced religiosity 
• Readiness for enhanced spiritual well-being 
• Risk for impaired religiosity 
• Risk for spiritual distress Spiritual distress

Continue

Pain Nursing Management

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Merskey & Bogduk). Pain is “an unpleasant sensory and emotional experience associatedwith actual or potential damage or described in terms of such damage; ef pain is always subjective” (International Association for the Study of Pain, 1979). Pain is categorized according to its duration, location, and etiology. Three basic categories of pain are generally recognized: acute pain, chronic (nonmalignant) pain, and cancer-related pain. 

One view explain that pain is a sense similar to vision or hearing, a component of the sensory that warns us of impending damage, gives accurate information to the brain about injuries, and helps us to heal. The inclusion of pain in The Senses: a Comprehensive Reference, alongside vision, hearing, or olfaction shows that this view is persuasive. But there has always been an alternative interpretation of pain. Pain is seen as a trigger of emotional states, a behavioral drive, and a highly effective learning tool. Aristotle, who was the originator of this view, made it very clear: there are only five senses – vision, hearing, touch, taste, and smell. Pain and pleasure are not senses but passions of the soul. 

Acute Pain 

For purposes of definition, acute pain can be described as lasting from seconds to 6 months. However, the 6-month time frame has been criticized (Brook) as inaccurate since many acute injuries heal within a few weeks and most heal by 6 weeks. Usually of recent onset and commonly associated with a specific injury, acute pain indicates that damage or injury has occurred. Pain is significant in that it draws attention to its existence and teaches the person to avoid similar potentially painful situations. If no lasting damage occurs and no systemic disease exists, acute pain usually decreases along with healing. 

In a situation where healing is expected in 3 weeks and the patient continues to suffer pain, it should be considered chronic and treated with interventions used for chronic pain. Waiting for the full 6-month time frame in this example could cause needless suffering. Unrelieved acute pain can affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems. The stress response (neuroendocrine response to stress) that occurs with trauma also occurs with other causes of severe pain. The stress response generally consists of increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids. 

Chronic (nonmalignant) Pain 

Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain. An episode of pain may assume the characteristics of chronic pain before 6 months have elapsed, or some types of pain may remain primarily acute in nature for longer than 6 months. 

Suppression of the immune function associated with chronic pain may promote tumor growth. Also, chronic pain often results in depression and disability. Although health care providers express concern about the large quantities of opioid medications required to relieve chronic pain in some patients, it is safe to use large doses of these medications to control progressive chronic pain. 

Cancer-Related Pain 

Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that after fear of dying, it is the second most common fear of newly diagnosed cancer patients (Lema). 

Pain in the patient suffering from cancer can be directly associated with the cancer (eg, bony infiltration with tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not associated with the cancer (eg, trauma). Most pain associated with cancer, however, is a direct result of tumor involvement. 

Pathophysiology of Pain 

The sensory experience of pain depends on the interaction between the nervous system and the environment. The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems. 

Peripheral Nervous System 

A number of algogenic (pain-causing) substances that affect the sensitivity of nociceptors are released into the extracellular tissue as a result of tissue damage. Histamine, bradykinin, acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain. The transmission of pain is also referred to as nociception. Prostaglandins are chemical substances thought to increase the sensitivity of pain receptors by enhancing the painprovoking effect of bradykinin. These chemical mediators also cause vasodilation and increased vascular permeability, resulting in redness, warmth, and swelling of the injured area. 

Once nociception is initiated, the nociceptive action potentials are transmitted by the peripheral nervous system (Porth, 2002). The first-order neurons travel from the periphery (skin, cornea, visceral organs) to the spinal cord via the dorsal horn. There are two main types of fibers involved in the transmission of nociception. Smaller, myelinated Ad (A delta) fibers transmit nociception rapidly, which produces the initial “fast pain.” Type C fibers are larger, unmyelinated fibers that transmit what is called second pain. This type of pain has dull, aching, or burning qualities that last longer than the initial fast pain. The type and concentration of nerve fibers to transmit pain vary by tissue type. 

