Planning Nursing Care Nursing Process

AMERICAN NURSING HISTORY

Davida Michaels 3/20/2020

Contents Planning Nursing Care ...... 3

Nursing Process ...... 3

Background and History ...... 3

Closer Look at Steps of the Nursing Process ...... 5

Assessment ...... 5

Diagnosis...... 5

Organization - Classification Systems ...... 6

Planning ...... 7

Planning – Goal Setting ...... 8

Implementation ...... 9

Evaluation ...... 9

References ...... 10

Planning Nursing Care

Nursing Process Planning for care begins on admission and is continually updated in response to condition changes. The nursing process is a systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health it-i is the essential core of nursing practice to deliver holistic, patient-focused care. Nursing process provides an organizing framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care.”

Background and History The term nursing process was introduced in 1955 by Lydia Hall who identified three steps of nursing process as: (1) observation, (2) administration of care and (3) validation.

Hall viewed nursing as the three C’s: Core, Care and Cure. The core is the patient receiving nursing care. Goals are set by the patient rather than by any other person according to his or her feelings and values. Care is focused on performing the task of nurturing patients including comfort measures, patient instruction, and helping the patient meet his or her needs when help is needed. Cure refers to therapeutic interventions by medical professionals. Hall believed that the cure circle is shared by the nurse with other health professionals, such as physicians or physical therapists.

In 1959, Dorothy Johnson described nursing as fostering the behavioral functioning of the client. Johnson identified three steps of nursing process: assessment, decision and nursing action.ii Johnson is

3 known for the development the Behavior System Model of Nursing which stressed the importance of research-based knowledge about the effect of nursing care on patients. When she first proposed the theory in 1968, she explained that it was to foster “the efficient and effective behavioral functioning in the patient to prevent illness.” The nursing process of the Behavior System Model of Nursing begins with an assessment and diagnosis of the patient. Once a diagnosis is made, the nurse and other healthcare professionals develop a nursing care plan of interventions and setting them in motion. The process ends with an evaluation, which is based on the balance of the subsystems.iii

In 1961 Ida Jean Orlando-Pelletieriv introduced d the “Deliberative Nursing Process Theory- which included five stages: assessment, diagnosis, planning, implementation, and evaluation. (ADPIE ).Orlando’s nursing theory stressed the reciprocal relationship between patient and nurse; what the nurse and the patient say and do affects them both. The result was an effective nursing care plan that could be easily adapted when and if any complications arise with the patient,. v

Listen to an oral history by Ida Jean Orlando - https://www.youtube.com/watch?v=w3Gn3Ph-00Q ]

In 1963, Lois Knowles at the University of Florida used a five step nursing process called the ‘five Ds’: discover, delve, decide, do and discriminate”. The discover and delve steps are relates to assessment phase, decide is the planning stage, do is the implementation stage; discriminate is the evaluation phase of client responses to nursing interventions

In 1967—Helen Yura and Mary B.Walsh. published The Nursing Process, which identified 4 strategic nursing care steps – also referred to as APIE:- Assessment, Planning, Implement and Evaluation.

Closer Look at Steps of the Nursing Process

Assessment In Notes on Nursing, Florence Nightingale cautions: "But if you cannot get the habit of observation one way or other, you had better give up the [idea of] being a nurse, for it is not your calling, however kind and anxious you may be." vi

Assessment establishes a data base by interviewing the individual and/or family members, observing their behavior and physical examination to identify problem(s). Assessment requires listening, critical thinking skills and data collection- subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. The data is recorded objectively and accurately – data is then organized and analyzed, to formulate a nursing diagnosis, goals and desired outcomes.

