- Email: [email protected]
Emergency Nursing Decisions: A Proposed System of Nursing Diagnosis
CLINICAL
Emergency Nursing Decisions: A Proposed System of Nursing Diagnosis Author: Jessica Castner, RN, MSN, CEN, Buffalo, NY
Jessica Castner, Nevada Chapter, is Clinical Assistant Professor, D’Youville College, Buffalo, NY, and Emergency Staff RN, Buffalo General Hospital, Buffalo, NY. For correspondence, E-mail: Jessica Castner, RN, MSN: [email protected]. J Emerg Nurs 2008;34:33-6. Available online 16 August 2007. 0099-1767/$34.00 Copyright n 2008 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.12.020
February 2008
34:1
E
mergency nurses make important life or death decisions. The decisions, or nursing diagnoses, often go undocumented and unrecognized because the process is not accurately reflected in standardized nursing diagnosis lists. A new set of nursing diagnoses that ref lects actual emergency nursing decisions and complies with nursing standards needs to be formulated. ENA recommends that the staff nurse perform and document all steps of the nursing process, including nursing diagnosis, as a minimum standard of nursing care.1 Diagnosis articulates the decisions the nurse has made by giving meaning and direction to assessment findings, and it labels the patient’s priority needs. Although one of the original purposes of formulating nursing diagnoses was to define nursing practice, emergency nurses should not solely rely on nursing diagnosis to define their unique and important contributions to emergency care.2 The North American Nursing Diagnosis Association (NANDA) approves a list of nursing diagnoses geared at decision processes and actions unique to nursing.3 The documents approved by NANDA are the most commonly used set of diagnostic labels in the nursing profession. This list helps define exclusive nursing practice aside from other disciplines, ensures that the nursing process is documented in patient records, acts as a potential reimbursement system, and creates an organizational framework for theory and research of independent nursing. Careful examination of emergency nursing reveals that most actions are collaborative actions; NANDA’s greatest strength is the definition of exclusive nursing practice. Much of the emergency nurse’s time is spent anticipating, administering, and monitoring medically driven
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CLINICAL/Castner
treatments, making it difficult to define the nurse’s exclusive function aside from other disciplines. In comparison with other nursing specialties, emergency nurses are in an environment where medical and other health care professionals are immediately available and involved in patient care and collaborative actions are identified, ordered, and carried out in incredibly rapid succession. For example, when a patient arrives with a compromised airway, the expert emergency nurse autonomously initiates positioning, suction, and administration of oxygen, prepares equipment for intubation, secures intravenous line access, and may request an order to ready a sedative and paralytic before the physician reaches the bedside. Teasing out only exclusive nursing diagnosis and functions at the point of care distracts from the important collaborative role. When a patient with chest pain arrives, the nurse often gathers a brief medical history, initiates intravenous line access, begins monitoring, administers oxygen, obtains an EKG, and considers the appropriateness of first-line medications nearly simultaneously. The nursing process and the role in collaborative diagnosis and treatment are eclipsed. In addition to minimizing collaborative decisions, NANDA is limited by academic wording and a focus on comprehensive assessment. NANDA labels appear to be an academic ref lection of the nursing process rather than the actual bedside decision made to direct care. In the emergency department, where a rapid salvo of focused assessments is interrupted by the decision to carry out priority interventions, a diagnosis that requires comprehensive assessment is unrealistic for the practice of emergency nursing. Unfortunately, the process of documenting nursing diagnosis has been overlooked or purposefully dropped in some emergency departments because of the limited usefulness of NANDA. A common undocumented use of nursing diagnosis in the emergency department is the triage nurse’s choice of protocols. He or she has chosen key signs and symptoms from the myriad of assessment findings available to direct collaborative care and intervention. The process of defining and documenting emergency nursing decisions directs quality patient interventions, enhances teaching and researching decision-making, organizes priorities in assessment, and standardizes, enhances, and credits the use of nursing direction in emergency care.
