Nursing Dx

Definition:Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

RELATED FACTORS
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]

DEFINING CHARACTERISTICS
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]

Objective
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]

Affective
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse

Sample Clinical Applications:Major life changes/events, hospital admissions/surgery, cancer, hyperthyroidism, drug intoxication/abuse, mental health disorders

DESIRED OUTCOMES/EVALUATION CRITERIA

Client Will (Include Specific Time Frame)
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.

ACTIONS/INTERVENTIONS

NURSING PRIORITY NO.1. To assess level of anxiety:
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.

• Determine current prescribed medication regimen and recent drug history of prescribed or OTC medications (e.g., steroids, thyroid preparations, weight-loss pills, caffiene. Can heighten feelings/sense of anxiety.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.

NURSING PRIORITY NO.2 To assist client to identify feelings and begin to deal with problems:
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Enables client to become comfortable and to begin looking at feelings and dealing with situation.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.

• Encourage client to acknowledge and to express feelings—for example, crying (sadness), laughing (fear, denial), swearing (fear, anger), and using Active-listening, reflection. Often acknowledging feelings enables client to accept and deal more appropriately with situation, thus relieving anxiety.
• Assist client to develop self-awareness of verbal and nonverbal behaviors. Becoming aware helps client to control these behaviors and begin to deal with issues that are causing anxiety.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Validates reality of feelings. False reassurances may be interpreted as lack of understanding or honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms initially. However, continued use of such mechanisms diverts the energy that the client needs for healing, thus delaying the client from focusing and dealing with his actual problems.
• Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem-solving. These may be useful for the moment but may eventually interfere with resolution of current situation.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.

Definition: Risk of hypersenitivity to natural latex rubber products

RISK FACTORS
History of reactions to latex
Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
History of allergies and asthma
Professions with daily exposure to latex
Multiple surgical procedures, especially from infancy
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida, myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g., neurogenic bladder, exstrophy of bladder), spinal cord trauma

DESIRED OUTCOMES/EVALUATION CRITERIA

Client Will (Include Specific Time Frame)
• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.

ACTIONS/INTERVENTIONS

NURSING PRIORITY NO.1 To assess causative/contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papya, peach, nectarine); asthma; skin conditions (e.g., eczema); those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products); those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most
severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Current information indicates that natural latex is found in thousands of medical supplies; however, many manufacturers are now using synthetic SB latex. These products have not been associated with allergic reactions, even among individuals that are sensitive to natural latex.

NURSING PRIORITY NO.2 To assist in correcting factors that could lead to latex allergy:
• Ascertain that facilities have established policies and procedures. Promotes awareness in the workplace to address safety and reduce risk to workers and client.
• Create latex-safe environments in care setting (e.g., substitute nonlatex products, such as natural rubber gloves, PCV IV tubing, latex-free tape, thermometers, electrodes, oxygen cannulas, etc.). Reduces risk of exposure.
• Promote good skin care when latex gloves may be preferred/required for barrier protection (e.g., in specific disease conditions such as HIV or during surgery). Use powder-free gloves, wash hands immediately after glove removal; refrain from use of oil-based hand cream. Reduces dermal and respiratory exposure to latex proteins that bind to the powder in gloves.
• Discuss necessity of avoiding latex exposure. Recommend/assist client/family to survey environment and remove any medical or household products containing latex. Avoidance of latex is the only way to prevent the allergy.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.

NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Instruct client/care providers about types of potential reactions. Reaction may be gradual and progressive (e.g., irritant contact rash with gloves); can be progressive, affecting multiple body systems; or may be sudden and anaphylactic requiring lifesaving treatment.
• Identify measures to take if reactions occur and ways to avoid exposure to latex products to reduce risk of injury. (Refer to ND latex Allergy Response.)
• Refer to allergist for testing as appropriate. Testing may include challenge test with latex gloves, skin patch test, or blood test for IgE.
• Encourage client to wear medical ID bracelet and emphasize importance of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Refer to resources (e.g., Latex Allergy News, National Institute for Occupational Safety and Health [NIOSH], Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]) for further information about common latex products in the home, latex-free products, and assistance.

DOCUMENTATION FOCUS

Assessment/Reassessment
• Assessment findings, pertinent history of contact with latex products, and frequency of exposure.

Planning
• Plan of care and who is involved in planning.
• Teaching plan.

Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.

Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.

Over time, the nursing process expanded to five steps and has gained widespread acceptance as the basis for providing effective nursing care. Nursing process is now included in the conceptual framework of all nursing curricula, is accepted in the legal definition of nursing in the Nurse Practice Acts of most states, and is included in the ANA Standards of Clinical Nursing Practice.
The five steps of the nursing process consist of the following:

Definition: A hypersensitive reaction to natural latex rubber products

RELATED FACTORS
Hypersensitivity to natural latex rubber protein

DEFINING CHARACTERISTICS
Subjective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Tightness in chest; [feeling breathless]
Gastrointestinal characteristics: Abdominal pain; nausea
Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal  congestion
Generalized characteristics: Generalized discomfort; increasing complaints of total body warmth
Type IV reactions occurring >1 hour after exposure to latex protein:
Discomfort reaction to additives such as thiurams and carbamates
Objective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Contact urticaria progressing to generalized symptoms
Edema of the lips/tongue/uvula/throat
Dyspnea; wheezing; bronchospasm; respiratory arrest
Hypotension; syncope; cardiac arrest
Orofacial characteristics: Edema of sclera/eyelids; erythema/tearing of the eyes; nasal facial/erythema; rhinorrhea
Generalized characteristics: Flushing; generalized edema; restlessness
Type IV reactions occurring >1 hour after exposure to latex protein:
Eczema; irritation; redness

Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida,
myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g.,
neurogenic bladder, exstrophy of bladder), spinal cord trauma

Client Will (Include Specific Time Frame)
• Be free of signs of hypersensitive response.
• Verbalize understanding of individual risks/responsibilities in avoiding exposure.
• Identify signs/symptoms requiring prompt intervention.

