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You are probably wondering, “What is scope of practice? What does it mean for me and my nursing practice?” Scope of practice is defined as services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license.^{American Nurses Association. (n.d.). Scope of practice. https://www.nursingworld.org/practice-policy/scope-of-practice/} Nursing scope of practice provides a framework and structured guidance for activities one can perform based on their nursing license. As a nurse and a nursing student, is always important to consider: Just because your employer asks you to do a task…can you perform this task according to your scope of practice – or are you putting your nursing license at risk?

Nurses must also follow legal standards in when providing nursing care. Standards are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, and federal regulators. These standards assure safe, competent care is provided to the public.

This chapter will provide an overview of basic concepts related to nursing scope of practice and standards of care.

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Brief History of Nursing

Before discussing scope and standards of nursing care, it is helpful to briefly review a history of the nursing profession. Florence Nightingale is considered to be the founder of modern nursing practice. In 1860 she established the first nursing school in the world. By establishing this school of nursing, Nightingale promoted the concept of nurses as a professional, educated workforce of caregivers for the sick.^{Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/}  See Figure 1.1^{“Florence Nightingale (H Hering NPG x82368).jpg” by Henry Hering (1814-1893) is in the Public Domain} for a portrait of Florence Nightingale. Florence Nightingale’s contributions to health care started during the Crimean War in 1854. Her team discovered that poor health care for wounded soldiers was being delivered by overworked medical staff in a dirty environment. Florence recorded the mortality rate in the hospital and created statistical models that demonstrated that out of every 1,000 injured soldiers, 600 were dying because of preventable communicable and infectious diseases. Florence’s nursing interventions were simple; she focused on providing a clean environment, clean water, and good nutrition to promote healing, such as providing fruit as part of the care for the wounded soldiers. With these simple actions, the mortality rate of the soldiers decreased from 60% to 2.2%. In 1859 Nightingale wrote a book titled Notes on Nursing that served as the cornerstone of the Nightingale School of Nursing curriculum. Nightingale believed in the importance of placing a patient in a environment that promoted healing where they could recover from disease. She promoted this knowledge as distinct from medical knowledge. Her emphasis on the value of the environment formed many of the foundational principles that we still use in creating a healing health care setting today. She also insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. She promoted the concept of confidentiality, stating a nurse “should never answer questions about her sick except to those who have a right to ask them.”^{Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/.} These nursing concepts formed the foundation of nursing practice as we know it today.

Modern nursing has reinvented itself a number of times as health care has advanced and changed over the past 160 years. With more than four million members, the nursing profession represents the largest segment of the United States’ health care workforce. Nursing practice covers a broad continuum, including health promotion, disease prevention, coordination of care, and palliative care when cure is not possible. Nurses directly affect patient care and provide the majority of patient assessments, evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces, and ambulatory settings. They are at the front lines in ensuring that patient care is delivered safely, effectively, and compassionately. Additionally, nurses attend to patients and their families in a holistic way that often goes beyond physical health needs and recognize social, mental, emotional, and spiritual needs.^{Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK209880/57413/}

American Nurses Association (ANA)

The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.”^{American Nurses Association. (n.d.). About ANA. https://www.nursingworld.org/ana/about-ana/} The ANA states that it exists to advance the nursing profession by doing the following:

• Fostering high standards of nursing practice
• Promoting a safe and ethical work environment
• Bolstering the health and wellness of nurses
• Advocating on health care issues that affect nurses and the public^{American Nurses Association. (n.d.). About ANA. https://www.nursingworld.org/ana/about-ana/}

The ANA sets many standard of care for professional nurses that will be discussed in the next section.

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Standards for nursing care are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, federal regulators, and other professional nursing organizations. These standards assure safe, competent care is provided to the public.

ANA Scope and Standards of Practice

The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal Considerations and Ethics” subsection of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently. ^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association}

The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised definition of nursing: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.

Nursing practice occurs “when” there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where” there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.

The Standards of Professional Nursing Practice are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Each of these standards is further discussed in the “Nursing Process” chapter of this book.

The Standards of Professional Performance are 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society. ^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} The 2021 Standards of Professional Performance are as follows:

• Ethics. The registered nurse integrates ethics in all aspects of practice.
• Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
• Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
• Communication. The registered nurse communicates effectively in all areas of professional practice.
• Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
• Leadership. The registered nurse leads within the profession and practice setting.
• Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
• Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
• Quality of Practice. The registered nurse contributes to quality nursing practice.
• Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
• Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
• Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, you must be dedicated to serve your community according to the ANA standards of care and code of ethics.^{Bostain, L. (2020, June 25). Nursing professionalism begins with you. American Nurse. https://www.myamericannurse.com/nursing-professionalism-begins-with-you/}

Nurse Practice Act

In addition to the professional standards of practice and professional performance set by the American Nurses Association, nurses must legally follow regulations set by the Nurse Practice Act and enforced by the Board of Nursing in the state where they are employed. The Board of Nursing is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates, based on the Nurse Practice Act enacted by that state’s legislature. The Nurse Practice Act establishes regulations for nursing practice within that state and defines the scope of nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the Board of Nursing.

To read more about the the Wisconsin Board of Nursing, Standards of Practice, and Rules of Conduct, use the hyperlinked PDFs provided below.^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf}

Nursing students must understand their scope of practice outlined in their state’s Nurse Practice Act. Nursing students are legally accountable for the quality of care they provide to patients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert individuals in authority regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.

Employer Policies, Procedures, and Protocols

In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every patient. If a nurse did not follow this policy and a patient developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow.  For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a patient’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing patient care.

Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing patient care.

Federal Regulations

In addition to nursing scope of practice and standards being defined by the American Nurses Association, state Nurse Practice Acts, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as the Joint Commission and the Centers for Medicare and Medicaid.

The Joint Commission

The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.^{The Joint Commission. (n.d.). https://www.jointcommission.org/} The Joint Commission sets standards for providing safe, high-quality health care.

National Patient Safety Goals

The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns.^{The Joint Commission. (n.d.). National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/} For example, National Patient Safety Goals for hospitals include the following:

• Identify Patients Correctly
• Improve Staff Communication
• Use Medicines Safely
• Use Alarms Safely
• Prevent Infection
• Identify Patient Safety Risks
• Prevent Mistakes in Surgery

Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily patient care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, bar code scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.

Use the hyperlinks provided below to read more about The Joint Commission and National Patient Safety Goals.

Joint Commission Center for Transforming Healthcare

The Joint Commission Center for Transforming Healthcare was developed in 2008 to help agencies develop effective solutions for critical safety problems with a goal to ultimately achieve zero harm to patients. Some of the projects the Center has developed include improved hand hygiene, effective handoff communications, and safe and effective use of insulin. The Center has also been instrumental in creating a focus on a safety culture in health care organizations. A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about patient risks and to report errors and near misses, all of which drive improvement in patient care and reduce the incidences of patient harm.^{Joint Commission Center for Transforming Healthcare. (n.d.). Creating a safety culture. https://www.centerfortransforminghealthcare.org/why-work-with-us/video-resources/creating-a-safety-culture} Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of patient harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about creating a safety culture, use the hyperlink provided below.

Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is another federal agency  that establishes regulations that affect nursing care. CMS is a part of the U.S. Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid. The CMS establishes and enforces regulations to protect patient safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to patients. This CMS regulation is often referred to as “checking the rights of medication administration.” You can read more information about checking the rights of medication administration in the “Administration of Enteral Medications” chapter of the Open RN Nursing Skills textbook.^{This work is a derivative of Nursing Skills by Open RN and is licensed under CC BY 4.0}

CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their patient outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal patient outcomes and maximum reimbursement.

Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.

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Health Care Settings

There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.

Primary Care

Primary care promotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.

Secondary care

Secondary care occurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the patient needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as burn care, neurosurgery, cardiac surgery, and transplant services.

Tertiary Care

Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a patient’s maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a patient who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Patients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.

Health Care Team

No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.

Health Care Providers

The Wisconsin Nurse Practice Act defines a provider as, “A physician, podiatrist, dentist, optometrist, or advanced practice nurse.”^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf} Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a patient’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the patient’s medical record with associated prescriptions (otherwise known as “orders”). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each patient is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe patient care. Providers typically visit hospitalized patients daily in what is referred to as “rounds.” It is helpful for nurses and nursing students to attend provider rounds for their assigned patients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and patient have a clear understanding of the goals of care and minimize the need for follow-up phone calls.

Nurses

There are three levels of nurses as defined by each state’s Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Nurse (APRN).

Licensed Practical/Vocational Nurses

The NCSBN defines a licensed practical nurse (LPN) as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide patient care.”^{NCSBN. https://www.ncsbn.org/} In some states, the term licensed vocational nurse (LVN) is used. LPN/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician.^{NCSBN. https://www.ncsbn.org/index.htm} LPNs provide “basic nursing care” and work with stable and/or chronically ill populations. Basic nursing care is defined by the Wisconsin Nurse Practice Act as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.”^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf} LPN/LVNs typically collect patient assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RN Nursing Skills textbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.

Registered Nurses

The NCSBN defines a Registered Nurse as “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide patient care.”^{NCSBN. https://www.ncsbn.org/index.htm} Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding patient care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.

Advanced Practice Nurses

Advanced Practice Nurses (APRN) are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Nurses: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.

Unlicensed Assistive Personnel

Unlicensed Assistive Personnel (UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.”^{NCSBN. https://www.ncsbn.org/index.htm}

CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist patients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect patient information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.

Interprofessional Team Members

Nurses, as the coordinator of a patient’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the patient toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.

Chain of Command

Nurses rarely make patient decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about patient care are typically communicated according to that agency’s chain of command. In the military, chain of command refers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the “vice president of nursing.” In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about patient care before “going up the chain of command.”

Nurse Specialties

Registered nurses can obtain several types of certifications as a nurse specialist. Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.

Now that we have discussed various settings where nurses work and various nursing roles, let’s review levels of nursing education and the national licensure exam (NCLEX).

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Nursing Education and the NCLEX

Everyone who wants to become a nurse has a story to tell about why they want to enter the nursing profession. What is your story? Perhaps it has been a lifelong dream to become a Life Flight nurse, or maybe you became interested after watching a nurse help you or a family member through the birth of a baby, heal from a challenging illness, or assist a loved one at the end of life. Whatever the reason, everyone who wants to become a nurse must do two things: graduate from a state-approved nursing program and pass the National Council Licensure Exam (known as the NCLEX).

Nursing Programs

There are several types of nursing programs you can attend to become a nurse. If your goal is to become a Licensed Practical Nurse (LPN), you must successfully complete a one-year nursing program, pass the NCLEX-PN exam, and apply to your state board of nursing to receive a LPN license.

If you want to become a Registered Nurse, you can obtain either a two-year associate degree (ADN) or a four-year baccalaureate of science in nursing degree (BSN). Associate degree nursing graduates often enroll into a baccalaureate or higher degree program after they graduate. Many hospitals hire ADN nurses on a condition they complete their BSN within a specific time frame. A BSN is required for military nursing, case management, public health nursing, and school-based nursing services. Another lesser-known option to become an RN is to complete a three-year hospital-based diploma program, which was historically the most common way to become a nurse. Diploma programs have slowly been replaced by college degrees, and now only nine states offer this option.^{NCSBN. (2019). 2018 NCLEX examination statistics 77. https://www.ncsbn.org/2018_NCLEXExamStats.pdf} After completing a diploma program, associate degree, or baccalaureate degree, nursing graduates must successfully pass the NCLEX-RN to apply for a registered nursing license from their state’s Board of Nursing.

