The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [44]
Cues to determine if the condition or response described by the diagnosis is present for the patient/client. The patient states they have pain.
Pain assessment: numerical rating scale (0–10) pain score >2.
Evidence of noxious stimuli, e.g. surgery, trauma.
Guarding of injury.
Reduction in patient’s normal mobility.
Refer to NANDA-I (2009) for a complete list of defining characteristics.
Related factors Injury agents (biological, chemical, physical, psychological).
Factors that contribute to the diagnosis being present. Individualized to each patient or client.
(Adapted from NANDA-I 2009)
Most significantly, the use of common language enables nurses to clearly and consistently express what they do for patients and why, making the contribution of different nursing roles clearly visible within the multidisciplinary care pathway (Delaney 2001, Elfrink et al. 2001, Grobe 1996, Moen et al. 1999). Secondly, an increasingly important reason for trying to structure nursing terms in a systematic way has been the need to create and analyse nursing information in a meaningful way for electronic care records (Clark 1999, Westbrook 2000). The term ‘nursing diagnosis’ is not commonly used within the UK as no definitive classifications or common languages are in general use; however, for the aforementioned reasons, the adaptation and implementation of standard nursing languages within clinical practice in the UK are being explored (Chambers 1998, Lyte and Jones 2004, Westbrook 2000).
Planning and implementing care
Nursing diagnoses provide a focus for planning and implementing effective and evidence-based care. This process consists of identifying nursing-sensitive patient outcomes and determining appropriate interventions that will enable the individual to reach their desired outcome. However, while nurses may gather valuable information through the assessment process, it is often the case that very little of this is translated into the documentation (Ford and Walsh 1994), resulting in the standard of care bearing little relationship to the written documentation (Ballard 2006, Ford and Walsh 1994). Therefore, when planning care, it is vital:
to determine the immediate priorities and recognize whether patient problems require nursing care or whether a referral should be made to someone else
to identify the anticipated outcome for the patient, noting what the patient will be able to do and in what time frame. The use of ‘measurable’ verbs that describe patient behaviour or what the patient says facilitates the evaluation of patient outcomes (see Box 2.11)
to determine the nursing interventions, that is, what nursing actions will prevent or manage the patient’s problems so that the patient’s outcomes may be achieved
to record the care plan for the patient which may be written or individualized from a standardized/core care plan or a computerized care plan.
(Alfaro-Lefevre 2002, Shaw 1998, White 2003)
Box 2.11 Examples of measurable and non-measurable verbs for use in outcome statements
Measurable verbs (use these to be specific)
State; verbalize; communicate; list; describe; identify
Demonstrate; perform
Will lose; will gain; has an absence of
Walk; stand; sit
Non-measurable verbs (do not use)
Know
Understand
Think
Feel
(Alfaro-Lefevre 2002, pp.134–135)
Outcomes should be patient focused and realistic, stating how the outcomes or goals are to be achieved and when the outcomes should be evaluated. Patient-focused outcomes centre on the desired results of nursing care, that is, the impact of care on the patient, rather than on what the nurse does. Outcomes may be short, intermediate or long term, enabling the nurse to identify the patient’s health status and progress (stability, improvement or deterioration) over time. Setting realistic outcomes and interventions requires the nurse to distinguish between nursing diagnoses that are life-threatening or an immediate risk to the patient’s safety and those that may be dealt with at a later stage. Identifying which nursing diagnoses/problems contribute to other problems