NURSING PRIORITY NO.1 To assess contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papaya, peach, nectarine), prior allergies, asthma, and skin conditions (e.g., eczema and other dermatitis), those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products), those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question new client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Basic safety information to help healthcare providers prevent/prepare for safe environment for client and themselves while providing care.
• Discuss history of exposure: client works in environment where latex is manufactured or latex gloves are used frequently; child was blowing up balloons (may be an acute reaction to the powder); use of condoms (may affect either partner); individual requires frequent catheterizations. Finding cause of reaction may be simple or complex but often requires diligent investigation and history-taking from multiple sources.
• Administer or note presence of positive skin-prick test (SPT), when performed. Sensitive, specific, and rapid test but should be used with caution in persons with suspected sensitivity, as it carries risk of anaphylaxis.
• Perform challenge/patch test, if appropriate, to identify specific allergens in client with known type IV hypersensitivity.
• Note response to radioallergosorbent test (RAST) or enzyme-linked latex-specific IgE (ELISA). Performed to measure the quantity of IgE antibodies in serum after exposure to specific antigens and has generally replaced skin tests and provocation tests, which are inconvenient, often painful, and/or hazardous to the client.

NURSING PRIORITY NO.2 To take measures to reduce/limit allergic response/avoid exposure to allergens:
• Ascertain client’s current symptoms, noting rash, hives, itching, eye symptoms, edema, diarrhea, nausea, and feeling of faintness. Baseline for determining where the client is along a continuum of symptoms so that appropriate treatments can be initiated.
• Determine time since exposure (e.g., immediate or delayed onset such as 24 to 48 hours).
• Assess skin (usually hands but may be anywhere) for dry, crusty, hard bumps, horizontal cracks caused by irritation from chemicals used in/on the latex item (e.g., latex or powder used in latex gloves, condoms, etc.). Dry itchy rash (contact irritation) is the most common response and is not a true allergic reaction but can progress to a delayed type of allergic contact dermatitis with oozing blisters and spread in a way similar to poison ivy.
• Assist with treatment of contact dermatitis/type IV reaction:
Wash affected skin with mild soap and water.
Wash hands between glove changes and after each glove removal.
Avoid oil-based salves or lotions when using latex gloves.
Consider application of topical steroid ointment.
Inform client that the most common cause is latex gloves but that many other products contain latex and could aggravate condition.
• Monitor closely for signs of systemic reactions (e.g., difficulty breathing or swallowing; wheezing; hoarseness; stridor; hypotension; tremors; chest pain; tachycardia; dysrhythmias; edema of face, eyelids, lips, tongue, and mucous membranes). Type IV response can progress to type I anaphylaxis.
• Note behavior such as agitation, restlessness, and expressions of fearfulness, in the presence of above listed symptoms. Indicative of severe allergic response that can result in anaphylactic reaction and lead to respiratory/cardiac arrest.
• Administer treatment, as appropriate, if severe/life-threatening reaction occurs:
Stop treatment or procedure, if needed.
Support airway and administer 100% oxygen or mechanical ventilation, if needed.
Administer emergency medications and treatments per protocol (e.g., antihistamines, epinephrine, corticosteroids, and IV fluids).
• Educate care providers in ways to prevent inadvertent exposure (e.g., post latex precaution signs in client’s room, document allergy to latex in chart, routinely monitor client’s environment for latex-containing products and remove them promptly) and in emergency treatment measures should they be needed.
• Ascertain that latex-safe environment (e.g., surgery/hospital room) and products are available according to recommended facility guidelines and standards, including equipment and supplies, (e.g., powder-free, low-protein latex products) and latex-free items (e.g., gloves, syringes, catheters, tubings, tape, thermometers, electrodes, oxygen cannulas, underpads, storage bags, diapers, feeding nipples, etc.), as appropriate.
• Notify physicians, colleagues, and medical products suppliers of condition (e.g., pharmacy so that medications can be prepared in latex-free environment, home-care oxygen company to provide latex-free cannulas).
• Encourage client to wear medical ID bracelet to alert providers to condition if client is unresponsive.

NURSING PRIORITY NO.3 To promote wellness (Teaching/Learning):
• Instruct in signs of reaction and emergency treatment needs. Reactions range from skin irritation to anaphylaxis. Reaction may be gradual but progressive, affecting multiple body systems, or may be sudden, requiring lifesaving treatment. Allergy can result in chronic illness, disability, career loss, hardship, and death. There is no cure except complete avoidance of latex
• Emphasize the critical importance of taking immediate action for type I reaction to limit life-threatening symptoms.
• Demonstrate procedure and recommend client carry auto-injectable epinephrine to provide timely emergency treatment, as needed.
• Emphasize necessity of informing all new care providers of hypersensitivity to reduce preventable exposures.

• Instruct client/family/SO that latex exposure occurs through contact with skin or mucous membrane, by inhalation, parenteral injection, or wound inoculation.
• Instuct client/SO(s) to survey and routinely monitor environment for latex-containing products, and replace as needed.
• Provide printed lists or Web sites for identifying common household products that may contain latex (e.g, carpet backing, hoses, rubber grip utensils, diapers, undergarments, shoes, toys, pacifiers, computer mouse pad, erasers, rubber bands, and much more) and where to obtain latex-free products and supplies.
• Provide resource and assistance numbers for emergencies. When allergy is suspected or the potential for allergy exists, protection must begin with identification and removal of possible sources of latex.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Recommend full medical workup for client presenting with hand dermatitis, especially if job tasks include use of latex.
• Contact suppliers to verify that latex-free equipment, products, and supplies are available, including (but not limited to) low-allergen/powder-free synthetic gloves, airways, masks, stethoscope tubings, IV tubing, tape, thermometers, urinary catheters, stomach and intestinal tubes, electrodes, oxygen cannulas, pencil erasers, wrist name bands, and rubber bands.
• Ascertain that procedures are in place to identify and resolve problems with medical devices relevant to allergic reactions or glove performance.
• Refer to resources, including but not limited to ALERT (Allergy to Latex Education & Resource Team, Inc.), Latex Allergy News, Spina Bifida Association, National Institute for Occupational Safety and Health (NIOSH), Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]), for further information about common latex products in the home, latex-free products, and assistance.