Diagnosis In 1953, Virginia Fry and R. Louise McManus introduced the discipline-specific term “nursing diagnosis” to describe a step necessary in developing a nursing care plan. The nursing diagnosis was used to standardize and define the concept of nursing care. Their hope this would help to nurses earn professional status.vii

In 1972, the New York State Nurse Practice Act identified diagnosing as part of the legal domain of professional nursing. The Act was the first legislative recognition of nursing’s independent role and diagnostic function. viii

Shoemaker defines a nursing diagnosis as:

“A nursing diagnosis is a clinical judgment about an individual, family or community which is derived through a deliberate, systematic process of data collection and analysis. It provides the basis for prescriptions for definitive therapy for which the nurse is accountable. It is expressed concisely and it includes the etiology of the condition when known.”ix

The North American Nursing Diagnosis Association (NANDAx) defined the difference between a medical and nursing diagnosis as:

“A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processesxi. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. The complimentary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient- specific outcomes.”xii Nurses formulate nursing diagnosis based on their assessment of an individual for a problem or problems caused by their disease ,condition or disorder. Using this data they can formulates one or more nursing diagnosis. Nursing diagnosis are the basis for establishing and carrying out a patient care plan..xiii

Organization - Classification Systems Development of a nursing nomenclature and classification system began as a movement to develop a language that would describe the clinical judgments made by nurses. There was great support by clinicians for describing problems that nurses are educated and licensed to treat which are not in medical language systemsxiv The North American Nursing Diagnosis Association (NANDA) is recognized in this and other countries as the pioneer in diagnostic classification in nursing. It began as a Task Force that was created at the First National Conference on Classification of Nursing Diagnoses, in 1973, and evolved into an incorporated Association in 1982 to assist nurses in the United States and Canada in classification. Initiation of work on classification for the nursing profession can be attributed to the foresight of two faculty at St. Louis University, Kristine Gebbie and Mary Ann Lavin who called the first conference on classification.xvxvi

 In 1982, the conference group accepted the name “North American Nursing Diagnosis Association (NANDA)” to recognize the participation and contribution of nurses in the United States and Canada.

 In 1984, NANDA renamed “patterns of unitary man” as “human response patterns” based on the work of Marjorie Gordon. Currently, the taxonomy is now called Taxonomy II.

 In 1990 during the 9th conference of NANDA, the group approved an official definition of nursing diagnosis: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

An actual nursing diagnosis is written as the problem/diagnosis related to (r/t) x factor/cause as evidenced by data/observations.A risk nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause.A syndrome nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause. A wellness nursing diagnosis is written as readiness to/for action.

Planning Planning nursing care is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Communication of care plans among nurses, and other healthcare providers is vital in the achievement of health care outcomes. Without the nursing care planning process,quality and consistency in patient care would be lost.

Nursing care plan formats are can be organized into four columns (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. A three column format can also be used with goals and interventions combined in one column. As a general rule the care plans were usually written in pencil so they could be updated and stuck in the Kardex. These care plans usually became quite messy and were not saved as part f the individual’s record. With the advent of computerized records, documentation regarding problems, goals and outcomes

Home Health Care plans were a exception as private insurance, Medicare and Medicaid reimbursement required information regarding problems, goals, interventions and outcomes and

7 were reviewed periodically by state surveyors and representatives of the patient’s payer source for both reimbursement and standards of care.

Discussing Nursing Care Plans, Sharon LaDuke wrote in 2008 xvii “in the 1930s the nursing care plan developed as a way for nursing team leaders to guide the care provided by less-educated members of the team. These individualized, handwritten plans were worthwhile: hospital stays were long enough, and the pace slow enough, to actually implement them.”

Nursing education found the written care plan a useful tool to aide learning. As a nursing student in the late 1960’s I can recall spending time in the library writing care plans…one patient in particular with chronic renal failure – with multiple diagnostic and lab tests stands out. While I don’t recall the exact number of pages it took hours! As a student this was a good learning experience; as a graduate RN I found that the traditional nursing care plan was not practicable. First, times had changed, acuity soared, and hospital stays shortened; second, many patients were admitted with multiple conditions. Considering that the nursing process and planning care is dynamic and goal directed- as conditions change and the patient’s progress – or lack of it – toward achievement of goals changes, so does the plan of care. Considering we live in the age of the computer and electronic health records which aids interdisciplinary communication, separate, nursing specific care plans are not necessary. As LaDuke concludes “Despite its rightful place of honor at the center of student nurse education, the nursing care plan—as we’ve known it— belongs to yesterday”xviii

Planning – Goal Setting Planning is the process of developing a plan and establishing SMART goals in order to achieve a desired outcome such as reducing pain or improving cardiovascular function.