NCLEX

Nursing graduates must successfully pass the National Council Licensure Examination (NCLEX) to receive a nursing license. Registered nurses must successfully pass the NCLEX-RN exam, and Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) must pass the NCLEX-PN exam.

The NCLEX-PN and NCLEX-RN are online, adaptive tests taken at a specialized testing center. The NCLEX tests knowledge, skills, and abilities essential to the safe and effective practice of nursing at the entry level. NCLEX exams are continually reviewed and updated based on surveys of newly graduated nurses every three years.

Both the NCLEX-RN and the NCLEX-PN are variable length tests that adapt as you answer the test items. The NCLEX-RN examination can be anywhere from 75 to 265 items, depending on how quickly you are able to demonstrate your proficiency. Of these items, 15 are unscored test items. The time limit for this examination is six hours. The NCLEX-PN examination can be anywhere from 85 to 205 items. Of these items, 25 are unscored items. The time limit for this examination is five hours.^{NCSBN. (2019). NCLEX & Other Exams. https://www.ncsbn.org/nclex.htm}

In 2023, the Next Generation NCLEX (NGN) is anticipated to go into effect.  Examination questions on the NGN will use the new Clinical Judgment Measurement Model as a framework to measure prelicensure nursing graduates’ clinical judgment and decision-making. The critical thinking model called the “Nursing Process” (discussed in Chapter 4 of this book) will continue to underlie the NGN, but candidates will notice new terminology used to assess their decision-making. For example, candidates may be asked to “recognize cues,” “analyze cues,” “create a hypothesis,” “prioritize hypotheses,” “generate solutions,” “take actions,” or “evaluate outcomes.”^{NCSBN. (2021). NCSBN Next Generation NCLEX Project. https://www.ncsbn.org/next-generation-nclex.htm} For this reason, many of the case studies and learning activities included in this book will use similar terminology as the NGN.

There will also be new types of examination questions on the NGN, including case studies, enhanced hot spots, drag and drop ordering of responses, multiple responses, and embedded answer choices within paragraphs of text. View sample NGN questions in the following hyperlink. NCSBN’s rationale for including these types of questions is to “measure the nursing clinical judgment and decision-making ability of prospective entry-level nurses to protect the public’s health and welfare by assuring that safe and competent nursing care is provided by licensed nurses.”^{NCSBN. (2021). NCSBN Next Generation NCLEX Project. https://www.ncsbn.org/next-generation-nclex.htm} Similar questions have been incorporated into learning activities throughout this textbook.

Use the hyperlinks below to read more information about the NCLEX and the Next Generation NCLEX.

Nurse Licensure Compact

The Nurse Licensure Compact (NLC) allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states. As of 2020, 33 states have implemented NLC legislation.

Advanced Nursing Degrees

After obtaining an RN license, nurses can receive advanced degrees to expand their opportunities in the nursing profession.

Master’s Degree in Nursing

A Master’s of Science in Nursing Degree (MSN) requires additional credits and years of schooling beyond the BSN. There are a variety of potential focuses in this degree, including Nurse Educator and Advanced Practice Nurse (APRN). Certifications associated with an MSN degree are Certified Nurse Educator (CNE), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), and Certified Nurse Midwife (CNM). Certifications require the successful completion of a certification exam, as well as continuing education requirements to maintain the certification. Scope of practice for advanced practice nursing roles is defined by each state’s Nurse Practice Act.

Doctoral Degrees in Nursing

Doctoral nursing degrees include the Doctor of Philosophy in Nursing (PhD) and the Doctor of Nursing Practice (DNP). PhD-prepared nurses complete doctoral work that is focused on research. They often teach in a university setting or environment to conduct research. DNP-prepared nurses complete doctoral work that is focused on clinical nursing practice. They typically have work roles in advanced nursing practice, clinical leadership, or academic settings.

Lifelong Learning

No matter what nursing role or level of nursing education you choose, nursing practice changes rapidly and is constantly updated with new evidence-based practices. Nurses must commit to lifelong learning to continue to provide safe, quality care to their patients. Many states require continuing education credits to renew RN licenses, whereas others rely on health care organizations to set education standards and ongoing educational requirements.

Now that we have discussed nursing roles and education, let’s review legal and ethical considerations in nursing.

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Legal Considerations

As discussed earlier in this chapter, nurses can be reprimanded or have their licenses revoked for not appropriately following the Nurse Practice Act in the state they are practicing. Nurses can also be held legally liable for negligence, malpractice, or breach of patient confidentiality when providing patient care.

Negligence and Malpractice

Negligence is a “general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.”^{Missouri Department of Health & Senior Services. (n.d.). Negligence and malpractice. https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circumstances.} Malpractice is a more specific term that looks at a standard of care, as well as the professional status of the caregiver.” ^{Missouri Department of Health & Senior Services. (n.d.). Negligence and malpractice. https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circumstances.}

To prove negligence or malpractice, the following elements must be established in a court of law:

• Duty owed the patient
• Breach of duty owed the patient
• Foreseeability
• Causation
• Injury
• Damages^{Missouri Department of Health & Senior Services. (n.d.). Negligence and malpractice. https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circumstances.}

To avoid being sued for negligence or malpractice, it is essential for nurses and nursing students to follow the scope and standards of practice care set forth by their state’s Nurse Practice Act; the American Nurses Association; and employer policies, procedures, and protocols to avoid the risk of losing their nursing license. Examples of nurses breach of duty that can be viewed as negligence include:^{Vera, M. (2020). Nursing care plan (NCP): Ultimate guide and database. https://nurseslabs.com/nursing-care-plans/#:~:text=Collaborative%20interventions%20are%20actions%20that,to%20gain%20their%20professional%20viewpoint.}

• Failure to Assess: Nurses should assess for all potential nursing problems/diagnoses, not just those directly affected by the medical disease. For example, all patients should be assessed for fall risk and appropriate fall precautions implemented.
• Insufficient monitoring: Some conditions require frequent monitoring by the nurse, such as risk for falls, suicide risk, confusion, and self-injury.
• Failure to Communicate:
  • Lack of documentation: A basic rule of thumb in a court of law is that if an assessment or action was not documented, it is considered not done. Nurses must document all assessments and interventions, in addition to the specific type of patient documentation called a nursing care plan.
  • Lack of provider notification: Changes in patient condition should be urgently communicated to the health care provider based on patient status. Documentation of provider notification should include the date, time, and person notified and follow-up actions taken by the nurse.

• Failure to Follow Protocols: Agencies and states have rules for reporting certain behaviors or concerns. For example, a nurse is required to report suspicion of patient, child, or elder abuse based on data gathered during an assessment.

Patient Confidentiality

In addition to negligence and malpractice, patient confidentiality is a major legal consideration for nurses and nursing students. Patient confidentiality is the right of an individual to have personal, identifiable medical information, referred to as protected health information (PHI), kept private. This right is protected by federal regulations called the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was enacted in 1996 and was prompted by the need to ensure privacy and protection of personal health records and data in an environment of electronic medical records and third-party insurance payers. There are two main sections of HIPAA law, the Privacy Rule and the Security Rule. The Privacy Rule addresses the use and disclosure of individuals’ health information. The Security Rule sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information. HIPAA regulations extend beyond medical records and apply to patient information shared with others. Therefore, all types of patient information should only be shared with health care team members who are actively providing care to them.

How do HIPAA regulations affect you as a student nurse? You are required to adhere to HIPAA guidelines from the moment you begin to provide patient care. Nursing students may be disciplined or expelled by their nursing program for violating HIPAA. Nurses who violate HIPAA rules may be fired from their jobs or face lawsuits. See the following box for common types of HIPAA violations and ways to avoid them.

Social Media Guidelines

Nursing students, nurses, and other health care team members must use extreme caution when posting to Facebook, Instagram, Twitter, Snapchat, and other social media sites. Information related to patients, patient care, and/or health care agencies should never be posted on social media; health care team members who violate this guideline can lose their jobs and may face legal action and students can be disciplined or expelled from their nursing program. Be aware that even if you think you are posting in a private group, the information can become public.

The American Nurses Association (ANA) has established the following principles for nurses using social media:^{American Nurses Association. (n.d.). Social media. https://www.nursingworld.org/social/}

• Nurses must not transmit or place online individually identifiable patient information.
• Nurses must observe ethically prescribed professional patient-nurse boundaries.
• Nurses should understand that patients, colleagues, organizations, and employers may view postings.
• Nurses should take advantage of privacy settings and seek to separate personal and professional information online.
• Nurses should bring content that could harm a patient’s privacy, rights, or welfare to the attention of appropriate authorities.
• Nurses should participate in developing organizational policies governing online conduct.

In addition to these principles, the ANA has also provided these tips for nurses and nursing students using social media:^{American Nurses Association. (n.d.). Social media. https://www.nursingworld.org/social/}

• Remember that standards of professionalism are the same online as in any other circumstance.
• Do not share or post information or photos gained through the nurse-patient relationship.
• Maintain professional boundaries in the use of electronic media. Online contact with patients blurs this boundary.
• Do not make disparaging remarks about patients, employers, or coworkers, even if they are not identified.
• Do not take photos or videos of patients on personal devices, including cell phones.
• Promptly report a breach of confidentiality or privacy.

Code of Ethics

In addition to legal considerations, there are also several ethical guidelines for nursing care.

There is a difference between morality, ethical principles, and a code of ethics. Morality refers to “personal values, character, or conduct of individuals within communities and societies.”^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/} An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). A code of ethics is set for a profession and makes their primary obligations, values, and ideals explicit.

The American Nursing Association (ANA) guides nursing practice with the Code of Ethics for Nurses.^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/} This code provides a framework for ethical nursing care and a guide for decision-making. The Code of Ethics for Nurses serves the following purposes:

• It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
• It is the profession’s nonnegotiable ethical standard.
• It is an expression of nursing’s own understanding of its commitment to society.^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/}

The ANA Code of Ethics contains nine provisions. See a brief description of each provision in the following box.

The ANA Center for Ethics and Human Rights

In addition to publishing the Code of Ethics, the ANA Center for Ethics and Human Rights was established to help nurses navigate ethical and value conflicts and life-and-death decisions, many of which are common to everyday practice.

Open Resources for Nursing (Open RN)

Professional Nursing Organizations

In addition to the ANA’s Nursing: Scope and Standards of Practice and Code of Ethics for Nurses, there are several professional nursing organizations that provide specialized standards for nursing care and promote continuous quality improvement. The following box contains examples of many organizations that significantly guide the overall nursing profession.

Open Resources for Nursing (Open RN)

The American Nursing Association (ANA), various professional nursing organizations, and federal agencies continually work to improve the quality of patient care. Nurses must also be individually dedicated to providing quality patient care based on current evidence-based practices.