The same noxious stimulus produces hyperalgesia, and the person reports greater pain than was felt at the first stimulus. For this reason, it is important to treat patients with analgesic agents when they first feel the pain. Patients require less medication and experience more effective pain relief if analgesia is administered before the patient becomes sensitized to the pain. Chemicals that reduce or inhibit the transmission or perception of pain include endorphins and enkephalins. These morphinelike neurotransmitters are endogenous (produced by the body). Endorphins and enkephalins are found in heavy concentrations in the central nervous system, particularly the spinal and medullary dorsal horn, the periaqueductal gray matter, hypothalamus, and amygdala. 

Central Nervous System 

After tissue injury occurs, nociception (the neurologic transmission of pain impulses) to the spinal cord via the Ad and C fibers continues. The fibers enter the dorsal horn, which is divided into laminae based on cell type. The laminae II cell type is commonly referred to as the substantia gelatinosa. In the substantia gelatinosa are projections that relay nociception to other parts of the spinal cord. 

Nociception continues from the spinal cord to the reticular formation, thalamus, limbic system, and cerebral cortex. Here nociception is localized and its characteristics become apparent to the person, including the intensity. The involvement of the reticular formation, limbic, and reticular activating systems is responsible for the individual variations in the perception of noxious stimuli. Individuals may report the same stimulus differently based on their anxiety, past experiences, and expectations. This is a result of the conscious perception of pain. 

The interconnections between the descending neuronal system and the ascending sensory tract are called inhibitory interneuronal fibers. These fibers contain enkephalin and are primarily activated through the activity of non-nociceptor peripheral fibers (fibers that normally do not transmit painful or noxious stimuli) in the same receptor field as the pain receptor, and descending fibers, grouped together in a system called descending control. 

The enkephalins and endorphins are thought to inhibit pain impulses by stimulating the inhibitory interneuronal fibers, which in turn reduce the transmission of noxious impulses via the ascending system (Puig & Montes). 

The noxious impulses are influenced by a “gating mechanism.” Melzack and Wall proposed that stimulation of the large-diameter fibers inhibits the transmission of pain, thus “closing the gate.” Conversely, when smaller fibers are stimulated, the gate is opened. The gating mechanism is influenced by nerve impulses that descend from the brain. 

Factors Influencing the Pain Response 

Pain experience is influenced by a number of factors, including; past experiences with pain, anxiety, culture, age, gender, and expectations about pain relief. These factors may increase or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain. 

Pharmacologic Interventions: 

• Approaches for Using Analgesic Agents
• Local Anesthetic Agents 
• Opioid Analgesic Agents 
• Nonsteroidal Anti-inflammatory Drugs 
• Tricyclic Antidepressant Agents and Anticonvulsant Medications 
• Routes of Administration; Parenteral, Oral, Rectal,Transdermal, Transmucosal, Intraspinal and Epidural 

Nonpharmacologic Interventions : 

• Cutaneous Stimulation and Massage 
• Ice and Heat Therapies 
• Transcutaneous Electrical Nerve Stimulation 
• Distraction 
• Relaxation Techniques 
• Guided Imagery 
• Hypnosis 

Nursing Management of Pain 

Nursing Assessment of Pain 

The factors to consider in a complete pain assessment are the intensity, timing, location, quality, personal meaning, aggravating and alleviating factors, and pain behaviors. The pain assessment begins by observing the patient carefully, noting the patient’s overall posture and presence or absence of overt pain behaviors and asking the person to describe, in his or her own words, the specifics of the pain. The words used to describe the pain may point toward the etiology. 