DOCUMENTATION FOCUS
Assessment/Reassessment
• Assessment findings/pertinent history of contact with latex products/frequency of exposure.
• Type/extent of symptoms.
Planning
• Plan of care and interventions and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Discharge needs/referrals made, additional resources available.

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway

RELATED FACTORS
Environmental
Smoking; secondhand smoke; smoke inhalation
Obstructed airway
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway
Physiological
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls
Neuromuscular dysfunction
Infection

DEFINING CHARACTERISTICS
Subjective
Dyspnea
Objective
Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]
Cough, ineffective/absent; excessive sputum
Changes in respiratory rate and rhythm
Difficulty vocalizing
Wide-eyed; restlessness
Orthopnea
Cyanosis

Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic fibrosis, neuromuscular diseases, inhalation injuries

Client Will (Include Specific Time Frame)
• Maintain airway patency.
• Expectorate/clear secretions readily.
• Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
• Verbalize understanding of cause(s) and therapeutic management regimen.
• Demonstrate behaviors to improve or maintain clear airway.
• Identify potential complications and how to initiate appropriate preventive or corrective actions.

NURSING PRIORITY NO.1 To maintain adequate, patent airway:
• Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
• Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
• Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
• Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
• Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
• Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
• Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
• Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.

• Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors.
• Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
• Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.

NURSING PRIORITY NO.2 To mobilize secretions:
• Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
• Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
• Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
• Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
• Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
• Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
• Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
• Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
• Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
• Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.

NURSING PRIORITY NO.3 To assess changes, note complications:
• Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.

• Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress.
• Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
• Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
• Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
• Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
• Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.

NURSING PRIORITY NO.4 To promote wellness (Teaching/Discharge Considerations):
• Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
• Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
• Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
• Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
• Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
• Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
• Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
• Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.

• Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association).
• Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)

DOCUMENTATION FOCUS
Assessment/Reassessment
• Related factors for individual client.
• Breath sounds, presence/character of secretions, use of accessory muscles for breathing.
• Character of cough/sputum.
Planning
• Plan of care and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.

Definition: At risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities
RISK FACTORS
History of previous intolerance
Presence of circulatory/respiratory problems, [dysrhythmias]
Deconditioned status; [aging]
Inexperience with the activity
[Diagnosis of progressive disease state/debilitating condition, anemia]
[Verbalized reluctance/inability to perform expected activity]
NOTE: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred; rather, nursing interventions are directed at prevention.
Sample Clinical Applications: Anemias, angina aortic stenosis, bronchitis, emphysema, dysmenorrhea, heart failure, HIV/AIDS, labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding

Client Will (Include Specific Time Frame)
• Verbalize understanding of potential loss of ability in relation to existing condition.
• Participate in conditioning/rehabilitation program to enhance ability to perform.

• Identify alternative ways to maintain desired activity level (e.g., if weather is bad, walking in a shopping mall could be an option).
• Identify conditions/symptoms that require medical reevaluation.

NURSING PRIORITY NO.1 To assess factors affecting current situation:
• Note presence of medical diagnosis and/or therapeutic regimens (e.g., AIDS, COPD, cancer, heart failure/other cardiac problems, anemia, multiple medications/treatment modalities, extensive surgical interventions, musculoskeletal trauma, neurological disorders) that have potential for interfering with client’s ability to perform at a desired level of activity.
Note: Many factors cause or contribute to fatigue, but activity intolerance implies that the individual cannot endure or adapt to increased energy or oxygen demands caused by an actvity.
• Ask client/SO about usual level of energy to identify potential problems and/or client’s/SO’s perception of client’s energy and ability to perform needed/desired activities. 
• Identify factors (e.g., age, functional decline, painful conditions, breathing problems, client resistive to efforts; vision or hearing impairments, climate, or weather; unsafe areas to exercise; need for mobility assistance, etc.) that could block/affect desired level of activity. 
• Determine current activity level and physical condition with observation, exercise tolerance testing, use of functional level classification system (e.g., Gordon’s), as appropriate. Provides baseline for comparison and opportunity to track changes.

NURSING PRIORITY NO.2 To develop/investigate alternative ways to remain active within the limits of the disabling condition/situation:
• Implement physical therapy/exercise program in conjunction with the client and other team members such as a physical and/or occupational therapist, exercise/rehabilitation physiologist. Collaborative program with short-term achievable goals enhances likelihood of success and may motivate client to adopt a lifestyle of physical exercise for enhancement of health.
• Promote/implement conditioning program and support inclusion in exercise/activity groups to prevent/limit deterioration.
• Instruct client in proper performance of unfamiliar activities and/or alternate ways of doing familiar activities to learn methods of conserving energy and promote safety in performing activities.

NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Discuss with client/SO relationship of illness/debilitating condition to inability to perform desired activity(ies). Understanding these relationships can help with acceptance of limitations or reveal opportunity for changes of practical value.

• Provide information regarding factors, such as smoking when one has respiratory problems, weight management, lack of motivation/interest in exercise. Education is essential to encourage modification of potential interferences to activity.
• Assist client/SO(s) with planning for changes that may become necessary (e.g., shifting of family responsibilities, use of supplemental oxygen to improve client’s ability to participate in desired activities). Anticipatory guidance facilitates adaptation if symptoms occur. (Refer to ND Activity Intolerance.)
• Identify and discuss symptoms for which client needs to seek medical assistance/ evaluation, providing for timely intervention.
• Refer to appropriate sources for assistance (e.g., smoking cessation, dietary counseling) and/or equipment, as needed, to sustain or improve activity level and to promote client safety.

DOCUMENTATION FOCUS
Assessment/Reassessment
• Identified/potential risk factors for individual.
• Current level of activity tolerance and blocks to activity.
Planning
• Treatment options, including physical therapy/exercise program, other assistive therapies
and devices.
• Lifestyle changes that are planned, who is to be responsible for each action, and monitoring
methods.
Implementation/Evaluation
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modification of plan of care.
Discharge Planning
• Referrals for medical assistance/evaluation.