Quality of Practice

One of the American Nurses Association (ANA) Standards of Professional Practice is “Quality of Practice.” This standard emphasizes that “nursing practice is safe, effective, efficient, equitable, timely, and person-centered.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} Quality is defined as, “The degree to which nursing services for healthcare consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} Every nurse is responsible for providing quality care to their patients by following the standards set forth by various organizations, as well as personally incorporating evidence-based practice. Quality is everyone’s responsibility and it takes the entire health care team to ensure that quality care is provided to each and every patient. For example, turning an immobile patient every two hours to prevent pressure injuries requires the dedication of many staff members throughout the day and night. Quality actions can also be formalized on a specific unit, such as the review of data related to patient falls with specific unit-based interventions formally put into place. This commitment to quality practice requires lifelong learning after you have completed your formal nursing education to remain current with new evidence-based practices.

Learning how to provide safe, quality nursing practice begins in nursing school. The Quality and Safety Education for Nurses (QSEN) project encourages future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.”^{QSEN Institute. (n.d.). Project overview. http://qsen.org/about-qsen/project-overview/} Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and implementing initiatives to resolve these gaps. Quality improvement is defined as the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, and educators – to make the changes that will lead to optimal patient outcomes (health), improved system performance (care), and enhanced professional development (learning).^{Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? BMJ Quality & Safety, 16(1), 2–3. https://doi.org/10.1136/qshc.2006.022046} As a nursing student, you can immediately begin to contribute to improving the quality of nursing practice by participating in quality improvement initiatives.

Open Resources for Nursing (Open RN)

Open Resources for Nursing (Open RN)

Advanced Practice Nurse (APRN): An RN who has a graduate degree and advanced knowledge. There are four categories of APRNs: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), or certified registered nurse anesthetist (CRNA). These nurses can diagnose illnesses and prescribe treatments and medications.^{NCSBN. https://www.ncsbn.org/index.htm}

ANA Standards of Professional Nursing Practice: Authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The Standards of Professional Nursing Practice describe a competent level of nursing practice as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

ANA Standards of Professional Performance: Standards that describe a competent level of behavior in the professional role of the nurse, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Basic nursing care: Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf}

Board of Nursing: The state-specific licensing and regulatory body that sets the standards for safe nursing care, decides the scope of practice for nurses within its jurisdiction, and issues licenses to qualified candidates.

Chain of command: A hierarchy of reporting relationships in an agency that establishes accountability and lays out lines of authority and decision-making power.

Code of ethics: A code that applies normative, moral guidance for nurses in terms of what they ought to do, be, and seek. A code of ethics makes the primary obligations, values, and ideals of a profession explicit.

Dysphagia: Impaired swallowing.

Ethical principle: An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness).

Evidence-based practice: A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Expressive aphasia: The impaired ability to form words and speak.

Licensed Practical Nurse/Vocational Nurse (LPN/LVN): An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by their state Board of Nursing to provide patient care.^{NCSBN. https://www.ncsbn.org/index.htm}

Malpractice: A specific term that looks at a standard of care, as well as the professional status of the caregiver.^{Missouri Department of Health & Senior Services. (n.d.). Negligence and malpractice. https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circumstances.}

Morality: Personal values, character, or conduct of individuals within communities and societies.^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/}

Negligence: A “general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.”^{Missouri Department of Health & Senior Services. (n.d.). Negligence and malpractice. https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circumstances.}

Nurse Licensure Compact (NLC): Allows a nurse to have one multistate license with the ability to practice in the home state and other compact states.

Nursing: Nursing integrates the art and science of caring and focused on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Nurse Practice Act (NPA): Legislation enacted by each state that establishes regulations for nursing practice within that state by defining the requirements for licensure, as well as the scope of nursing practice.

Patient confidentiality: Keeping your patient’s Protected Health Information (PHI) protected and known only by those health care team members directly providing care for the patient.

Primary care: Care that is provided to patients to promote wellness and prevent disease from occurring. This includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations.

Protocol: A precise and detailed written plan for a regimen of therapy.^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf}

Provider: A physician, podiatrist, dentist, optometrist, or advanced practice nurse provider.^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf}

Quality: The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Registered Nurse (RN): An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination, and is licensed by a state board of nursing to provide patient care.^{NCSBN. https://www.ncsbn.org/index.htm}

Safety culture: A culture established within health care agencies that empowers nurses, nursing students, and other staff members to speak up about risks to patients and to report errors and near misses, all of which drive improvement in patient care and reduce the incident of patient harm.

Scope of practice: Services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license.

Secondary care: Care that occurs when a person has contracted an illness or injury and is in need of medical care.

Tertiary care: A type of care that deals with the long-term effects from chronic illness or condition, with the purpose to restore physical and mental function that may have been lost. The goal is to achieve the highest level of functioning possible with this chronic illness.

Unlicensed Assistive Personnel: Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs) or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.^{NCSBN. https://www.ncsbn.org/index.htm}

Open Resources for Nursing (Open RN)

Strong communication skills are essential to provide safe, quality, patient-centered care. Nurses develop therapeutic relationships with patients and family members each day to ensure that health care concerns and needs are addressed. If communication breaks down, information exchange stops and needs go unidentified. Nurses optimize communication channels with patients and families by establishing trust and actively listening to health care concerns. Additionally, the nurse is vital for ensuring that information transfer occurs within the multidisciplinary team. Communication with other health care team members is professional, organized, accurate, complete, and concise. This chapter will review methods for establishing good communication.

Before getting started, view the following video and reflect on the often invisible needs of those around us and the difference we can make by creating caring human connections.

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Effective communication is one of the Standards of Professional Performance established by the American Nurses Association. The standard states, “The registered nurse communicates effectively in all areas of practice.”^{American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association.} There are several concepts related to effective communication such as demonstrating appropriate verbal and nonverbal communication, using assertive communication, being aware of personal space, and overcoming common barriers to effective communication.

Types of Communication

Verbal Communication

Effective communication requires each interaction to include a sender of the message, a clear and concise message, and a receiver who can decode and interpret that message. The receiver also provides a feedback message back to the sender in response to the received message. See Figure 2.1^{“Osgood-Schramm-model-of-communication.jpg“ by Jordan Smith at eCampus Ontario is licensed under CC BY 4.0. Access for free at https://ecampusontario.pressbooks.pub/communicationatwork/chapter/1-3-the-communication-process/} for an image of effective communication between a sender and receiver.

Nurses assist patients and their family members to understand health care needs and treatments by using verbal, nonverbal, and written communication. Verbal communication is more than just talking. Effective verbal communication is defined as an exchange of information using words understood by the receiver in a way that conveys professional caring and respect.^{This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0} Nurses who speak using extensive medical jargon or slang may create an unintended barrier to their own verbal communication processes. When communicating with others, it is important for the nurse to assess the receiver’s preferred method of communication and individual receiver characteristics that might influence communication, and subsequently adapt communication to meet the receiver’s needs. For example, the nurse may adapt postsurgical verbal instruction for a pediatric versus an adult patient. Although the information requirements regarding signs of infection, pain management, etc., might be similar, the way in which information is provided may be quite different based on developmental level. Regardless of the individual adaptations that are made, the nurse must be sure to always verify patient understanding.

Nonverbal Communication

In addition to communicating verbally, the nurse must also be aware of messages sent by nonverbal communication. Nonverbal communication can have a tremendous impact on the communication experience and may be much more powerful than the verbal message itself. You may have previously learned that 80% of communication is nonverbal communication (see Figure 2.2^{“Constituents of Communication.png” by jb11ko, lb13an, ad14xz, jb12xu is licensed under CC BY-SA 4.0}). The importance of nonverbal communication during communication has also been described in percentages of 55, 38, and 7, meaning 55% of communication is body language, 38% is tone of voice, and 7% is the actual words spoken.^{Thompson, J. (2011). Is nonverbal communication a numbers game? Psychology Today. https://www.psychologytoday.com/us/blog/beyond-words/201109/is-nonverbal-communication-numbers-game}

Nonverbal communication includes body language and facial expressions, tone of voice, and pace of the conversation. For example, compare the nonverbal communication messages in Figures 2.3^{“I’m angry” by WiLPrZ is licensed under CC BY-NC-ND 2.0} and 2.4.^{“Happy Toddler” by Chris Bloom is licensed under CC BY-SA 2.0} What nonverbal cues do you notice about both toddlers?

Nurses should be attentive to their nonverbal communication cues and the messages they provide to patients and their families. Nurses should be purposeful in their use of nonverbal communication that conveys a feeling of caring.^{This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0} What nonverbal cues do you notice about the nurse in Figure 2.5^{“PIXNIO-42752-4542×3003.jpg” by James Gathany, Judy Schmidt, USCDCP is in the Public Domain} that provide a perception of professional caring?

Nurses use nonverbal communication such as directly facing patients at eye level, leaning slightly forward, and making eye contact to communicate they care about what the person is telling them and they have their full attention.^{Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11(6), 395-398. https://doi.org/10.1016/j.nepr.2011.03.021}

Communication Styles

In addition to verbal and nonverbal communication, people communicate with others using three styles. A passive communicator puts the rights of others before their own. Passive communicators tend to be apologetic or sound tentative when they speak and often do not speak up if they feel as if they are being wronged. Aggressive communicators, on the other hand, come across as advocating for their own rights despite possibly violating the rights of others. They tend to communicate in a way that tells others their feelings don’t matter. However, assertive communicators respect the rights of others while also standing up for their own ideas and rights when communicating. An assertive person is direct, but not insulting or offensive.^{This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0} Assertive communication refers to a way of conveying information that describes the facts and the sender’s feelings without disrespecting the receiver’s feelings. Using “I” messages such as,  “I feel…,” “I understand…,” or “Help me to understand…” are strategies for assertive communication. This method of communicating is different from aggressive communication that uses “you” messages and can feel as if the sender is verbally attacking the receiver rather than dealing with the issue at hand. For example, instead of saying to a coworker, “Why is it always so messy in your patients’ rooms? I dread following you on the next shift!,” an assertive communicator would use “I” messages to say, “I feel frustrated spending the first part of my shift decluttering our patients’ rooms. Help me understand why it is a challenge to keep things organized during your shift?”

Using assertive communication is an effective way to solve problems with patients, coworkers, and health care team members.