SMART criteria are commonly attributed to Peter Drucker’s management by objectives concept. The first-known use of the term occurs in the November 1981 issue of Management Review by George T. Doran. “There’s a S.M.A.R.T. way to write management’s goals and objectives.”

A pair of university psychologists, Edwin Locke and Gary Latham, helped develop the SMART criteria through field experiments. Goal-setting theory was developed within organizational psychology over a 25-year period, based on some 400 laboratory and field studies.xix

People who are engaged in the goal-setting process and invested in the outcomes are more likely to adhere to their plan of care and treatment. What patients are willing (and able) to do to accomplish a goal is critical to its achievement, which means that collaborative goal-setting is crucial. The acronym SMART stands for specific, measurable, achievable, realistic, and timely. By the time one is finished setting a SMART goal, it should be clear what the expected outcome, how one will measure it, and the time-frame in which it will be completed.

A care plan should involve the steps and strategies that need to be taken in order to achieve the desired goal. Intervention strategies are developed to help keep the individual on track and may be communicated to the individual and/or medical team or performed directly by a member of the medical team as part of the treatment.

Implementation The implementation phase of the process is the actionable part of the process. The implementation phase may be performed using a combination of direct care and indirect care.

Direct care is care that is given directly to the patient in either a physical or verbal manner such as assisting the patient with mobility, performing physical care such as wound care or educating the patient and/or family in caring for a member of their family.

Indirect care is care that is given while away from the patient such as remote cardiac monitoring or supervising nursing assistants and advocating on behalf of the individual.

Evaluation Evaluation includes assessment of individual progress towards meeting his/her goals and achieving the desired outcomes. Here you evaluate if the plan is working and bringing the individual closer to his/her goals. This phase also includes recognition of difficulties in meeting goals and possible causes requiring changes in the plan of care.

References i Ejeh, Sandra N. ADVANCES IN NURSING PROCESS: NANDA-I, NIC,NOC, PowerPoint presentation downloaded 3/15/2020 ii Ibid (op.cit canestar). iii https://nurseslabs.com/dorothy-e-johnsons-behavioral-system-model/ iv Ibid v https://nurseslabs.com/ida-jean-orlandos-deliberative-nursing-process-theory/ vi Nightingale, Florence . 1969/1860. Notes on Nursing: What it is and what it is not.. Dover Publications, Inc. New York. viiMatt Vera, BSN, R.N. Nursing Diagnosis List: Complete Guide and Examples, Everything you need to know about nursing diagnosis .https://nurseslabs.com/nursing-diagnosis/ viii ix Shoemaker, Joyce 1985 Characteristics of a Nursing Diagnosis. Occupational Health Nursing, August 1985. p.387 x Note NANDA is now global and known as NANDA International xi https://kb.nanda.org/article/AA-00266/0/What-is-the-difference-between-a-medical-diagnosis-and-a-nursing- diagnosis-.html xii Ibid xiii Roseman University ABSN(Accelerated Bachelor Science Nursing) | What is a three-part nursing diagnosis? Published online July 9, 2014 Downloaded 3/17/2020 xiv Citation: Gordon, M. (Sept. 30, 1998): Nursing Nomenclature and Classification System Development Online Journal of Issues in Nursing. Vol. 3, No. 2, Manuscript 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/ No2Sept1998/NomenclatureandClassification.aspx’ xv Ibid and xvi https://nurseslabs.com/nursing-diagnosis/ xvii SharonLaDuke, Viewpoint .AJN t June 2008 t Vol. 108, No. 6 xviii Ibid xix Hunt, Joe Beyond SMART Goals: How to Build Better Results http://www.houseofhunt.com/executive-edge/executive-edge-june-2016-smart-goals/