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities
RELATED FACTORS
Generalized weakness
Sedentary lifestyle
Bedrest/immobility
Imbalance between oxygen supply and demand, [anemia]
[Cognitive deficits/emotional status; secondary to underlying disease process/depression]
[Pain, vertigo, dysrhythmias, extreme stress]
DEFINING CHARACTERISTICS
Subjective
Verbal report of fatigue/weakness
Exertional discomfort/dyspnea
[Verbalizes no desire and/or lack of interest in activity]
Objective
Abnormal heart rate/blood pressure response to activity
Electrocardiographic changes reflecting arrhythmias/or ischemia
[Pallor, cyanosis]
FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987):
Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath
than normally
Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest

Sample Clinical Applications: Anemias, angina, aortic stenosis, bronchitis, emphysema, diabetes mellitus, dysmenorrhea, heart failure, human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS), labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding

Client Will (Include Specific Time Frame)
• Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate in necessary/desired activities.
• Report measurable increase in activity tolerance.
• Demonstrate a decrease in physiological signs of intolerance (e.g., pulse, respirations, and
blood pressure remain within client’s usual range).

NURSING PRIORITY NO.1 To identify causative/precipitating factors:

• Note presence of acute or chronic illness, such as heart failure, hypothyroidism, diabetes mellitus, AIDS, cancers, acute and chronic pain, etc. Many factors cause or contribute tofatigue, but acitivity intolerance implies that the client cannot endure or adapt to increasedenergy or oxygen demands caused by an actvity.

• Assess cardiopulmonary response to physical activity by measuring vital signs, noting heart rate/regularity, respiratory rate/work of breathing, and blood pressure before, during, andafter activity. Note progression/accelerating degree of fatigue. Dramatic changes in heartrate and rhythm, changes in usual blood pressure, and progressively worsening fatigue resultfrom imbalance of oxygen supply and demand. These changes are potentially greater in thefrail, elderly population.

• Note treatment-related factors such as side effects/interactions of medications. Caninfluence presence and degree of fatigue.

• Determine if client is receiving medications such as vasodilators, diuretics, or beta-blockers.Orthostatic hypotension can occur with activity because of medication effects(vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.

• Note client reports of difficulty accomplishing tasks or desired activities. Evaluate current limitations/degree of deficit in light of usual status and what the client perceives causes, exacerbates, and helps the problem. Provides comparative baseline and influences choice of interventions and may reveal causes that the client is unaware of affecting energy, such as sleep deprivation, smoking, poor diet, depression, or lack of support. 1
• Ascertain ability to sit, stand, and move about as desired. Note degree of assistance necessary, and/or use of assistive equipment. Helps to differentiate between problems relating to movement and problems with oxygen supply and demand characterized by fatigue and weakness.
• Identify activity needs versus desires (e.g., client barely able to walk upstairs but states would like to play racquetball). Assists caregiver in dealing with reality of situation, as well as the feasibility of goals client wants to achieve when developing activity plan. 

• Assess emotional/psychological factors affecting the current situation. Stress and/or depression may be exacerbating the effects of an illness, or depression may be the result of therapy/limitations.

NURSING PRIORITY NO.2 To assist client to deal with contributing factors and manage activities within individual limits:
• Monitor vital signs, before and during activity, watching for changes in blood pressure, heart and respiratory rate, as well as postactivity vital sign response. Vital signs increase during activity and should return to baseline within 5 to 7 minutes after activity if response to activity is normal.
• Observe respiratory rate, noting breathing pattern, breath sounds, skin color, and mental status. Pallor and/or cyanosis, presence of respiratory distresss, or confusion may be indicative of need for oxygen during activities, especially if respiratory infection or compromise is present.
• Plan care with rest periods between activities to reduce fatigue.
• Assist with self-care activities. Adjust activities/reduce intensity level, or discontinue activities that cause undesired physiological changes. Prevents overexertion.
• Increase exercise/activity levels gradually; encourage stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair, etc. Methods of conserving energy.
• Encourage expression of feelings contributing to/resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Helps to minimize frustration, rechannel energy.
• Involve client/significant others (SOs) in planning of activities as much as possible. May give client opportunity to perform desired/essential activities during periods of peak energy.
• Assist with activities and provide/monitor client’s use of assistive devices. Enables client to maintain mobility while protecting from injury.
• Promote comfort measures and provide for relief of pain to enhance client’s ability and desire to participate in activities. (Refer to NDs acute Pain, chronic Pain.)
• Provide referral to collaborative disciplines such as exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists. May be needed to develop individually appropriate therapeutic regimens.
• Prepare for/assist with and monitor effects of exercise testing. May be performed to determine degree of oxygen desaturation and/or hypoxemia that occurs with exertion, or to optimize titration of supplemental oxygen when used.
• Implement graded exercise/rehabilitation program under direct medical supervision. Gradual increase in activity avoids excessive myocardial workload/excessive oxygen demand.

• Administer supplemental oxygen, medications, prepare for surgery, as indicated. Type of therapy or medication is dependent on the underlying condition and might include medications (such as antiarryhthmics) or surgery (e.g., stents or CABG) to improve myocardial perfusion and systemic circulation. Other treatments might include iron preparations or blood transfusion to treat severe anemia, or use of oxygen and bronchodilators to improve respiratory function.

NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Review expectations of client/SO(s)/providers and explore conflicts/differences. Helps to establish goals and to reach agreement for the most effective plan.
• Assist/direct client/SO to plan for progressive increase of activity level aiming for maximal activity within the client’s ability. Promotes improved or more normal activity level, stamina, and conditioning.
• Instruct client/SOs in monitoring response to activity and in recognizing signs/symptoms that indicate need to alter activity level. Assists in self-management of condition and in understanding of reportable problems.
• Give client information that provides evidence of daily/weekly progress to sustain motivation.
• Assist client to learn and demonstrate appropriate safety measures to prevent injuries.
• Provide information about proper nutrition to meet metabolic and energy needs, obtaining or maintaining normal body weight. Energy is improved when nutrients are sufficient to meet metabolic demands.
• Encourage client to use relaxation techniques such as visualization/guided imagery as appropriate. Useful in maintaining positive attitude and enhancing sense of well-being.
• Encourage participation in recreation/social activities and hobbies appropriate for situation. (Refer to ND deficient Diversional Activity.)
• Monitor laboratory values (such as for anemia) and pulse oximetry.

DOCUMENTATION FOCUS
Assessment/Reassessment
• Level of activity as noted in Functional Level Classification.
• Causative/precipitating factors.
• Client reports of difficulty/change.
Planning
• Plan of care and who is involved in planning.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Implemented changes to plan of care based on assessment/reassessment findings.
• Teaching plan and response/understanding of teaching plan.
• Attainment/progress toward desired outcome(s).
Discharge Planning
• Referrals to other resources.
• Long-term needs and who is responsible for actions.

Concept mapping is an exciting alternative format for illustrating a written plan of care. A mapped care plan will look very different from traditional plans of care, which are usually completed on linear forms.

To begin mapping a client plan of care, you must begin with the central topic—the client. Now you are thinking like a nurse. Create a shape that signifies “client” to you and place that at your map’s center. If your hand just can’t start at the center, then put the shape at the top. This will help you remember that the client is the focus of your plan, not the medical diagnosis or condition. All other pieces of the map will be connected in some manner to the client. Many different pieces of information about the client can be connected directly to the client. For example, each of the following pieces of critical client data could stem from the center:

Now, you must do a bit of thinking about how you think. To create the rest of your map, ask yourself how you plan client care. For example, which of these items do you see first orthink of first as the basis for your plan: the clustered assessment data, nursing diagnoses, oroutcomes? Whichever piece you choose becomes your first layer of connections. Supposewhen thinking about a plan of care for a female client with heart failure, you think first interms of all the nursing diagnoses about that woman and her condition. Your map would startwith the diagnoses featured as the first “branches,” each one being listed separately in someway on the map.

Completing the map then becomes a matter of adding the rest of the pieces of the plan using the nursing process and your own way of thinking/planning as your guide. If you began your map using nursing diagnoses, you might think, “What signs and symptoms or data support these diagnoses?” Then, you would connect clusters of supporting data to the related nursing diagnosis. Or you might think, “What client outcomes am I trying to achieve when I address this nursing diagnosis?” In that case, you would next connect client outcomes (or NOC labels) to the nursing diagnoses.

To keep your map clear, as suggested previously, use different colors and maybe a different shape/spoke/line for each piece of the care plan that you are adding. For example:

• Red for signs and symptoms (to signify danger)
• Yellow for nursing diagnoses (for “stop and think what this is”)
• Green for nursing interventions/NIC labels (for “go”)
• Blue (or some other color) for outcomes/NOC labels

When all the pieces of the nursing process are represented, each “branch” of the map is complete. There should be a nursing diagnosis (supported by subjective and objective assessment data), nursing interventions, desired client outcome(s), and any evaluation data, all connected in a manner that shows there is a relationship between them.
It is critical to understand that there is no preset order for the pieces, because one cluster is not more or less important than another (or one is not “subsumed” under another). It is important, however, that those pieces within a branch be in the same order in each branch.
So, you might ask, how is this different than writing out information in a linear manner? What makes mapping so special? One of the things you may have discovered about caring for clients is that the care you deliver is very interconnected. Taking care of one problem often results in the simultaneous correction of another. For example, if you resolve a fluid volume problem in a client with heart failure, you will also positively impact the client’s gas exchange and decrease his or her anxiety. These kinds of interconnections cannot be shown on linear plans of care, yet they are what practicing nurses see in their mind’s eye all the time. These interconnections can be represented on a map with arrows or dotted or dashed lines that tie related ideas together. Then, defining phrases that explain the nature of the interconnection can be added to further clarify the relationship.
In addition to the pieces of the nursing process, there are other components of care that can be illustrated on a map. Nurses have certain responsibilities when clients have diagnostic tests (such as an angiography or a bronchoscopy). These tests can be connected to the appropriate piece of your map, along with the correct nursing interventions related to those tests. Another item to be added would be potential complications (collaborative problems).
Taking your clients’ needs one step further, try asking every client you have (medical, surgical, or otherwise), “What is the most important thing to you now in relation to why you are here?” Obtaining this information builds an alliance between you and your client, and together you can work toward that desired outcome. Add it to your map and see how your plan of care becomes more client-centered.

Have you ever asked yourself whether you are more right-brained or left-brained? Those who naturally use their left brains are more linear in their thinking. Right-brain thinkers see more in pictures and illustrations. It is best for nurses to use the whole brain (right and left) when thinking about providing the broad scope of nursing care to clients.

No More Columns!

Traditional nursing care plans are linear—that is, they are designed in columns. They speak almost exclusively to the left brain. The traditional nursing care plan is organized according to the nursing process, which guides us in problem-solving the nursing care we give. However, the linear nature of the traditional plan does not facilitate interconnecting data from one “row” to another or between parts in a column. Concept mapping allows us to show the interconnections between various client symptoms, interventions, or problems as they impact each other.

You can keep the parts that are great about traditional care plans (problem-solving and categorizing) but change the linear/columnar nature of the plan to a design that uses the whole brain—bringing left-brained, linear problem-solving together with the freewheeling, interconnected, creative right brain. Joining concept mapping and care planning enables you to create a whole picture of a client with all the interconnections identified.

There are several diverse and innovative ways to mind map or to concept map nursing care plans. he examples in this chapter use mind mapping and require placing the client at the center, with all ideas on one page (for a whole picture); the examples also use color-coding and creative energy. When doing a large mapped plan of care, a light posterboard is often used so that all ideas fit on one page.