Personal Space

While being aware of verbal and nonverbal messages and communicating assertively, it is also important to be aware of others’ personal space. Proxemics is the study of personal space and provides guidelines for professional communication. The public zone is over 10 feet of distance between people and generally avoids physical contact. The social zone is four to 10 feet of distance between people. It is used during social interactions and business settings. The personal zone is 18 inches to four feet of space and is generally reserved for friends and family. Less than 18 inches is reserved for close relationships but may be invaded when in crowds or playing sports.^{Psychology Today. (n.d.) Proxemics. https://www.psychologytoday.com/us/basics/proxemics} Nurses usually communicate within the social zone to maintain professional boundaries. However, when assessing patients and performing procedures, nurses often move into a patient’s personal zone. Nurses must be aware of patients’ feelings of psychological discomfort that can occur when invading this zone. Additionally, cultural considerations may impact the appropriateness of personal space when providing patient care. See Figure 2.6 for example of personal space zones.^{“Personal Space.svg” by WebHamster is licensed under CC BY-SA 3.0}

Overcoming Common Barriers to Communication

It is important for you to reflect on personal factors that influence your ability to communicate effectively. There are many factors that can cause the message you are trying to communicate to become distorted and not perceived by the receiver in the way you intended. It is important to seek feedback that your message is clearly understood. Nurses must be aware of these potential barriers and try to reduce their impact by continually seeking feedback and checking understanding.^{SkillsYouNeed. (n.d.). Barriers to effective communication. https://www.skillsyouneed.com/ips/barriers-communication.html}

Common barriers to communication in health care and strategies to overcome them are described in the following box.^{SkillsYouNeed. (n.d.). Barriers to effective communication. https://www.skillsyouneed.com/ips/barriers-communication.html}

Open Resources for Nursing (Open RN)

Therapeutic communication is a type of professional communication used by nurses with patients and defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.”^{Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968} Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients.^{Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/.} Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During active listening, we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening.^{This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0}

Touch

Touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 2.7^{Flickr – Official U.S. Navy Imagery – A nurse examines a newborn baby..jpg” by MC2 John O’Neill Herrera/U.S. Navy is in the Public Domain} for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nurses assist patients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication, nurses often ask open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own.^{American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/} Table 2.3a describes a variety of therapeutic communication techniques.^{American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/}

Table 2.3a Therapeutic Communication Techniques

In addition to the therapeutic techniques listed in Table 2.3a, nurses and nursing students should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others.^{Balchan, M. (2016). The Magic of Genuine Communication. http://michaelbalchan.com/communication/} Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors.^{Morrison, E. (2019). Empathetic Communication in Healthcare. https://www.cibhs.org/sites/main/files/file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691}

Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several nontherapeutic responses to avoid. These responses often block the patient’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses.^{Burke, A. (2021). Therapeutic Communication: NCLEX-RN. https://www.registerednursing.org/nclex/therapeutic-communication/} 

Table 2.3b Nontherapeutic Responses

Strategies for Effective Communication

In addition to using therapeutic communication techniques, avoiding nontherapeutic responses, and overcoming common barriers to communication, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like?^{Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/}

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized patients include the following:

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the patient’s treatment plan and progress. This information helps you to provide safe patient care as changes occur and also to accurately answer the patient’s questions.
• Review information periodically with the patient to improve understanding.
• Use patient communication boards in their room to set goals and communicate important reminders with the patient, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives patients and families the feeling that they always know the current plan of care. However, keep patient confidentiality in mind regarding information to publicly share on the board that visitors may see.
• Provide printed information on medical procedures, conditions, and medications. It helps patients and family members to have multiple ways to provide information.^{Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/}

Adapting Your Communication

When communicating with patients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to the patient’s age and developmental level includes the following strategies:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with patients who have impaired hearing and vision.^{Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116}

Patients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to portions of the brain that are responsible for language. Aphasia usually occurs suddenly, often following a stroke or head injury, and impairs the  patient’s expression and understanding of language. Global aphasia is caused by injuries to multiple language-processing areas of the brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly important for understanding spoken language, accessing vocabulary, using grammar, and producing words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.^{National Institute on Deafness and Other Communication Disorders (NIDCD). (2017, March 6). Aphasia. https://www.nidcd.nih.gov/health/aphasia}

The most common type of aphasia is Broca’s aphasia. People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. They are often aware of their difficulties and can become easily frustrated.  See the hyperlink in the box below for evidence-based strategies to enhance communication with a person with impaired speech.^{Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116.}

Maintaining Patient Confidentiality

When communicating with patients, their friends, their family members, and other members of the health care team, it is vital for the nurse to maintain patient confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) provides standards for ensuring privacy of patient information that are enforceable by law. Nurses must always be aware of where and with whom they share patient information. For example, information related to patient care should not be discussed in public areas, paper charts must be kept in secure areas, computers must be logged off when walked away from, and patient information should only be shared with those directly involved in patient care. For more information about patient confidentiality, see the “Legal Considerations & Ethics” section in the “Scope of Practice” chapter.

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Professional communication with other members of the health care team is an important component of every nurse’s job. See Figure 2.8^{“1322557028-huge.jpg” by LightField Studios is used under license from Shutterstock.com} for an image illustrating communication between health care team members. Common types of professional interactions include reports to health care team members, handoff reports, and transfer reports.

Reports to Health Care Team Members

Nurses routinely report information to other health care team members, as well as urgently contact health care providers to report changes in patient status.

Standardized methods of communication have been developed to ensure that information is exchanged between health care team members in a structured, concise, and accurate manner to ensure safe patient care. One common format used by health care team members to exchange patient information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

• • Introduction: Introduce your name, role, and the agency from which you are calling.
  • Situation: Provide the patient’s name and location, why you are calling, recent vital signs, and the status of the patient.
  • Background: Provide pertinent background information about the patient such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
  • Assessment: Share abnormal assessment findings and your evaluation of the current patient situation.
  • Request/Recommendations: State what you would like the provider to do, such as reassess the patient, order a lab/diagnostic test, prescribe/change medication, etc.
  • Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the patient’s chart.

Read an example of an ISBARR report in the following box. A hyperlink is provided to a printable ISBARR reference card.

Handoff Reports

Handoff reports are defined by The Joint Commission as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.”^{The Joint Commission. (n.d.). Sentinel event alert 58: Inadequate hand-off reports. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-58-inadequate-hand-off-communication/} In 2017, The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors. Strategies for improving handoff communication have been implemented at agencies across the country.

Although many types of nursing shift-to-shift handoff reports have been used over the years, evidence strongly supports that bedside handoff reports increase patient safety, as well as patient and nurse satisfaction, by effectively communicating current, accurate patient information in real time.^{Dorvil, B. (2018). The secrets to successful nurse bedside shift report implementation and sustainability. Nursing Management, 49(6), 20-25. https://doi.org/10.1097/01.NUMA.0000533770.12758.44} See Figure 2.9^{“618721604-huge” by Rido is used under license from Shutterstock.com.} for an image illustrating two nurses participating in a handoff report. Bedside reports typically occur in hospitals and include the patient, along with the off-going and the oncoming nurses in a face-to-face handoff report conducted at the patient’s bedside. HIPAA rules must be kept in mind if visitors are present or the room is not a private room. Family members may be included with the patient’s permission. See a sample checklist for a bedside handoff report from the Agency for Healthcare Research and Quality in Figure 2.10.^{“Strat3_Tool_2_Nurse_Chklst_508.pdf” by AHRQ is licensed under CC0} Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts. For example, the “assessment” portion of the bedside handoff report includes detailed pertinent data the oncoming nurse needs to know, such as current head-to-toe assessment findings to establish a baseline; information about equipment such as IVs, catheters, and drainage tubes; and recent changes in medications, lab results, diagnostic tests, and treatments.

Transfer Reports

Transfer reports are provided by nurses when transferring a patient to another unit or to another agency. Transfer reports contain similar information as bedside handoff reports, but are even more detailed when the patient is being transferred to another agency. Checklists are often provided by agencies to ensure accurate, complete information is shared.

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Using Technology to Access Information

Most patient information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain patient confidentiality. Intranet refers to a private computer network within an institution. An electronic health record (EHR) is a real-time, patient-centered record that makes information available instantly and securely to authorized users.^{HealthIT.gov. (2019, September 10). What is an electronic health record (EHR)? https://www.healthit.gov/faq/what-electronic-health-record-ehr} Computers used to access an EHR can be found in patient rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 2.11^{“Winn_Army_Community_Hospital_Pharmacy_Stays_Online_During_Power_Outage.jpg” by Flickr user MC4 Army is licensed under CC BY 2.0} for an image of a nurse documenting in an EHR.

The EHR for each patient contains a great deal of information. The most frequent pieces of information that nurses access include the following:

• History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the patient is admitted to the facility. An H&P includes important information about the patient’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
• Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
• Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
• Treatment Administration Records (TARs): In many facilities, treatments are documented on a treatment administration record.
• Laboratory results: This section includes results from blood work and other tests performed in the lab.
• Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
• Progress notes: This section contains notes created by nurses and other health care providers regarding patient care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.

Legal Documentation

Nurses and health care team members are legally required to document care provided to patients. In a court of law, the rule of thumb used is, “If it wasn’t documented, it wasn’t done.” Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. All types of documentation must include the date, time, and signature of the person documenting. Any type of documentation in the EHR is considered a legal document and must be completed in an accurate and timely manner. Abbreviations should be avoided in legal documentation.

Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.

Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the “Planning” section of the “Nursing Process” chapter.

Common Types of Documentation

Common formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.

Charting by Exception

Charting by exception (CBE) documentation was designed to decrease the amount of time required to document care. CBE contains a list of normal findings. After performing an assessment, nurses confirm normal findings on the list found on assessment and write only brief progress notes for abnormal findings or to document communication with other team members.

Focused DAR Notes

Focused DAR notes are a type of progress note that are commonly used in combination with charting by exception documentation. DAR stands for Data, Action, and Response. Focused DAR notes are brief.  Each note is focused on one patient problem for efficiency in documenting and reading.

• Data: This section contains information collected during the patient assessment, including vital signs and physical examination findings found during the “Assessment” phase of the nursing process. The Assessment phase is further discussed in the “Nursing Process” chapter.
• Action: This section contains the nursing actions that are planned and implemented for the patient’s focused problem. This section correlates to the “Planning” and “Implementation” phases of the nursing process and are further discussed in the “Nursing Process” chapter.
• Response: This section contains information about the patient’s response to the nursing actions and evaluates if the planned care was effective. This section correlates to the “Evaluation” phase of the nursing process that is further discussed in the “Nursing Process” chapter.

Narrative Notes

Narrative notes are a type of progress note that chronicles assessment findings and nursing activities for the patient that occurred throughout the entire shift or visit. View sample narrative note documentation according to body system in each assessment chapter of the Open RN Nursing Skills textbook.

SOAPIE Notes

SOAPIE is a mnemonic for a type of progress note that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. SOAPIE progress notes are written by nurses, as well as other members of the health care team.

• Subjective: This section includes what the patient said, such as,  “I have a headache.” It can also contain information related to pertinent medical history and why the patient is in need of care.
• Objective: This section contains the observable and measurable data collected during a patient assessment, such as the vital signs, physical examination findings, and lab/diagnostic test results.
• Assessment: This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
• Plan: This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
• Interventions: This section describes the actions implemented.
• Evaluation: This section describes the patient response to interventions and if the planned outcomes were met.

Patient Discharge Summary

When a patient is discharged from an agency, a discharge summary is documented in the patient record, along with clear verbal and written patient education and instructions provided to the patient. Discharge summary information is frequently provided in a checklist format to ensure accuracy and includes the following:

• Time of departure and method of transportation out of the hospital (e.g., wheelchair)
• Name and relationship of person accompanying the patient at discharge
• Condition of the patient at discharge
• Patient education completed and associated educational materials or other information provided to the patient
• Discharge instructions on medications, treatments, diet, and activity
• Follow-up appointments or referrals given

See Figure 2.12^{“1934626790-huge.jpg” by TommyStockProject is used under license from Shutterstock.com} for an image of a nurse providing discharge instructions to a patient. Discharge teaching typically starts at admission and continues throughout the patient’s stay.

Minimum Data Set (MDS) Charting

In long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument Minimum Data Set (MDS) is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life.^{Centers for Medicare & Medicaid Services. (2019, October). Long-term care facility resident assessment instrument 3.0 user’s manual. https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf} This tool also guides nursing care plan development.

Patient Scenario

Mr. Hernandez is a 47-year-old patient admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The patient sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he had significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the patient has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally. Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand. Mrs. Hernandez is present at the patient’s bedside and has provided additional information about the patient. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure, but is otherwise healthy.