Instruments for assessing the perception of pain: Pain Intensity Scales 

Simple Descriptive Pain Intensity Scale 

• 0: No pain 
• 1: Mild pain 
• 2: Moderate pain 
• 3: Severe pain 
• 4: Very severe pain 
• 5: Worst possible pain

0 – 10 Numeric Pain Intensity Scale 

Visual Analog Scale (VAS) 

1. No pain 
2. Pain as bad as it could possibly be 

Nurses Role in Pain Management: 

• Identifying Goals for Pain nursing management 
• Establishing the Nurse–Patient Relationship and Teaching 
• Providing Physical Care 
• Managing Anxiety Related to Pain

NURSING DIAGNOSIS	OUTCOME	NURSING INTERVENTIONS	EVALUATION
Pain	• Reports relief that pain is accepted as real and that he or she will receive assistance in pain relief • Reports lower intensity of pain and discomfort after interventions implemented • Reports less disruption from pain and discomfort after use of intervention • Uses pain medication as prescribed • Identifies effective pain relief strategies • Demonstrates use of new strategies to relieve pain and reports their effectiveness • Experiences minimal side effects of analgesia without interruption to treat side effects • Increases interactions with family and friends	1. Reassure patient that you know pain is real and will assist him or her in dealing with it. 2. Use pain assessment scale to identify intensity of pain. 3. Assess and record pain and its characteristics: location, quality, frequency, and duration. 4. Administer balanced analgesics as prescribed to promote optimal pain relief. 5. Read minister pain assessment scale. 6. Document severity of patient’s pain on chart. 7. Obtain additional prescriptions as needed. 8. Identify and encourage patient to use strategies that have been successful with previous pain. 9. Teach patient additional strategies to relieve pain and discomfort: distraction, relaxation, cutaneous stimulation, etc. 10. Instruct patient and family about potential side effects of analgesics and their prevention and management.	1. Achieves pain relief a. Rates pain at a lower intensity (on a scale of 0 to 10) after intervention b. Rates pain at a lower intensity for longer periods 2. Patient or family administers prescribed analgesic medications correctly a. States correct dose of medication b. Administers correct dose using correct procedure c. Identifies side effects of medication d. Describes actions taken to prevent or correct side effects 3. Uses nonpharmacologic pain strategies as recommended a. Reports practice of nonpharmacologic strategies b. Describes expected outcomes of nonpharmacologic strategies 4. Reports minimal effects of pain and minimal side effects of interventions a. Participates in activities important to recovery (eg, drinking fluids, coughing, ambulating) b. Participates in activities important to self and to family (eg, family activities, interpersonal relationships, parenting, social interaction, recreation, work) c. Reports adequate sleep and absence of fatigue and constipation

Continue

Nursing Process

Nursing Process 

The nursing process is a problem solving process consists of elements assessment, planning, implementation, and evaluation. Many a priori assumptions have been identified and studied concern the nursing process approach to patient care that includes decision making as a characteristic of the process. These assumptions are that the nursing process is a holistic, scientific, individualized, problem-solving approach with an emphasis on diagnosing. 

Shore (1988) described the nursing process as “combining the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method.” 

The nursing process is used by nurses every day to help patients improve their health and assist doctors in treating patients. Nursing requires the use of this process day in and day out. The process is based on theories and practices taught in nursing school. It is a form of problem solving. The nursing process is made up of a series of stages that are used to achieve the objective – the health improvement of the patient. The nursing process can stop at any stage as deemed necessary or can repeat as needed. This process is inclusive of physical health as well as the emotional aspects of patient health. 

Nursing knowledge is used throughout the process to formulate changes in approach to the patient’s changing condition. During the process, nurses use this knowledge to identify problems and changes that are occurring to the patient. Caring for a patient requires the nurse to communicate with the patient to determine how they are feeling and gain the results of implemented care from the patient. 

Phases of the nursing process include:

• Assessment of the patient’s needs 
• Diagnosis of human response needs that nurses can deal with 
• Planning of patient’s care 
• Implementation of care 
• Evaluation of the success of the implemented care 

Nursing Process diagram Nursing Process diagram

Nursing Assessment

Assessment is widely recognized as the first step in the nursing process. Nurses use assessment to determine patients actual and potential needs, the assistance patients require, and the desired outcomes to evaluate the care provided. Process includes using communication and physical assessment skills to establish a relationship and to gather needed information. The important content will vary with the patient but generally includes physical assessment, other diagnostic data, and assessment of the meaning of the health experience, quality of life, symptoms, and cultural factors that may affect health. Communication is essential in assessment, and is both the means for nurses and patients to influence each other and the process that leads to therapeutic and supportive influences on patients’ health. Patients’ successful communication of their needs to nurses is vital to individualized care. Individualized patient care has been found to produce more favorable outcomes and to reduce the cost of health care (Attree, 2001). 