Components of a Concept Map

Tony Buzan developed the idea of concept mapping, a way to depict how ideas about a main subject are related. Mapping represents graphically the relationships and interrelationships of ideas and concepts. It fosters and encourages critical thinking through brainstorming about a particular subject.

Instead of starting at the top of the page, concept mapping starts in the page’s center. The main concept of our thinking goes in this center stage place.

From that central thought, simply begin thinking of other main ideas that relate to the central topic. These ideas radiate out from the central idea likes spokes of a wheel (see subsequent discussion); however, they do not have to be added in a balanced manner; the “wheel” does not have to be round.

You will generate further ideas related to each spoke (see subsequent discussion); and your mind will race with even more ideas from those thoughts, which can be represented through pictures or words.

As you think of new ideas, write them down immediately. This may require going back and forth from one area of the page to another. Writing your concept map by hand allows you to move faster. Avoid using a computer to generate a map because this hinders the fast-paced process. You can group different concepts together by color-coding or by placement on the page (see subsequent discussion).

As you see connections and interconnections between groups of ideas, use arrows or lines to connect those concepts (refer to the dotted lines). You can also add defining phrases that explain how the interconnected thoughts relate to one another, as in the following figure.

Some left-brain thinkers find it very difficult to start their ideas in the middle of a page. If you are this type of thinker, try starting at the top of the page (see subsequent discussion), but you must still represent your ideas in illustration form, not in paragraphs.

oncept maps created by different people look different. They are unique to the mind’s eye picture so don’t expect your map to be the same as someone else’s.

The plan of care may be recorded on a single page or in a multiple-page format, with one page for each nursing diagnosis or client diagnostic statement. The format for documenting the plan of care is determined by agency policy. As a practicing professional, you might use a computer with a plan-of-care database, preprinted standardized care plan forms, or clinical pathways. Whichever form you use, the plan of care enables visualization of the nursing process and must reflect the basic nursing standards of care; personal client data; nonroutine care; and qualifiers for interventions and outcomes, such as time, frequency, or amount.

As students, you are asked to develop plans of care that often contain more detail than what you see in the hospital plans of care. This is to help you learn how to apply the nursing process and create individualized client care plans. However, even though much time and energy may be spent focusing on filling the columns of traditional clinical care plan forms, some students never develop a holistic view of their clients and fail to visualize how each client need interacts with other identified needs. A new technique or learning tool has been developed to assist you in visualizing the linkages, to enhance your critical thinking skills, and to facilitate the creative process of planning client care.

Concept maps allow you to do something that is different and creative. They require you to think (and learn), make connections, and use colors and shapes. They help you to focus on the client; and having the map on one page helps you to understand the “whole picture” better. Concept maps also help you to become better organized and to develop your own unique approach to “thinking like a nurse” much sooner.

Concept mapping is painting a picture using colors of the rainbow on blank paper to tell the story of your client using “NANDA” nursing diagnoses and the nursing process. Previously, I was a student in prison (my mind) who hated the words “CARE PLAN,” writing page after page in narrative form. It was laborious to do and boring to read. There was no life or heartbeat.

Concept mapping opened the prison doors, and my care plan took on human form with a VOICE, a beating HEART, and COLOR while still incorporating the nursing process and standardized nursing language. My mind now took on the professional thought process that NANDA, NIC, and NOC were created to facilitate nursing; however, the magic was in concept mapping, which removed all my fears, and the client became a beautiful painting with a heartbeat.

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments/assumptions. Self-awareness is a crucial factor in this interaction, because perceptions, judgments, and assumptions can easily color the assessment findings.

Validation is an ongoing process that occurs during the data-collection phase and upon its completion, when the data are reviewed and compared. The nurse should review the data to be sure that the recordings are factual, to identify errors of omission, and to compare the objective and subjective data for congruencies or inconsistencies that require additional investigation or a more focused assessment. Data that are grossly abnormal are rechecked, and any temporary factors that may affect the data are identified/noted. Validation is particularly important when the data are conflicting, when the data’s source may be unreliable, or when serious harm to the client could result from any inaccuracies. Validating the information can avoid the possibility of making wrong inferences or conclusions that could result in inaccurate nursing diagnoses, incorrect outcomes, or inappropriate nursing actions. This can be done by sharing the assumptions with the individuals involved (e.g., client, significant other/family) and having them verify the accuracy of those conclusions. Sharing pertinent data with other healthcare professionals, such as the physician, dietician, or physical therapist can aid in collaborative planning of care. Data given in confidence should not be shared with other individuals (unless withholding that information would hinder appropriate evaluation or care of the client).

 Data gathered during the interview and physical examination, and from other records/sources are organized and recorded in a concise, systematic way and clustered into similar categories. Various formats have been used to accomplish this, including a review of body systems. This approach has been utilized by both medicine and nursing for many years but was initially developed to aid the physician in making medical diagnoses. Currently, nursing is developing and fine-tuning its own tools for recording and clustering data. Several nursing models available to guide data collection include Doenges and Moorhouse Diagnostic Divisions (Table 3–1), Gordon’s Functional Health Patterns, and Guzzetta’s Clinical Assessment Tool.
The use of a nursing model as a framework for data collection (rather than a body-systems approach [assessing the heart, moving on to the lungs] or the commonly known head-to-toe approach) has the advantage of focusing data collection on the nurse’s phenomena of concern—the human responses to health and illness. This facilitates the identification and validation of nursing diagnosis labels to describe the data accurately.