The nurse notes that the patient’s jaw is wired and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.

Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.

Sample Documentation

Mr. Hernandez has impaired verbal communication due to facial fracture and inability to enunciate words around his wired jaw. He understands both verbal and written communication. Mr. Hernandez has left sided facial swelling, but no visual impairment. He has a left arm fracture but is able to move and write with his right hand. The patient is supplied with communication cards and marker board. He responds appropriately with written communication and is able to signal his needs. 

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Aphasia: A communication disorder that results from damage to portions of the brain that are responsible for language.

Assertive communication: A way to convey information that describes the facts, the sender’s feelings, and explanations without disrespecting the receiver’s feelings. This communication is often described as using “I” messages: “I feel…,” “I understand…,” or “Help me to understand…”

Bedside nurse handoff report: A handoff report in hospitals that involves patients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the patient’s bedside.

Broca’s aphasia: A type of aphasia where patients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca’s aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated.

Charting by exception: A type of documentation where a list of “normal findings” is provided and nurses document assessment findings by confirming normal findings and writing brief documentation notes for any abnormal findings.

DAR: A type of documentation often used in combination with charting by exception. DAR stands for Data, Action, and Response. Focused DAR notes are brief, and each note is focused on one patient problem for efficiency in documenting, as well as for reading.

Electronic Health Record (EHR): A digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

Global aphasia: A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.

Handoff report: A process of exchanging vital patient information, responsibility, and accountability between the off-going and incoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices.

ISBARR: A mnemonic for the format of professional communication among health care team members that includes Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life.

Narrative note: A type of documentation that chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift.

Nontherapeutic responses: Responses to patients that block communication, expression of emotion, or problem-solving.

Progressive relaxation: Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness.

Relaxation breathing: A breathing technique used to reduce anxiety and control the stress response.

SOAPIE: A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.

Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.

Therapeutic communication techniques: Techniques that encourage patients to explore feelings, problem solve, and cope with responses to medical conditions and life events.

Verbal communication: Exchange of information using words understood by the receiver.

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No matter who we are or where we come from, every person belongs to a culture. The impact of culture on a person’s health is profound because it affects many health beliefs, such as perceived causes of illness, ways to prevent illness, and acceptance of medical treatments. Culturally responsive care integrates these cultural beliefs into an individual’s health care. Culturally responsive care is intentional and promotes trust and rapport with patients. At its heart, culturally responsive care is patient-centered care. The American Nurses Association (ANA) states, “The art of nursing is demonstrated by unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association}

Nurses provide holistic care when incorporating their patients’ physical, mental, spiritual, cultural, and social needs into their health care (referred to as holism). As a nursing student, you are undertaking a journey of developing cultural competency with an attitude of cultural humility as you learn how to provide holistic care to your patients. Cultural competency is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.^{Centers for Disease Control and Prevention. (2020, October 21). Cultural competence in health and human services. https://npin.cdc.gov/pages/cultural-competence,Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3,Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100} Cultural humility is defined by the American Nurses Association as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} The bottom line is you will improve the quality of your nursing care by understanding, respecting, and responding to a patient’s experiences, values, beliefs, and preferences.^{U.S. Department of Health and Human Services. (n.d.). Cultural and Linguistically Appropriate Services (CLAS) in Maternal Health Care. https://thinkculturalhealth.hhs.gov/}

This chapter will focus on developing culturally competency and cultural humility and providing culturally responsive care.

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Let’s begin the journey of developing cultural competency by exploring basic concepts related to culture.

Culture and Subculture

Culture is a set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group. The word “culture” may at times be interchanged with terms such as ethnicity, nationality, or race. See Figure 3.1^{“Cultural diversity large.jpg” by მარიამ იაკობაძე is licensed under CC BY-SA 4.0} for an illustration depicting culture by various nationalities. Cultural beliefs and practices bind group or community members together and help form a cohesive identity.^{Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3,Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100} Culture has an enduring influence on a person’s view of the world, expressed through language and communication patterns, family connections and kinship, religion, cuisine, dress, and other customs and rituals.^{Campinha-Bacote, J. (2011). Coming to know cultural competence: An evolutionary process. International Journal for Human Caring, 15(3), 42-48.} Culture is not static but is dynamic and ever-changing; it changes as members come into contact with beliefs from other cultures. For example, sushi is a traditional Asian dish that has become popular in America in recent years.

Nurses and other health care team members are impacted by their own personal cultural beliefs. For example, a commonly held belief in American health care is the importance of timeliness; medications are administered at specifically scheduled times, and appearing for appointments on time is considered crucial.

Most cultural beliefs are a combination of beliefs, values, and habits that have been passed down through family members and authority figures. The first step in developing cultural competence is to become aware of your own cultural beliefs, attitudes, and practices.

Nurses should also be aware of subcultures. A subculture is a smaller group of people within a culture, often based on a person’s occupation, hobbies, interests, or place of origin. People belonging to a subculture may identify with some, but not all, aspects of their larger “parent” culture. Members of the subculture share beliefs and commonalities that set them apart and do not always conform with those of the larger culture. See Table 3.2a for examples of subcultures.

Table 3.2a Examples of Subcultures

Culture is much more than a person’s nationality or ethnicity. Culture can be expressed in a multitude of ways, including the following:

• Language(s) spoken
• Religion and spiritual beliefs
• Gender identity
• Socioeconomic status
• Age
• Sexual orientation
• Geography
• Educational background
• Life experiences
• Living situation
• Employment status
• Immigration status
• Ability/Disability

People typically belong to more than one culture simultaneously. These cultures overlap, intersect, and are woven together to create a person’s cultural identity. In other words, the many ways in which a person expresses their cultural identity are not separated, but are closely intertwined, referred to as intersectionality.

Assimilation

Assimilation is the process of adopting or conforming to the practices, habits, and norms of a cultural group. As a result, the person gradually takes on a new cultural identity and may lose their original identity in the process.^{Cole, N. L. (2018). How different cultural groups become more alike: Definition, overview and theories of assimilation. ThoughtCo. https://www.thoughtco.com/assimilation-definition-4149483} An example of assimilation is a newly graduated nurse, who after several months of orientation on the hospital unit, offers assistance to a colleague who is busy. The new nurse has developed self-confidence in the role and has developed an understanding that helping others is a norm for the nurses on that unit.

Assimilation is not always voluntary, however, and may become a source of distress. There are historic examples of involuntary assimilation in many countries. For example, in the past, authorities in the United States and Canadian governments required indigenous children to attend boarding schools, separated them from their families, and punished them for speaking their native language.^{The Truth and Reconciliation Commission of Canada.(2015). Honoring the truth, reconciling for the future: A summary of the final report of the truth and reconciliation commission of Canada. http://www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_the_Future_July_23_2015.pdf,Smith, A. (2007, March 26). Soul wound: The legacy of Native American schools. Amnesty International Magazine. https://web.archive.org/web/20121206131053/http://www.amnestyusa.org/node/87342}

Cultural Values and Beliefs

Culture provides an important source of values and comfort for patients, families, and communities. Think of culture as a thread that is woven through a person’s world and impacts one’s choices, perspectives, and way of life. It plays a role in all of a person’s life events and threads its way through the development of one’s self-concept, sexuality, and spirituality. It affects lifelong nutritional habits, as well as coping strategies with death and dying.

Culture influences how a patient interprets “good” health, as well as their perspectives on illness and the causes of  illness. The manner in which pain is expressed is also shaped by a person’s culture. See Table 3.2b for additional examples of how a person’s culture impacts common values and beliefs regarding family patterns, communication patterns, space orientation, time orientation, and nutritional patterns. As you read Table 3.2b, take a moment to reflect on your own cultural background and your personally held beliefs for each of these concepts.

Table 3.2b Cultural Concepts

A person’s culture can also affect encounters with health care providers in other ways, such as the following:

• Level of family involvement in care
• Timing for seeking care
• Acceptance of treatment (as preventative measure or for an actual health problem)
• The accepted decision-maker (i.e., the patient or other family members)
• Use of home or folk remedies
• Seeking advice or treatment from nontraditional providers
• Acceptance of a caregiver of the opposite gender

Cultural Diversity and Cultural Humility

Cultural diversity is a term used to describe cultural differences among people. See Figure 3.2^{“Pure_Diversity,_Mirta_Toledo_1993.jpg” by Mirta Toledo is licensed under CC BY-SA 4.0} for artwork depicting diversity. While it is useful to be aware of specific traits of a culture or subculture, it is just as important to understand that each individual is unique and there are always variations in beliefs among individuals within a culture. Nurses should, therefore, refrain from making assumptions about the values and beliefs of members of specific cultural groups.^{Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100} Instead, a better approach is recognizing that culture is not a static, uniform characteristic but instead realizing there is diversity within every culture and in every person. The American Nurses Association (ANA) defines cultural humility as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association}

Current demographics in the United States reveal that the population is predominantly white. People who were born in another country, but now live in the United States, comprise approximately 14% of the nation’s total population. However, these demographics are rapidly changing. The United States Census Bureau projects that more than 50 percent of Americans will belong to a minority group by 2060. With an increasingly diverse population to care for, it is imperative for nurses to integrate culturally responsive care into their nursing practice.^{Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100,Kaihlanen, A. M., Hietapakka, L., & Heponiemi, T. (2019) Increasing cultural awareness: Qualitative study of nurses’ perceptions about cultural competence training. BMC Nursing, 18(1), 1–9. https://doi.org/10.1186/s12912-019-0363-x} Creative a culturally responsive environment is discussed in a later subsection of this chapter.

Concepts Related to Culture

There are additional concepts related to culture that can impact a nurse’s ability to provide culturally responsive care, including stereotyping, ethnocentrism, discrimination, prejudice, and bias. See Table 3.2c for definitions and examples of these concepts.