34
A system of nursing diagnosis that reflects actual emergency nursing processes and is easily documented to meet nursing standards must be established to direct the nurse to priority interventions. The NANDA diagnostic labels of ‘‘Airway clearance, ineffective,’’ ‘‘Gas exchange, impaired,’’ ‘‘Cardiac output, alteration,’’ and ‘‘Breathing pattern, ineffective’’ attempt to describe some of the diagnostic labels used by emergency nurses.4 However, at the actual decision point, emergency nurses rarely if ever organize their thoughts in this academic wording. Experienced and certified emergency nurses acknowledge that anticipating and understanding the medical diagnosis is a driving factor in proper emergency nursing care and must be given consideration in the nursing process.5,6 Nursing remains an independent body of knowledge, but the 2 spheres of medical and nursing science are closely aligned in the ED setting, unlike other health care settings where they may barely overlap. An emergency nurse’s diagnosis list needs to address the truly interdisciplinary nature of our work rather than attempting to label thought processes in an exclusive vacuum. Most often, emergency nurses use the collaborative ABC checklist or system assessment, and the actual nursing decision uses the template ‘‘Nursing care needed: System: Clarifier’’ (see Tables 1 and 2 for suggested checklists of system). This system is user friendly at the point of decision because it is simply organized, easily prioritized, easy to recall, plainly worded, and lends itself to an easily documented diagnosis. The clarifier is individualized to the patient and expertise level of the nurse. The most clinically relevant symptom or symptoms ascertained to direct care are noted. To limit redundancy, there is no need to use entire clusters of symptoms found in this phase. Examples of clarifiers include chest pain, abdominal pain, vaginal bleeding, altered level of consciousness, f lank pain, suicidal ideation, and dyspnea with fever. The clarifier is left to the individual nurse’s priority assessment, and the nurse may use his or her own words. Therefore, the nursing diagnosis for a patient with nausea, vomiting, diaphoresis, shortness of breath, and chest pressure would be ‘‘Nursing care needed: Cardiovascular: chest pain.’’ The patient vomiting coffee ground emesis might be ‘‘Nursing care needed: Gastrointestinal and Cardiovascular: potential bleeding.’’ When giving discharge instructions to a patient who rides
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February 2008
CLINICAL/Castner
TABLE 1
TABLE 2
Nursing diagnosis checklist for the emergency department based on grouping NANDA diagnoses
Nursing diagnosis checklist for the emergency department based on systems assessed
Nursing care needed: Airway Breathing Circulation Comfort Compliance* Elimination Family and support Emotions/feelings Injury/infection Teaching/learning Nutrition Self-care Spirit Thoughts/mental Growing/parenting
Nursing care needed: Respiratory Cardiovascular Neurologic Metabolic Gastrointestinal Genitourinary Musculoskeletal Integument Eye, ear, nose, throat Emotional Psychological Spiritual
NANDA, North American Nursing Diagnosis Association. *Includes adherence to national recommendations such as smoking cessation, diet, and exercise, as well as safety laws.
a motorcycle without a helmet, the diagnosis may be ‘‘Nursing care needed: Compliance: state motorcycle helmet law.’’ More controversially, the expert emergency nurse may wish to list the potential medical diagnosis suspected, such as ‘‘Nursing care needed: Genitourinary and Emotional: potential threatened abortion,’’ ‘‘Nursing care needed: Neurological: potential stroke,’’ or ‘‘Nursing care needed: Airway, potential epiglottitis.’’ Careful wording is necessary to ensure the emergency nurse remains within his or her legal scope of practice while accurately documenting the decision and direction of collaborative interventions. Criticisms of such a check list may include limiting the holistic nursing approach, disconnecting the specialty of emergency nursing from other nursing specialties, or undermining the unique and autonomous contributions emergency nurses make to emergency care by using medical language and systems. Holistic nursing may be enhanced by ensuring that at least one comfort, compliance, self-care, or emotional assessment finding is diagnosed in each visit. The proposed checklists use a language common to the nursing profession that other specialties should not
February 2008
34:1
have difficulty in understanding and incorporating. The wording pragmatically ref lects actual practice of decision making and may even enhance nursing continuity. Reorganizing the ideas of nursing diagnosis into simply worded, easy-to-recall dimensions would augment the thought system proficient nurses already use and expand the practicality, bedside legitimacy, and use of nursing diagnosis. Acknowledging the more collaborative nature of our work does not undermine the emergency nurse’s importance or independence. Rather, the diagnostic labels do not capture the indispensable and unique contributions emergency nursing contribute to health care. Some unique and important functions of the emergency nurse include: 1. Managing patient f low to ensure the most efficient access to emergency care 2. Autonomously anticipating and initiating the direction of collaborative care 3. Ensuring the safety of patients by serving as a check to the appropriateness of ordered interventions 4. Adding quality to all emergency care through individualizing patient education, emotional and spiritual support, and environmental control 5. Monitoring therapies of all disciplines administered for expected and detrimental effects 6. Coordinating and prioritizing the care of all disciplines
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CLINICAL/Castner
7. Remaining exquisitely in tune to clusters and causative factors in emergency care related to social policy, insurance, injury prevention, and patient population characteristics, including reporting and educating the public on these topics These nursing actions are of national importance, because the Institute of Medicine has identified access to emergency care and safety in the delivery of health care as national priorities.7,8 These nationally prioritized and unique functions of emergency nurses are not properly defined in NANDA at this time. Streamlining and simplifying nursing diagnosis in the emergency setting ref lect the actual thought processes of the emergency nurse, lend to the collaborative nature of emergency nursing, and provide for easy documentation and compliance with nursing standards. This article attempts to provide an alternative to NANDA diagnosis that is more useful to the emergency nurse. These systems will need refinement and debate to ensure continued usefulness and appropriateness and to standardize the clarifiers used. Potential research topics highlighted by this subject include identifying the most common wording emergency nurses use at the point of delivery and diagnosis, qualitatively investigating what decisions emergency nurses make, recording the amount of time and importance to outcomes of collaborative versus independent nursing care in the emergency setting, quantifying how nurses enhance the safety and quality of emergency care, and identifying accuracy of the proposed diagnosis and influence on patient care and outcomes.