TABLE 3–1
GENERAL ASSESSMENT TOOL
This is a suggested guideline/tool applicable in most care settings for creating a client database. It provides a nursing focus (Doenges & Moorhouse’s Diagnostic Divisions of Nursing Diagnoses) that will facilitate planning client care. Although the sections are alphabetized here for ease of presentation, they can be prioritized or rearranged to meet individual needs.
Adult Medical/Surgical Assessment Tool
General Information

Name:                                          Age:                        DOB:                 Gender :                       Race:                   

Admission Date:                                           Time:                             From:                                                    
Reason for this visit/admission (primary concern):                                                                                            
Source of Information: Reliability (1–4 with 4 = very reliable):                                                                         
A

Information in the client database is obtained primarily from the client (who is the most important source) and then from family members/significant others (secondary sources), as appropriate, through conversation and by observation during a structured interview. Clearly, the interview involves more than simply exchanging and processing data. Nonverbal communication is as important as the client’s choice of words in providing the data. The ability to collect data that are meaningful to the client’s health concerns depends heavily on the nurse’s knowledge base; on the choice and sequence of questions; and on the ability to give meaning to the client’s responses, integrate the data gathered, and prioritize the resulting information. Insight into the nature and behavior of the client is essential as well.

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments/assumptions. Self-awareness is a crucial factor in the interaction, because perceptions, judgments, and assumptions can easily color the assessment findings unless they are recognized.

The quality of a history improves with experience with the interviewing process. Tips for obtaining a meaningful history include the following:
• Be a good listener.
• Listen carefully and attentively for whole thoughts and ideas, not merely isolated facts.
• Use skills of active listening, silence, and acceptance to provide ample time for the person to respond. Be as objective as possible.
• Identify only the client’s or significant others’ contributions to the history.

The interview question is the major tool used to acquire information. How the question is phrased is a skill that is important in obtaining the desired results and in getting the information necessary to make accurate nursing diagnoses. Note: Some questioning strategies to avoid include closed-ended and leading questions, probing, and agreeing or disagreeing that implies the client is “right” or “wrong.” It is important to remember, too, that the client has the right to refuse to answer any question at all, no matter how reasonably phrased.

Nine effective data-collection questioning techniques include the following:
1. Open-ended questions allow clients maximum freedom to respond in their own way, impose no limitations on how the question may be answered, and can produce considerable information.
2. Hypothetical questions pose a situation and ask the client how it might be handled.
3. Reflecting or “mirroring responses” are useful techniques in getting at underlying meanings that might not be verbalized clearly.
4. Focusing consists of eye contact (within cultural limits), body posture, and verbal responses.
5. Giving broad openings encourages the client to take the initiative in what is to be discussed.
6. Offering general leads encourages the client to continue.
7. Exploring pursues a topic in more depth.
8. Verbalizing the implied gives voice to what has been suggested.
9. Encouraging evaluation helps clients to consider the quality of their own experiences.

The client’s medical diagnosis can provide a starting point for gathering data. Knowledge of the anatomy and physiology of the specific disease process/severity of the condition also helps in choosing and prioritizing precise portions of the assessment. For example, when examining a client with severe chest pain, it may be wise to evaluate the pain and the cardiovascular system in a focused assessment before addressing other areas, possibly at a later time. Likewise, the duration and length of any assessment depend on circumstances such as the client’s condition and the situation’s urgency.

The data collected about the client or significant others contain a vast amount of information, some of which may be repetitious. However, some of it will be valuable for eliciting information that was not recalled or volunteered previously. Enough material needs to be noted in the history so that a complete picture is presented, and yet not so much that the information will not be read or used.

The physical examination is performed to gather objective information and serves as a screening device. Four common methods used during the physical examination are inspection, palpation, percussion, and auscultation. These techniques incorporate the senses of sight, hearing, touch, and smell. For the data collected during the physical examination to be meaningful, it is vital to know the normal physical and emotional characteristics of humans well enough to be able to recognize deviations. To gain as much information as possible from the assessment procedure, the same format should be used each time a physical examination is performed to lessen the possibility of omissions.

Laboratory and other diagnostic studies are a part of the information-gathering stage providing supportive evidence. These studies aid in the management, maintenance, and restoration of health. In reviewing and interpreting laboratory tests, it is important to remember that the origin of the test material does not always correlate to an organ or body system (e.g., a urine test to detect the presence of bilirubin and urobilinogen could indicate liver disease, biliary obstruction, or hemolytic disease). In some cases, the results of a test are nonspecific, because they indicate only a disorder or abnormality and not the location of the cause of the problem (e.g., an elevated erythrocyte sedimentation rate suggests the presence but not the location of an inflammatory process).
In evaluating laboratory tests, it is advisable to consider which medications (e.g., heparin, promethazine) are being administered to the client, including over-the-counter and herbal supplements (e.g., vitamin E), because these have the potential to alter, blur, or falsify results, creating a misleading diagnostic picture.

The Nursing: Scope & Standard of Practice addresses the assessment process. The standard stipulates that the data-collection process is systematic and ongoing. The nurse collects client health data from the client, significant others, and healthcare providers when appropriate. The priority of the data-collection activities is determined by the client’s immediate condition or needs. Pertinent data are collected using appropriate assessment techniques and instruments. Relevant data are documented in a retrievable form.

The assessment step of the nursing process is focused on eliciting a profile of the client that allows the nurse to identify client problems or needs and corresponding nursing diagnoses, to plan care, to implement interventions, and to evaluate outcomes. This profile, or client database, supplies a sense of the client’s overall health status, providing a picture of the client’s physical, psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. It is a combination of data gathered from the history-taking interview (a method of obtaining SUBJECTIVE information by talking with the client or significant other(s) and listening to their responses), from the physical examination (a “hands-on” means of obtaining OBJECTIVE information), and from the results of laboratory/diagnostic studies. To be more specific, subjective data are what the client/significant others perceive and report, and objective data are what the nurse observes and gathers from other sources.

Assessment involves three basic activities:
• Systematically gathering data
• Organizing or clustering the data collected
• Documenting the data in a retrievable format

The assessment step of the nursing process emphasizes and should provide a holistic view of the client. The generalized assessment done during the overall data-gathering creates a profile of the client. A focused, or more detailed, assessment may be warranted given the client’s condition or emergent time constraints, or it may be done to obtain more information about a specific issue that needs expansion or clarification. Both types of assessments provide important data that complement each other. A successfully completed assessment creates a picture of clients’ states of wellness, their response to health concerns or problems, and individual risk factors—this is the foundation for identifying appropriate nursing diagnoses, developing client outcomes, and choosing relevant interventions necessary for providing individualized care.