Physical assessment skills are routinely included in nursing curricula. They include (a) a general survey of patients’ appearance and behaviors; (b) assessment of vital signs, temperature, pulse, respiration rates, and blood pressure; (c) assessment of height and weight; and (d) physical examination to assess patients’ structures, organs, and body systems. Physical assessment can be complete, assessing all of the persons’ organs and body systems, or modified to focus only on areas suggested by the persons’ health history or symptoms. Effective assessment is the essential basis for providing effective nursing care. 

Nursing Diagnosis

Nursing diagnosis is the second step in the nursing process. It is the judgment made about the meaning of a cluster of signs and symptoms (defining characteristics) found in the nursing assessment of the patient. Without a nursing diagnosis, a nurse is left rudderless to determine what goals should be set for the patient, what outcomes are desired, or what interventions to choose to meet the goals and resolve the nursing diagnosis. 

NANDA, International (2003) defines a nursing diagnosis as a “clinical judgment about individual, family, or community responses to actual or potential health conditions/problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”. There are three types of nursing diagnoses: actual, risk, and wellness. 

An actual nursing diagnosis is a human response to health conditions/problems/life processes that exist in individuals, families, or communities. An actual nursing diagnosis is “supported by defining characteristics (manifestations, signs, symptoms) that cluster in patterns of related cues or inferences” (NANDA). 

A risk nursing diagnosis describes a human response that may develop in vulnerable individuals, families, or communities. It is “supported by risk factors that contribute to increased vulnerability” (NANDA). 

A wellness nursing diagnosis describes a human response that indicates a readiness for enhancement in levels of wellness in the individual, family, or community (NANDA). 

The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining characteristics (or cues) as appropriate. 

Planning

Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care. 

An intervention is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (Dochterman & Bulechek, 2004). 

The Nursing Interventions Classification (NIC) is a comprehensive standardized classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice care, to primary care) and all specialties (from critical care to ambulatory care and long-term care). NIC is recognized by the American Nurses Association (ANA).

Nursing Outcomes Classification
The definition of a nursing-sensitive patient outcome is an individual, family or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention(s). Each outcome has an associated group of indicators that are used to determine patient status in relation to the outcome. (Moorhead, Johnson, & Maas, 2004).
The Nursing Outcomes Classification (NOC) is a comprehensive, research-based standard ized classification of patient/client, family, and community outcomes developed to evaluate the effects of nursing interventions across the continuum of care. An outcome is stated as a variable concept representing an individual, family, or community condition that is measurable along a continuum and responsive to nursing interventions. The outcomes in the classification are grouped into seven domains: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge and Behavior, Perceived Health, Family Health, and Community Health. Within each domain are several classes that contain the outcomes specific to that class. The Nursing Outcomes Classification is the most comprehensive classification of nursing-sensitive patient outcomes currently available for nurses to use with individuals, families, and communities across the care continuum and in specialty practice.

Implementation

Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Legal and ethical concerns related to interventions also must be considered. Before implementing the interventions in Nursing care Plans, the nurse needs to understand the reason for doing each Nursing intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are 

1. Consistent with the established plan of care
2. Implemented in a safe and appropriate manner, 
3. Evaluated for effectiveness, and 
4. Documented in a timely manner. 

Evaluation

Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s health record. 

Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine:

• appropriateness of nursing actions
• the need to revise interventions
• development of new client needs
• the need for referral to other resources, and
• the need to rearrange priorities to meet changing demands of care. 

To effectively use the nursing process, the nurse must possess, and be able to apply, certain skills. Particularly important is a thorough knowledge of science and theory, as applied not only in nursing but also in other related disciplines, such as medicine and psychology.

Continue

Nursing Theory and Nursing Practice

Florence Nightingale taught us that nursing theories describe and explain what is and what is not nursing (Nightingale, 1859/1992). Today knowledge development in nursing is taking place on several fronts, with a variety of scholarly approaches contributing to advances in the discipline. 