7. Institute of Medicine. Emergency medical services: at the crossroads. Washington (DC): The National Academies Press; 2006. 8. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington (DC): National Academies Press; 2006.
REFERENCES 1. Emergency Nurses Association. Scope of emergency nursing practice (online). Available from: URL: http://www.ena.org/pdf/ scopeEmNP.PDF. 2. North American Nursing Diagnosis Association. Home page (online). Available from: URL: http://nanda.org. 3. North American Nursing Diagnosis Association. About NANDA International (online). Available from: URL: http://nanda.org/html/ about.html. 4. Carpenito LJ. Handbook of nursing diagnosis. 7th ed. Philadelphia: Lippincott; 1999. 5. Emergency Nurses Association. CEN review manual. 3rd ed. Dubuque (IA): Kendall/Hunt; 2001. 6. Emergency Nurses Association. Sheehy’s manual of emergency care. 6th ed. St Louis: Elsevier Mosby; 2005.
36
JOURNAL OF EMERGENCY NURSING
34:1
February 2008
Emergency Nursing Decisions: A Proposed System of Nursing Diagnosis Author: Jessica Castner, RN, MSN, CEN, Buffalo, NY
Jessica Castner, Nevada Chapter, is Clinical Assistant Professor, D’Youville College, Buffalo, NY, and Emergency Staff RN, Buffalo General Hospital, Buffalo, NY. For correspondence, E-mail: Jessica Castner, RN, MSN: [email protected]. J Emerg Nurs 2008;34:33-6. Available online 16 August 2007. 0099-1767/$34.00 Copyright n 2008 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.12.020
February 2008
34:1
E
mergency nurses make important life or death decisions. The decisions, or nursing diagnoses, often go undocumented and unrecognized because the process is not accurately reflected in standardized nursing diagnosis lists. A new set of nursing diagnoses that ref lects actual emergency nursing decisions and complies with nursing standards needs to be formulated. ENA recommends that the staff nurse perform and document all steps of the nursing process, including nursing diagnosis, as a minimum standard of nursing care.1 Diagnosis articulates the decisions the nurse has made by giving meaning and direction to assessment findings, and it labels the patient’s priority needs. Although one of the original purposes of formulating nursing diagnoses was to define nursing practice, emergency nurses should not solely rely on nursing diagnosis to define their unique and important contributions to emergency care.2 The North American Nursing Diagnosis Association (NANDA) approves a list of nursing diagnoses geared at decision processes and actions unique to nursing.3 The documents approved by NANDA are the most commonly used set of diagnostic labels in the nursing profession. This list helps define exclusive nursing practice aside from other disciplines, ensures that the nursing process is documented in patient records, acts as a potential reimbursement system, and creates an organizational framework for theory and research of independent nursing. Careful examination of emergency nursing reveals that most actions are collaborative actions; NANDA’s greatest strength is the definition of exclusive nursing practice. Much of the emergency nurse’s time is spent anticipating, administering, and monitoring medically driven
JOURNAL OF EMERGENCY NURSING
33
CLINICAL/Castner
treatments, making it difficult to define the nurse’s exclusive function aside from other disciplines. In comparison with other nursing specialties, emergency nurses are in an environment where medical and other health care professionals are immediately available and involved in patient care and collaborative actions are identified, ordered, and carried out in incredibly rapid succession. For example, when a patient arrives with a compromised airway, the expert emergency nurse autonomously initiates positioning, suction, and administration of oxygen, prepares equipment for intubation, secures intravenous line access, and may request an order to ready a sedative and paralytic before the physician reaches the bedside. Teasing out only exclusive nursing diagnosis and functions at the point of care distracts from the important collaborative role. When a patient with chest pain arrives, the nurse often gathers a brief medical history, initiates intravenous line access, begins monitoring, administers oxygen, obtains an EKG, and considers the appropriateness of first-line medications nearly simultaneously. The nursing process and the role in collaborative diagnosis and treatment are eclipsed. In addition to minimizing collaborative