Table 3.2c Concepts Related to Culture

Race is a socially constructed idea because there are no true genetically- or biologically-distinct races. Humans are not biologically different from each other. Racism presumes that races are distinct from one another, and there is a hierarchy to race, implying that races are unequal. Ernest Grant, president of the American Nurses Association (ANA), recently declared that nurses are obligated “to speak up against racism, discrimination, and injustice. This is non-negotiable.”^{American Nurses Association. (2020, June 1). ANA president condemns racism, brutality and senseless violence against black communities. https://www.nursingworld.org/news/news-releases/2020/ana-president-condemns-racism-brutality-and-senseless-violence-against-black-communities/} As frontline health care providers, nurses have an obligation to recognize the impact of racism on their patients and the communities they serve.^{Fulbright-Sumpter, D. (2020). “But I’m not racist …” The nurse’s role in dismantling institutionalized racism. Texas Nursing, 94(3), 14–17.}

Sexual Orientation and Gender Identity

Culture can exert a powerful influence on a person’s sexual orientation and gender expression. Sexual orientation refers to a person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors.^{Brydum, S. (2015, July 31). The true meaning of the word cisgender. The Advocate. https://www.advocate.com/transgender/2015/07/31/true-meaning-word-cisgender} The acronym LGBTQ stands for lesbian, gay, bisexual, transgender, queer, or questioning in reference to sexual orientation. (A “+” is sometimes added after LGBTQ to capture additional orientations). See Figure 3.3^{“Dublin_LGBTQ_Pride_Festival_2013_-_LGBT_Rights_Matter_(9183564890).jpg” by infomatique is licensed under CC BY-SA 2.0} for an image of participants in a LGBTQ  rally in Dublin. Historically, individuals within the LGBTQ community have experienced discrimination and prejudice from health care providers and avoided or delayed health care due to these negative experiences. Despite increased recognition of this group of people in recent years, members of the LGBTQ community continue to experience significant health disparities. Persistent cultural bias and stigmatization of lesbian, gay, bisexual, or transgender (LGBTQ) people have also been shown to contribute to higher rates of substance abuse and suicide rates in this population.^{Cole, N. L. (2018). How different cultural groups become more alike: Definition, overview and theories of assimilation. ThoughtCo. https://www.thoughtco.com/assimilation-definition-4149483,U.S. Department of Health and Human Services. Healthy People 2020. Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health,Chance, T.  F. (2013). Going to pieces over LGBT health disparities: How an amended affordable care act could cure the discrimination that ails the LGBT community. Journal of Health Care Law and Policy, 16(2), 375–402. https://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1309&context=jhclp}

Gender identity refers to a person’s inner sensibility that they are a man, a woman, or perhaps neither. Cisgender is the term used to describe a person whose identity matches their sex assigned at birth.^{Brydum, S. (2015, July 31). The true meaning of the word cisgender. The Advocate. https://www.advocate.com/transgender/2015/07/31/true-meaning-word-cisgender} To the extent that a person’s gender identity does not conform with the sex assigned to them at birth, they may identify as transgender or as gender nonbinary. Transgender people, like cisgender people, “may be sexually oriented toward men, women, both sexes, or neither sex.”^{Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender population size in the United States: A meta-regression of population-based probability samples. American Journal of Public Health, 107(2), e1–e8. https://doi.org/10.2105/AJPH.2016.303578} Gender expression refers to a person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms.^{Keuroghlian, A. S., Ard, K. L., & Makadon, H. J. (2017). Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments. Sexual Health, 14(1), 119–122. https://doi.org/10.1071/SH16145}Sharing pronouns as part of a basic introduction to a patient can assist a transgender patient to feel secure sharing their pronouns in a health care setting. Asking a patient for their pronoun (he, she, they, ze, etc.) is considered part of a nursing assessment.

Related Ethical Considerations

Justice, a principle and moral obligation to act on the basis of equality and equity, is a standard linked to fairness for all in society.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} The ANA states this obligation guarantees not only basic rights (respect, human dignity, autonomy, security, and safety) but also fairness in all operations of societal structures. This includes care being delivered with fairness, rightness, correctness, unbiasedness, and inclusiveness while being based on well-founded reason and evidence.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association}

Social justice is related to respect, equity, and inclusion. The ANA defines social justice as equal rights, equal treatment, and equitable opportunities for all.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} The ANA further states, “Nurses need to model the profession’s commitment to social justice and health through actions and advocacy to address the social determinants of health and promote well-being in all settings within society.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} Social determinants of health are nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association} Health outcomes impacted by social determinants of health are referred to as health disparities. Health disparities are further discussed in a subsection later in this chapter.

Open Resources for Nursing (Open RN)

Th Patient’s Bill of Rights is an evolving document related to providing culturally competent care. In 1973 the American Hospital Association (AHA) adopted the Patient’s Bill of Rights.^{American Hospital Association. (2003). The patient care partnership. https://www.aha.org/other-resources/patient-care-partnership} See the following box to review the original Patient’s Bill of Rights. The bill has since been updated, revised, and adapted for use throughout the world in all health care settings. There are different versions of the bill, but, in general, it safeguards a patient’s right to accurate and complete information, fair treatment, and self-determination when making health care decisions. Patients should expect to be treated with sensitivity and dignity and with respect for their cultural values. While the Patient’s Bill of Rights extends beyond the scope of cultural considerations, its basic principles underscore the importance of cultural competency when caring for people.

Open Resources for Nursing (Open RN)

The freedom to express one’s cultural beliefs is a fundamental right of all people. Nurses realize that people speak, behave, and act in many different ways due to the influential role that culture plays in their lives and their view of the world. Cultural compe­tence is a lifelong process of applying evidence-based nursing in agreement with the cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.^{Centers for Disease Control and Prevention. (2020, October 21). Cultural competence in health and human services. https://npin.cdc.gov/pages/cultural-competence,Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3,Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100}

Culturally-competent care requires nurses to combine their knowledge and skills with awareness, curiosity, and sensitivity about their patients’ cultural beliefs. It takes motivation, time, and practice to develop cultural competence, and it will evolve throughout your nursing career. Culturally competent nurses have the power to improve the quality of care leading to better health outcomes for culturally diverse patients. Nurses who accept and uphold the cultural values and beliefs of their patients are more likely to develop supportive and trusting relationships with their patients. In turn, this opens the way for optimal disease and injury prevention and leads towards positive health outcomes for all patients .

The roots of providing culturally-competent care are based on the original transcultural nursing theory developed by Dr. Madeleine Leininger. Transcultural nursing incorporates cultural beliefs and practices of individuals to help them maintain and regain health or to face death in a meaningful way.^{Murphy, S. C. (2006). Mapping the literature of transcultural nursing. Journal of the Medical Library Association: JMLA, 94(2 Suppl), e143–e151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463039/} See Figure 3.4^{“Leininger.jpg” by Juda712 is licensed under CC BY-SA 3.0} for an image of Dr. Leininger. Read more about transcultural nursing theory in the following box.

Nurses have an ethical and moral obligation to provide culturally competent care to the patients they serve.^{Young, S., & Guo, K. (2016). Cultural diversity training: The necessity for cultural competence for healthcare providers and in nursing practice. The Health Care Manager, 35(2), 94-102. https://doi.org/10.1097/hcm.0000000000000100} The “Respectful and Equitable Practice” Standard of Professional Performance set by the American Nurses Association (ANA) states that nurses must practice with cultural humility and inclusiveness.  The ANA Code of Ethics also states that the nurse should collaborate with other health professionals, as well as the public, to protect human rights, fight discriminatory practices, and reduce disparities.^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/} Additionally, the ANA Code of Ethics also states that nurses “are expected to be aware of their own cultural identifications in order to control their personal biases that may interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the patient’s culture…nurses should possess knowledge and understanding how oppression, racism, discrimination, and stereotyping affect them personally and in their work.”^{American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/}

Developing cultural competence begins in nursing school.^{Gillson, S., & Cherian, N. (2019). The importance of teaching cultural diversity in baccalaureate nursing education. Journal of Cultural Diversity, 26(3), 85–88.,Gavin-Knecht, J., Fontana, J. S., Fischer, B., Spitz, K. R., & Tetreault, J. N. (2018). An investigation of the development of cultural competence in baccalaureate nursing students: A mixed methods study. Journal of Cultural Diversity, 26(3), 89-95.} Culture is an integral part of life, but its impact is often implicit. It is easy to assume that others share the same cultural values that you do, but each individual has their own beliefs, values, and preferences. Begin the examination of your own cultural beliefs and feelings by answering the questions below.^{Zeran, V. (2016). Cultural competency and safety in nursing education: A case study. Northern Review, 43, 105–115. https://thenorthernreview.ca/index.php/nr/article/view/591}

The Process of Developing Cultural Competence

Dr. Josephine Campinha-Bacote is an influential nursing theorist and researcher who developed a model of cultural competence. The model asserts there are specific characteristics that a nurse becoming culturally competent possesses, including cultural awareness, cultural knowledge, cultural skill, and cultural encounters.^{Transcultural C.A.R.E. Associates. (2020). The Process of Cultural Competemility. http://transculturalcare.net/the-process-of-cultural-competence-in-the-delivery-of-healthcare-services/}

Cultural awareness is a deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, attitudes, practices, and problem-solving strategies of a patient’s culture. To become culturally aware, the nurse must undergo reflective exploration of personal cultural values while also becoming conscious of the cultural practices of others. In addition to reflecting on one’s own cultural values, the culturally competent nurse seeks to reverse harmful prejudices, ethnocentric views, and attitudes they have. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures. Although cultural diversity training is typically a requirement for health care professionals, cultural desire refers to the intrinsic motivation and commitment on the part of a nurse to develop cultural awareness and cultural competency.^{Anti-Defamation League. (2013). Imagine a world without hate: Anti-Defamation League 2012 Annual Report. https://www.adl.org/media/4528/download.}

Acquiring cultural knowledge is another important step towards becoming a culturally competent nurse. Cultural knowledge refers to seeking information about cultural health beliefs and values to understand patients’ world views. To acquire cultural knowledge, the nurse actively seeks information about other cultures, including common practices, beliefs, values, and customs, particularly for those cultures that are prevalent within the communities they serve.^{Gillson, S., & Cherian, N. (2019). The importance of teaching cultural diversity in baccalaureate nursing education. Journal of Cultural Diversity, 26(3), 85–88.} Cultural knowledge also includes understanding the historical backgrounds of culturally diverse groups in society, as well as physiological variations and the incidence of certain health conditions in culturally diverse groups. Cultural knowledge is best obtained through cultural encounters with patients from diverse backgrounds to learn about individual variations that occur within cultural groups and to prevent stereotyping.

While obtaining cultural knowledge, it is important to demonstrate cultural sensitivity. Cultural sensitivity means being tolerant and accepting of cultural practices and beliefs of people. Cultural sensitivity is demonstrated when the nurse conveys nonjudgmental interest and respect through words and action and an understanding that some health care treatments may conflict with a person’s cultural beliefs.^{Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18, 174. https://doi.org/10.1186/s12939-019-1082-3} Cultural sensitivity also implies a consciousness of the damaging effects of stereotyping, prejudice, or biases on patients and their well-being. Nurses who fail to act with cultural sensitivity may be viewed as uncaring or inconsiderate, causing a breakdown in trust for the patient and their family members. When a patient experiences nursing care that contradicts with their cultural beliefs, they may experience moral or ethical conflict, nonadherence, or emotional distress.

Cultural desire, awareness, sensitivity, and knowledge are the building blocks for developing cultural skill. Cultural skill is reflected by the nurse’s ability to gather and synthesize relevant cultural information about their patients while planning care and using culturally sensitive communication skills. Nurses with cultural skill  provide care consistent with their patients’ cultural needs and deliberately take steps to secure a safe health care environment that is free of discrimination or intolerance. For example, a culturally skilled nurse will make space and seating available within a patient’s hospital room for accompanying family members when this support is valued by the patient.^{Brooks, L., Manias, E., & Bloomer, M. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007}

Cultural encounters is a process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

By developing the characteristics of cultural awareness, cultural knowledge, cultural skill, and cultural encounters, a nurse develops cultural competence.