Nursing practice increasingly takes place in interdisciplinary community settings, and the form of nursing in acute care settings is rapidly changing. Various paradigms and value systems that express perspectives held by several Groups within the discipline ground the knowledge and practice of nursing. Because the language of nursing is continually being formed and distinguished, it often seems confusing, as does any language that is new to the ears and eyes. Nurses, who have active commitments to the work of the discipline, whether in nursing practice, research, education, or administration, are essential for the continuing development of nursing theory. This chapter offers an approach to understanding nursing theory within three contexts: nursing knowledge, nursing as a discipline, and nursing as a professional practice. 

Definitions of Nursing Theory

Nursing theory is a conceptualization of some aspect of reality (invented or discovered) that pertains to nursing. The conceptualization is articulated for the purpose of describing, explaining, predicting or prescribing nursing care. (Meleis, 1997). Nursing theory is an inductively and/or deductively derived collage of coherent, creative, and focused nursing phenomena that frame, give meaning to, and help explain specific and selective aspects of nursing research and practice. (Silva, 1997) 

Types of Nursing Theory 

Barnum (1998) divides theories into those that describe and those that explain nursing phenomena. Types of nursing theories generally include grand theory, middle-range theory, and practice theory. These will be described below:

Grand Nursing Theory 

Grand theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing. Although there is debate about which nursing theories are grand in scope, the following are usually considered to be at this level: Leininger’s Theory of Culture Care Diversity and Universality, Newman’s Theory of Health as Expanding Consciousness, Rogers’ Science of Unitary Human Beings, Orem’s Self-Care Deficit Nursing Theory, and Parse’s Theory of Human Becoming. 

Middle range Nursing Theory

Nursing scholars proposed using this level of theory because of the difficulty in testing grand theory (Jacox, 1974). Middle-range theories are narrower in scope than grand theories and offer an effective bridge between grand theories and nursing practice. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies. The methods used for developing middle range theories are many and represent some of the most exciting work being published in nursing today. Many of these new theories are built on content of related disciplines and brought into nursing practice and research (Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, 1997; Eakes, Burke, & Hainsworth, 1998). The literature also offers middle-range nursing theories that are directly related to grand theories of nursing (Olson & Hanchett, 1997; Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998). Reports of nursing theory developed at this level include implications for instrument development, theory testing through research, and nursing practice strategies. 

Nursing Practice Theory 

Nursing practice theory has the most limited scope and level of abstraction and is developed for use within a specific range of nursing situations. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. At the same time, nursing questions, actions, and procedures may be described or developed as nursing practice theories. Benner (1984) demonstrated that dialogue with expert nurses in practice is fruitful for discovery and development of practice theory. Research findings on various nursing problems offer data to develop nursing practice theories as nursing engages in research-based development of theory and practice. Nursing practice theory has been articulated using multiple ways of knowing through reflective practice (Johns & Freshwater, 1998). The process includes quiet reflection on practice, remembering and noting features of nursing situations, attending to one’s own feelings, reevaluating the experience, and integrating new knowing with other experience (Gray & Forsstrom, 1991). 

Nursing Is a Professional Practice 

The major reason for structuring and advancing nursing knowledge is for the sake of nursing practice. The primary purpose of nursing theories is to further the development and understanding of nursing practice. Theory-based research is needed in order to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost-effective (Gioiella, 1996). Because nursing theory exists to improve practice, the test of nursing theory is a test of its usefulness in professional practice (Fitzpatrick, 1997). From the viewpoint of practice, Gray and Forsstrom (1991) suggest that through use of theory, nurses find different ways of looking at and assessing phenomena, have rationale for their practice and criteria for evaluating outcomes. Development of nursing knowledge is a result of theory-based nursing inquiry. The circle continues as data, conclusions, and recommendations of nursing research are evaluated and developed for use in practice. Nursing theory must be seen as practical and useful to practice and the insights of practice must in turn continue to enrich nursing theory.

Continue