decisions, NANDA is limited by academic wording and a focus on comprehensive assessment. NANDA labels appear to be an academic ref lection of the nursing process rather than the actual bedside decision made to direct care. In the emergency department, where a rapid salvo of focused assessments is interrupted by the decision to carry out priority interventions, a diagnosis that requires comprehensive assessment is unrealistic for the practice of emergency nursing. Unfortunately, the process of documenting nursing diagnosis has been overlooked or purposefully dropped in some emergency departments because of the limited usefulness of NANDA. A common undocumented use of nursing diagnosis in the emergency department is the triage nurse’s choice of protocols. He or she has chosen key signs and symptoms from the myriad of assessment findings available to direct collaborative care and intervention. The process of defining and documenting emergency nursing decisions directs quality patient interventions, enhances teaching and researching decision-making, organizes priorities in assessment, and standardizes, enhances, and credits the use of nursing direction in emergency care.
34
A system of nursing diagnosis that reflects actual emergency nursing processes and is easily documented to meet nursing standards must be established to direct the nurse to priority interventions. The NANDA diagnostic labels of ‘‘Airway clearance, ineffective,’’ ‘‘Gas exchange, impaired,’’ ‘‘Cardiac output, alteration,’’ and ‘‘Breathing pattern, ineffective’’ attempt to describe some of the diagnostic labels used by emergency nurses.4 However, at the actual decision point, emergency nurses rarely if ever organize their thoughts in this academic wording. Experienced and certified emergency nurses acknowledge that anticipating and understanding the medical diagnosis is a driving factor in proper emergency nursing care and must be given consideration in the nursing process.5,6 Nursing remains an independent body of knowledge, but the 2 spheres of medical and nursing science are closely aligned in the ED setting, unlike other health care settings where they may barely overlap. An emergency nurse’s diagnosis list needs to address the truly interdisciplinary nature of our work rather than attempting to label thought processes in an exclusive vacuum. Most often, emergency nurses use the collaborative ABC checklist or system assessment, and the actual nursing decision uses the template ‘‘Nursing care needed: System: Clarifier’’ (see Tables 1 and 2 for suggested checklists of system). This system is user friendly at the point of decision because it is simply organized, easily prioritized, easy to recall, plainly worded, and lends itself to an easily documented diagnosis. The clarifier is individualized to the patient and expertise level of the nurse. The most clinically relevant symptom or symptoms ascertained to direct care are noted. To limit redundancy, there is no need to use entire clusters of symptoms found in this phase. Examples of clarifiers include chest pain, abdominal pain, vaginal bleeding, altered level of consciousness, f lank pain, suicidal ideation, and dyspnea with fever. The clarifier is left to the individual nurse’s priority assessment, and the nurse may use his or her own words. Therefore, the nursing diagnosis for a patient with nausea, vomiting, diaphoresis, shortness of breath, and chest pressure would be ‘‘Nursing care needed: Cardiovascular: chest pain.’’ The patient vomiting coffee ground emesis might be ‘‘Nursing care needed: Gastrointestinal and Cardiovascular: potential bleeding.’’ When giving discharge instructions to a patient who rides
JOURNAL OF EMERGENCY NURSING
34:1
February 2008
CLINICAL/Castner
TABLE 1
TABLE 2
Nursing diagnosis checklist for the emergency department based on grouping NANDA diagnoses
Nursing diagnosis checklist for the emergency department based on systems assessed
Nursing care needed: Airway Breathing Circulation Comfort Compliance* Elimination Family and support Emotions/feelings Injury/infection Teaching/learning Nutrition Self-care Spirit Thoughts/mental Growing/parenting
Nursing care needed: Respiratory Cardiovascular Neurologic Metabolic Gastrointestinal Genitourinary Musculoskeletal Integument Eye, ear, nose, throat Emotional Psychological Spiritual
NANDA, North American Nursing Diagnosis Association. *Includes adherence to national recommendations such as smoking cessation, diet, and exercise, as well as safety laws.