Open Resources for Nursing (Open RN)

Despite decades of promoting cultural competent care and the Patient’s Bill of Rights, disparities in health care continue. Vulnerable populations continue to experience increased prevalence and burden of diseases, as well as problems accessing quality health care. In 2003 the Institute of Medicine (IOM) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, sharing evidence that “bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care.”^{Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley, B. D., Stith, A. Y., Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press. https://doi.org/10.17226/12875} The health care system in the United States was shaped by the values and beliefs of mainstream white culture and originally designed to primarily serve English-speaking patients with financial resources.^{Meedzan, N. (2015). Cultural immersion experiences in nursing education. In S. Breakey, I. Corless, N. Meedzan, & P. Nicholas (Eds.) Global nursing in the 21st century. Springer. pp. 441-452.} In addition, most health care professionals in the United States are members of the white culture and medical treatments tend to arise from that perspective.^{Hart, P. L., & Mareno, N. (2016). Nurses’ perceptions of their cultural competence in caring for diverse patient populations. Online Journal of Cultural Competence in Nursing & Healthcare, 6(1), 121–137. https://doi.org/10.9730/ojccnh.org/v6n1a10,Ong-Flaherty, C. (2015). Critical cultural awareness and diversity in nursing: A minority perspective. Nurse Leader, 13(5), 58-62. http://dx.doi.org/10.1016/j.mnl.2015.03.012}

The term health disparities describes the differences in health outcomes that result from social determinants of health. Social determinants of health are conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.^{Healthy People 2020. (2020). Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health}

Vulnerable populations experience increased prevalence and burden of diseases, as well as problems accessing quality health care because of social determinants of health. Health disparities negatively impact groups of people based on their ethnicity, gender, age, mental health, disability, sexual orientation, gender identity, socioeconomic status, geographic location, or other characteristics historically linked to discrimination or exclusion.^{U.S. Department of Health and Human Services. Healthy People 2020. Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health} A related term is health care disparity that refers to differences in access to health care and insurance coverage. Health disparities and health care disparities can lead to decreased quality of life, increased personal costs, and lower life expectancy. More broadly, these disparities also translate to greater societal costs, such as the financial burden of uncontrolled chronic illnesses.

The Agency for Healthcare Research and Quality (AHRQ) releases an annual National Healthcare Quality and Disparities Report that provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. Quality is described in terms of patient safety, person-centered care, care coordination, effective treatment, healthy living, and care affordability.^{Agency for Healthcare Research and Quality. (2020). 2019 National healthcare quality and disparities report. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html} Although access to health care and quality have improved since 2000 in the wake of the Affordable Care Act (ACA), the 2019 report shows continued disparities, especially for poor and uninsured populations:

• For about 40% of quality measures, Blacks, African Americans, and Alaska Natives received worse care than Whites. For more than one third of quality measures, Hispanics received worse care than Whites.
• For nearly a quarter of quality measures, residents of large metropolitan areas received worse care than residents of suburban areas. For one third of quality measures, residents of rural areas received worse care than residents of suburban areas.^{Agency for Healthcare Research and Quality. (2020). 2019 National healthcare quality and disparities report. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html}

There are several initiatives and agencies designed to combat the problem of health disparities in the United States. See Table 3.5 for a list of hyperlinks to available resources to combat health disparities.

Table 3.5 Resources to Combat Health Disparities

See the following box for an example of nurses addressing a community health care disparity during the water crisis in Flint, Michigan.

Nurses Addressing the Flint Michigan Water Crisis^{Householder, M. (2016, April 12). Health workers get lead-test help from Flint student nurses. Associated Press. https://detroit.cbslocal.com/2016/04/12/health-workers-get-lead-test-help-from-flint-student-nurses/.}

In 2014 the water system in Flint, Michigan, was discovered to be contaminated with lead. The city’s children were found to have perilously elevated lead levels. Children from poor households were most affected by the crisis. Lead is a dangerous neurotoxin. Elevated lead levels are linked to slowed physical development; low IQ; problems with cognition, attention, and memory; and learning disabilities.

In Flint approximately 150 local nurses and nursing students answered the call, organizing and arranging educational seminars, as well as setting up lead testing clinics to determine who had been affected by the water contamination. A nursing student involved in the effort told CBS Detroit that this situation has illustrated that “the need for health care, the need for nursing, goes way outside the hospital walls.” See Figure 3.5“Flint_Water_Crisis.jpg” by Shannon Nobles is licensed under CC BY-SA 4.0  for an image of the water crisis in Flint, Michigan.

 

Reflective Questions

1. What factors led to the children from poor households being so adversely harmed by this crisis?
2. What are ways that you as a future nurse can make a difference for vulnerable or marginalized people?

Providing culturally responsive care is a key strategy for reducing health disparities.^{Zeran, V. (2016). Cultural competency and safety in nursing education: A case study. Northern Review, 43, 105–115. https://thenorthernreview.ca/index.php/nr/article/view/591} While there are multiple determinants contributing to a person’s health, nurses play an important role in reducing health disparities by providing a culturally sensitive environment, performing a cultural assessment, and providing culturally responsive care. These interventions will be further discussed in the following sections. On the other hand, a lack of culturally responsive care potentially contributes to miscommunication between the patient and the nurse. The patient may experience distress or loss of trust in the nurse or the health care system as a whole and may not adhere to prescribed treatments. Nurses are uniquely positioned to directly impact patient outcomes as we become more aware of unacceptable health disparities and work together to overcome them.^{Colorado Nurses Foundation and Colorado Nurses Association. (2020). Owning our biases: How nursing can change the healthcare landscape. Colorado Nurse, 120(3). https://assets.nursingald.com/uploads/publication/pdf/2103/Colorado_Nurse_8_20.pdf}

Open Resources for Nursing (Open RN)

Providing culturally responsive care integrates an individual’s cultural beliefs into their health care. Begin by conveying cultural sensitivity to patients and their family members with these suggestions:^{Brooks, L., Manias, E., & Bloomer, M. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007}

• Set the stage by introducing yourself by name and role when meeting the patient and their family for the first time. Until you know differently, address the patient formally by using their title and last name. Ask the patient how they wish to be addressed and record this in the patient’s chart. Respectfully acknowledge any family members and visitors at the patient’s bedside.
• Begin by standing or sitting at least arm’s length from the patient.
• Observe the patient and family members in regards to eye contact, space orientation, touch, and other nonverbal communication behaviors and follow their lead.
• Make note of the language the patient prefers to use and record this in the patient’s chart. If English is not the patient’s primary language, determine if a medical interpreter is required before proceeding with interview questions. See the box below for guidelines in using a medical interpreter.
• Use inclusive language that is culturally sensitive and appropriate. For example, do not refer to someone as “wheelchair bound”; instead say “a person who uses a wheelchair.” ^{UK Office for Disability Issues. (2018, December 13). Inclusive language: Words to use and avoid when writing about disability.  https://www.gov.uk/government/publications/inclusive-communication/inclusive-language-words-to-use-and-avoid-when-writing-about-disability.}
• Be open and honest about the extent of your knowledge of their culture. It is acceptable to politely ask questions about their beliefs and seek clarification to avoid misunderstandings.
• Adopt a nonjudgmental approach and show respect for the patient’s cultural beliefs, values, and practices. It is possible that you may not agree with a patient’s cultural expressions, but it is imperative that the patient’s rights are upheld. As long as the expressions are not unsafe for the patient or others, the nurse should attempt to integrate them into their care.
• Assure the patient that their cultural considerations are a priority their care.

  Guidelines for Using a Medical Interpreter^{Juckett, G., & Unger, K. (2014). Appropriate use of medical interpreters. American Family Physician, 90(7), 476-80. https://pubmed.ncbi.nlm.nih.gov/25369625/}

  When caring for a patient whose primary language is not English and they have a limited ability to speak, read, write, or understand the English language, seek the services of a trained medical interpreter. Health care facilities are mandated by The Joint Commission to provide qualified medical interpreters. Use of a trained medical interpreter is linked to fewer communication errors, shorter hospital stays, reduced 30-day readmission rates, and improved patient satisfaction.

  Refrain from asking a family member to act as an interpreter. The patient may withhold sensitive information from them, or family members may possibly edit or change the information provided. Unfamiliarity with medical terminology can also cause misunderstanding and errors.

  Medical interpreters may be on-site or available by videoconferencing or telephone. The nurse should also consider coordinating patient and family member conversations with other health care team members to streamline communication, while being aware of cultural implications such who can discuss what health care topics and who makes the decisions. When possible, obtain a medical interpreter of the same gender as the patient to prevent potential embarrassment if a sensitive matter is being discussed.

  Guidelines for working with a medical interpreter:

  • Allow extra time for the interview or conversation with the patient.
  • Whenever possible, meet with the interpreter beforehand to provide background.
  • Document the name of the medical interpreter in the progress note.
  • Always face and address the patient directly, using a normal tone of voice. Do not direct questions or conversation to the interpreter.
  • Speak in the first person (using “I”).
  • Avoid using idioms, such as, “Are you feeling under the weather today?” Avoid abbreviations, slang, jokes, and jargon.
  • Speak in short paragraphs or sentences. Ask only one question at a time. Allow sufficient time for the interpreter to finish interpreting before beginning another statement or topic.
  • Ask the patient to repeat any instructions and explanations given to verify that they understood.

Open Resources for Nursing (Open RN)

After establishing a culturally sensitive environment, nurses should incorporate a cultural assessment when caring for all patients. There are many assessment guides used for patient interviews that are adaptable to a variety of health care settings and are designed to facilitate understanding and communication. The Four Cs of Culture model^{Galanti, G. A. (2014). Caring for patients from different cultures (5th ed.). University of Pennsylvania Press.} is an example of a quick cultural assessment tool that asks questions about what the patient Considers to be a problem, the Cause of the problem, how they are Coping with the problem, and how Concerned they are about the problem. See the following box for examples of sample answers to the four Cs assessment.

A more comprehensive cultural assessment tool, inspired by R. E. Spector’s Heritage Assessment interview,^{Spector, R. E. (2017). Cultural diversity in health and illness (9th ed.). Pearson Education.} is described in the following box.

Open Resources for Nursing (Open RN)

After establishing a culturally sensitive environment and performing a cultural assessment, nurses and nursing students can continue to promote culturally responsive care. Culturally responsive care includes creating a culturally safe environment, using cultural negotiation, and considering the impact of culture on patients’ time orientation, space orientation, eye contact, and food choices.

Culturally Safe Environment

A primary responsibility of the nurse is to ensure the environment is culturally safe for the patient. A culturally safe environment is a safe space for patients to interact with the nurse, without judgment or discrimination, where the patient is free to express their cultural beliefs, values, and identity. This responsibility belongs to both the individual nurse and also to the larger health care organization.

Cultural Negotiation

Many aspects of nursing care are influenced by the patient’s cultural beliefs, as well as the beliefs of the health care culture. For example, the health care culture in the United States places great importance on punctuality for medical appointments, yet a patient may belong to a culture that views “being on time” as relative. In some cultures, time is determined simply by whether it is day or night or time to wake up, eat, or sleep. Making allowances or accommodations for these aspects of a patient’s culture is instrumental in fostering the nurse-patient relationship. This accommodation is referred to as cultural negotiation. See Figure 3.6^{“handshake-3378251_1920.jpg” by geralt is licensed under CC0} for an image illustrating cultural negotiation. During cultural negotiation, both the patient and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the patient’s cultural needs. Cultural negotiation is reciprocal and collaborative. When a patient’s cultural needs do not significantly or adversely affect their treatment plan, their cultural needs should be accommodated when feasible.

As an example, think about the previous example of a patient for whom a fixed schedule is at odds with their cultural views. Instead of teaching the patient to take a daily medication at a scheduled time, the nurse could explain that the patient should take the medication every day when he gets up. Another example of cultural negotiation is illustrated by a scenario in which the nurse is preparing a patient for a surgical procedure. As the nurse goes over the preoperative checklist, the nurse asks the patient to remove her head covering (hijab). The nurse is aware that personal items should be removed before surgery; however, the patient wishes to keep on the hijab. As an act of cultural negotiation and respect for the patient’s cultural beliefs, the nurse makes arrangements with the surgical team to keep the patient’s hijab in place for the surgical procedure and covering the patient’s hijab with a surgical cap.