We will look at the process and progress of describing the work of nursing. At first glance, it seems a simple task. However, over many years, the profession has struggled with it. The struggle, in part, is a result of changes in healthcare delivery and financing, the expansion of nursing’s role, and the dawning of the computer age. Gordon reminds us that classification system development parallels knowledge development in a discipline. As
theory development and research have begun to define nursing, it has become necessary for nursing to find a common language to describe what nursing is, what nursing does, and how to codify it. Thus, the terms “classification systems” and “standardized language” were born, and the work continues.

Changes in the healthcare system occur at an ever-increasing rate. One of these changes is the movement toward a paperless (computerized or electronic) client record. The use of electronic healthcare information systems is rapidly expanding, and the focus has shifted from its original uses—financial and personnel management functions—to the efficient documentation of the client encounter, whether that is a single office visit or a lengthy hospitalization. The move to electronic documentation is being fueled by changes in healthcare delivery and reimbursement as well as the advent of alternative healthcare settings (outpatient surgeries, home health, rehabilitation or subacute units, extended or long-term care facilities, etc.), all of which
increase the need for a commonality of communication to ensure continuity of care for the client, who moves from one setting or level of care to another.

These changes in the business and documentation of healthcare require the industry to generate data about its operations and outcomes. Evaluation and improvement of provided services are important to the delivery of cost-effective client care. Therefore, providers and consumers interested in outcomes of care benefit from accurate documentation of the care provided and the client’s response. With the use of language or terminology that can be coded, healthcare information can be recorded in terms that are universal and easily entered into an electronic database and that can generate meaningful reporting data about its operation and outcomes. In short, standardized language is required.

A standardized language contains formalized terms that have definitions and guidelines for use. For example, if the impact of nursing care on financial and clinical outcomes is to be analyzed, coding of this information is essential. While it has been relatively easy to code medical procedures, nursing is more of an enigma, because its work has not been so clearly defined.

Since the 1970s, nursing leaders have been working to define the profession of nursing and to develop a commonality of words describing practice (a framework of communication and ocumentation) so that nursing’s contribution to healthcare is captured, is visible in healthcare databases, and is thereby recognized as essential. Therefore, the focus of the profession has been on the effort to classify tasks and to develop standardized nursing languages (SNLs) to better demonstrate what nursing is and what nursing does.

Around the world, nursing researchers continue their efforts to identify and label people’s experiences with (and responses to) health and illness as they relate to the scope of nursing practice. The use of universal nursing terminology directs our focus to the central content and process of nursing care by identifying, naming, and standardizing the “what” and “how” of the work of nursing—including both direct and indirect activities. This wider application for a standardized language has spurred its development.

A recognized pioneer in SNL is NANDA International’s (formerly North American Nursing Diagnosis Association) “nursing diagnosis.” Simply stated, a nursing diagnosis is defined as a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable. NANDA-I nursing diagnoses currently include 188 labels with definitions, defining characteristics, and related or risk factors used to define a client need or problem. Once the client’s need is defined, outcomes can be developed and nursing interventions chosen to achieve the desired outcomes.

The linkage of client problems or nursing diagnoses to specific nursing interventions and client outcomes has led to the development of several other SNLs, including Home Health Care Classification (HHCC; now Clinical Care Classification), Nursing Interventions Classification (NIC), 5 Nursing Outcomes Classification NOC), Omaha System-Community Health Classification System (OS), Patient Care Data Set (PCDS),  and Perioperative Nursing Data Set (PNDS).

Whereas some of these languages (e.g., OS, PCDS, and PNDS) are designed for a specific client population, the NANDA, NIC, and NOC languages are comprehensively designed for use across systems and settings and at individual, family, and community or population levels.

NIC is a comprehensive standardized language providing 514 direct and indirect intervention labels with definitions. A list of activities a nurse might choose to carry out each intervention is also provided and can be modified as necessary to meet the specific needs of the client. These research-based interventions address general practice and specialty areas.

NOC is also a comprehensive standardized language providing 330 outcome labels with definitions; a set of indicators describing specific client, caregiver, family, or community states related to the outcome; and a 5-point Likert-type measurement scale that facilitates tracking clients across care settings and that can demonstrate client progress even when outcomes are not fully met. The outcomes are research-based and are applicable in all care settings and clinical specialties.

In addition, NIC and NOC have been linked to the Omaha System problems, to resident assessment protocols (RAPs) used in extended/long-term care settings, and to NANDA-I. This last linkage created the NANDA, NIC, NOC (NNN) Taxonomy of Nursing Practice. The combination of NANDA-I nursing diagnoses, NOC outcomes, and NIC interventions in a common unifying structure provides a comprehensive nursing language recognized by the American Nurses Association (ANA) and is coded in the Systematized Nomenclature of Medicine (SNOMED) in support of the electronic client record.

Having an SNL entered into international coded terminology allows nursing to describe the care received by the client and to document the effects of that care on client outcomes, and it facilitates the comparison of nursing care across worldwide settings and diverse databases. In addition, it supports research by comparing client care delivered by nurses with that delivered by other providers, which is essential if nursing’s contribution is to be recognized and nurses are to be reimbursed for the care they provide.

Today, 13 versions of SNLs are recognized by the ANA and have been submitted to the National Library of Medicine for inclusion in the Unified Medical Language System Metathesaurus. The Metathesaurus provides a uniform, integrated distribution format from over 100 biomedical vocabularies and classifications (the majority in English and some in multiple languages), and it links many different names for the same concepts, establishing new relationships between terms from different source vocabularies.

Indexing of the entire medical record supports disease management activities (including decision support systems), research, and analysis of outcomes for quality improvement for all healthcare disciplines. Coding also supports telehealth (the use of telecommunications technology to provide medical information and healthcare services over distance) and facilitates access to healthcare data across care settings and different computer systems.