a motorcycle without a helmet, the diagnosis may be ‘‘Nursing care needed: Compliance: state motorcycle helmet law.’’ More controversially, the expert emergency nurse may wish to list the potential medical diagnosis suspected, such as ‘‘Nursing care needed: Genitourinary and Emotional: potential threatened abortion,’’ ‘‘Nursing care needed: Neurological: potential stroke,’’ or ‘‘Nursing care needed: Airway, potential epiglottitis.’’ Careful wording is necessary to ensure the emergency nurse remains within his or her legal scope of practice while accurately documenting the decision and direction of collaborative interventions. Criticisms of such a check list may include limiting the holistic nursing approach, disconnecting the specialty of emergency nursing from other nursing specialties, or undermining the unique and autonomous contributions emergency nurses make to emergency care by using medical language and systems. Holistic nursing may be enhanced by ensuring that at least one comfort, compliance, self-care, or emotional assessment finding is diagnosed in each visit. The proposed checklists use a language common to the nursing profession that other specialties should not
February 2008
34:1
have difficulty in understanding and incorporating. The wording pragmatically ref lects actual practice of decision making and may even enhance nursing continuity. Reorganizing the ideas of nursing diagnosis into simply worded, easy-to-recall dimensions would augment the thought system proficient nurses already use and expand the practicality, bedside legitimacy, and use of nursing diagnosis. Acknowledging the more collaborative nature of our work does not undermine the emergency nurse’s importance or independence. Rather, the diagnostic labels do not capture the indispensable and unique contributions emergency nursing contribute to health care. Some unique and important functions of the emergency nurse include: 1. Managing patient f low to ensure the most efficient access to emergency care 2. Autonomously anticipating and initiating the direction of collaborative care 3. Ensuring the safety of patients by serving as a check to the appropriateness of ordered interventions 4. Adding quality to all emergency care through individualizing patient education, emotional and spiritual support, and environmental control 5. Monitoring therapies of all disciplines administered for expected and detrimental effects 6. Coordinating and prioritizing the care of all disciplines
JOURNAL OF EMERGENCY NURSING
35
CLINICAL/Castner
7. Remaining exquisitely in tune to clusters and causative factors in emergency care related to social policy, insurance, injury prevention, and patient population characteristics, including reporting and educating the public on these topics These nursing actions are of national importance, because the Institute of Medicine has identified access to emergency care and safety in the delivery of health care as national priorities.7,8 These nationally prioritized and unique functions of emergency nurses are not properly defined in NANDA at this time. Streamlining and simplifying nursing diagnosis in the emergency setting ref lect the actual thought processes of the emergency nurse, lend to the collaborative nature of emergency nursing, and provide for easy documentation and compliance with nursing standards. This article attempts to provide an alternative to NANDA diagnosis that is more useful to the emergency nurse. These systems will need refinement and debate to ensure continued usefulness and appropriateness and to standardize the clarifiers used. Potential research topics highlighted by this subject include identifying the most common wording emergency nurses use at the point of delivery and diagnosis, qualitatively investigating what decisions emergency nurses make, recording the amount of time and importance to outcomes of collaborative versus independent nursing care in the emergency setting, quantifying how nurses enhance the safety and quality of emergency care, and identifying accuracy of the proposed diagnosis and influence on patient care and outcomes.
7. Institute of Medicine. Emergency medical services: at the crossroads. Washington (DC): The National Academies Press; 2006. 8. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington (DC): National Academies Press; 2006.
REFERENCES 1. Emergency Nurses Association. Scope of emergency nursing practice (online). Available from: URL: http://www.ena.org/pdf/ scopeEmNP.PDF. 2. North American Nursing Diagnosis Association. Home page (online). Available from: URL: http://nanda.org. 3. North American Nursing Diagnosis Association. About NANDA International (online). Available from: URL: http://nanda.org/html/ about.html. 4. Carpenito LJ. Handbook of nursing diagnosis. 7th ed. Philadelphia: Lippincott; 1999. 5. Emergency Nurses Association. CEN review manual. 3rd ed. Dubuque (IA): Kendall/Hunt; 2001. 6. Emergency Nurses Association. Sheehy’s manual of emergency care. 6th ed. St Louis: Elsevier Mosby; 2005.
36
JOURNAL OF EMERGENCY NURSING
34:1
February 2008