Decision-Making

Health care culture in the United States mirrors cultural norms of the country, with an emphasis on individuality, personal freedom, and self-determination. This perspective may conflict with a patient whose cultural background values group decision-making and decisions made to benefit the group, not necessarily the individual. As an example, in the 2019 film The Farewell, a Chinese-American family decides to not tell the family matriarch she is dying of cancer and only has a few months left to live. The family keeps this secret from the woman in the belief that the family should bear the emotional burden of this knowledge, which is a collectivistic viewpoint in contrast to American individualistic viewpoint.

Space Orientation

The amount of space that a person surrounds themselves with to feel comfortable is influenced by culture. (Read more about space orientation in the “Communication” chapter.) See Figure 3.7^{“Proxemics.png” by Natbrock Alicia Tom is licensed under CC BY-SA 3.0} for an image illustrating space orientation. For example, for some people, it would feel awkward to stand four inches away from another person while holding a social conversation, but for others a small personal space is expected when conversing with another.^{Kreuz, R., & Roberts, R. (2019). Proxemics 101: Understanding personal space across cultures. The MITPress Reader. https://thereader.mitpress.mit.edu/understanding-personal-space-proxemics/}There are times when a nurse must enter a patient’s intimate or personal space, which can cause emotional distress for some patients. The nurse should always ask for permission before entering a patient’s personal space and explain why and what is about to happen.

Patients may also be concerned about their modesty or being exposed. A patient may deal with the violation of their space by removing themselves from the situation, pulling away, or closing their eyes. The nurse should recognize these cues for what they are, an expression of cultural preference, and allow the patient to assume a position or distance that is comfortable for them.

Similar to cultural influences on personal space, touch is also culturally determined. This has implications for nurses because it may be inappropriate for a male nurse to provide care for a female patient and vice versa. In some cultures, it is also considered rude to touch a person’s head without permission.

Eye Contact

Eye contact is also a culturally mediated behavior. See Figure 3.8^{“271509.png” by amcolley is in the Public Domain} for an image of eye contact. In the United States, direct eye contact is valued when communicating with others, but in some cultures, direct eye contact is interpreted as being rude or bold. Rather than making direct eye contact, a patient may avert their eyes or look down at the floor to show deference and respect to the person who is speaking. The nurse should notice these cultural cues from the patient and mirror the patient’s behaviors when possible.

Food Choices

Culture plays a meaningful role in the dietary practices and food choices of many people. Food is used to celebrate life events and holidays. Most cultures have staple foods, such as bread, pasta, or rice and particular ways of preparing foods. See Figure 3.9^{“wanna-cuppa-singapore-cafe-food-bistro-trees-dishes-craft-beer-ale-breakfast-lunch-dinner-dark-1920×1080.jpg” by Jennette Kwok is licensed under CC BY-NC-SA 4.0} for an image of various food choices. Special foods are prepared to heal and to cure or to demonstrate kinship, caring, and love. For example, in the United States, chicken noodle soup is often prepared and provided to family members who are ill.

Conversely, certain foods and beverages (such as meat and alcohol) are forbidden in some cultures. Nurses should accommodate or negotiate dietary requests of their patients, knowing that food holds such an important meaning to many people.

Summary

In summary, there are several steps in the journey of becoming a culturally competent nurse with cultural humility who provides culturally responsive care to patients. As you continue in your journey of developing cultural competency, keep the summarized points in the following box in mind.

Patient Scenario

Mrs. Rosas is a 76-year-old patient admitted to the cardiology floor with an exacerbation of congestive heart failure. The patient’s primary language is Spanish, and she has a limited understanding of English. The patient’s daughter reports that the patient has been experiencing increased swelling in her ankles and increased shortness of breath over the last three weeks. Her daughter also reports that the patient has noted unexplained weight gain. During the admission assessment the nurse attempts to collect additional information related to current symptoms, diet, and history. The patient nods in response to questions and converses quietly in Spanish with her daughter.

Applying the Nursing Process

Assessment: The nurse notes that the patient does not respond to questions appropriately and is unable to converse in English. She defers to her daughter to provide interpretation of questions and relay information.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Rosas.

Nursing Diagnosis: Impaired Verbal Communication related to cultural incongruence as evidenced by inability to speak the language of the caregiver.

Overall Goal: The patient will use effective communication techniques.

SMART Expected Outcome: Mrs. Rosas will utilize interpreter services in order to receive information and express needs throughout her hospitalization.

Planning and Implementing Nursing Interventions:

The nurse will provide patient with interpreter services in order to facilitate patient communication. In-person interpreter or language line telephone services will be utilized to ensure that the patient receives information about her care. The nurse will eliminate distractions such as the television, hallway noise, etc., to decrease sources of additional stimuli in the communication experience. The nurse will communicate directly with the patient, utilizing appropriate eye contact, and nonverbal cues to enhance the communication experience.

Sample Documentation

Mrs. Rosas has impaired verbal communication due to limited English proficiency. She requires education regarding cardiac diet, fluid restriction, and exacerbation warning signs. Interpreter services have been utilized to ensure that communication and education needs are appropriate. Mrs. Rosas communicates freely through the interpreter and acknowledges understanding of the education that has been provided. 

Evaluation

During the patient’s hospitalization, Mrs. Rosas engages with staff through the use of interpreter services and actively participates in her own care.

Open Resources for Nursing (Open RN)

Open Resources for Nursing (Open RN)

View these supplementary videos regarding cultural diversity and cultural competence:

Haley Yeates | It’s Past Time to Appreciate Cultural Diversity^{TED Institute. (2018, February 15). It’s (past) time to appreciate cultural diversity | Hayley Yeates | TED Institute. [Video]. YouTube. Video licensed under CC BY–NC–ND 4.0.}

Becoming a Culturally Competent Nurse^{Johnson & Johnson Nursing. (2018, December 3). Becoming a culturally competent nurse. [Video]. YouTube. All rights reserved. https://www.youtube.com/watch?v=r62Zp99U67Y&feature=emb_title}

Open Resources for Nursing (Open RN)

Assimilation: The process of adopting or conforming to the practices, habits, and norms of a cultural group. As a result, the person gradually takes on a new cultural identity and may lose their original identity in the process.

Bias: To carry an attitude, opinion, or inclination (positive or negative) towards a group or members of a group. Bias can be a conscious attitude (explicit), or a person may not be aware of their bias (implicit).

Cultural awareness: A deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, lifeways, practices, and problem-solving strategies of a patient’s culture. Cultural awareness goes beyond a simple awareness of the existence of other cultures and involves an interest, curiosity, and appreciation of other cultures.

Cultural competency: The process of applying evidence-based nursing in agreement with the preferred cultural values, beliefs, worldview, and practices of patients to produce improved patient outcomes.

Cultural diversity: Cultural differences in people.

Cultural encounters: A process where the nurse directly engages in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to prevent possible stereotyping.

Cultural humility: A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Cultural negotiation: A process where the patient and nurse seek a mutually acceptable way to deal with competing interests of nursing care, prescribed medical care, and the patient’s cultural needs. Cultural negotiation is reciprocal and collaborative. When the patient’s cultural needs do not significantly or adversely affect their treatment plan, the cultural needs can be accommodated.

Culturally responsive care: Nursing actions that integrate a person’s cultural beliefs into their care.

Culturally safe environment: A safe space for patients to interact with health professionals, without judgment or discrimination, where the patient is free to express their cultural beliefs, values, and identity.

Culture: A set of beliefs, attitudes, and practices shared by a group of people or community that is accepted, followed, and passed down to other members of the group.

Discrimination: Unfair and different treatment of another person or group, denying them opportunities and rights to participate fully in society.

Ethnocentrism: The belief that one’s culture (or race, ethnicity, or country) is better and preferable than another’s.

Gender expression: A person’s outward demonstration of gender in relation to societal norms, such as in style of dress, hairstyle, or other mannerisms.

Gender identity: A person’s inner sensibility that they are a man, a woman, or perhaps neither.

Health disparities: Differences in health outcomes resulting from entrenched economic, sociopolitical, or environmental disadvantages. Health disparities negatively impact groups of people based on their ethnicity, gender, age, mental health, disability, sexual orientation or gender identity, socioeconomic status, geographic location, or other characteristics historically linked to discrimination or exclusion.

Health care disparities: Differences in access to health care and insurance coverage.

Holism: Treatment of the whole person, including physical, mental, spiritual, and social needs.

Intersectionality: The many ways in which a person expresses their cultural identity are not separated, but are closely intertwined.

Justice: A principle and moral obligation to act on the basis of equality and equity; a standard linked to fairness for all in society.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

LGBTQ: Lesbian, gay, bisexual, transgender, queer, or questioning in reference to sexual orientation.

Prejudice: To “prejudge”; a preconceived idea, often unfavorable, about a person or group of people.

Race: A socially constructed idea; there are no truly genetically or biologically distinct races. Humans are biologically similar to each other, not different.

Racism: The presumption that races are distinct from one another and there is a hierarchy to race, implying that races are unequal. In racism, expression of one’s cultural beliefs is viewed as a heritable trait.

Sexual orientation: A person’s physical and emotional interest or desire for others. Sexual orientation is on a continuum and is manifested in one’s self-identity and behaviors.

Social determinants of health: Nonmedical factors that influence health outcomes, including conditions in which people are born, grow, work, live, and age, and the wider sets of forces and systems shaping the conditions of daily life.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Social justice: Equal rights, equal treatment, and equitable opportunities for all.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Stereotyping: Assuming that a person has the attributes, traits, beliefs, and values of a group because they are a member of that group.

Subculture: A smaller group of people within a larger culture, often based on a person’s occupation, hobbies, interests, or place of origin.

Transcultural nursing: Incorporating cultural beliefs and practices of people to help them maintain and regain health or to face death in a meaningful way.

Open Resources for Nursing (Open RN)

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the nursing process as standards of professional nursing practice to provide safe, patient-centered care.

Open Resources for Nursing (Open RN)

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”^{Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.}  Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness: Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility: Recognizing your intellectual limitations and abilities
• Nonjudgmental: Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity: Being honest and demonstrating strong moral principles
• Perseverance: Persisting in doing something despite it being difficult
• Confidence: Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings: Wanting to explore different ways of knowing
• Curiosity: Asking “why” and wanting to know more

Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”^{Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.} To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience.^{Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15(7), 37-39.}

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning involves noticing cues, making generalizations, and creating hypotheses. Cues are data that  fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A generalization is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A hypothesis is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1.^{“The Detective” by paurian is licensed under CC BY 2.0} Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Example: A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example: Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2).^{“In the Quiet Zone…” by C.O.D. Library is licensed under CC BY-NC-SA 2.0} The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Clinical judgment is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.” ^{NCSBN. (n.d.). NCSBN clinical judgment model. https://www.ncsbn.org/14798.htm} The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP) is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3^{“The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0} for an illustration of the nursing process.

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

Assessment

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff.^{American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

The “Assessment” component of the nursing process is further described in the “Assessment” section of this chapter.

Diagnosis

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} A nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses.^{American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

The “Diagnosis” component of the nursing process is further described in the “Diagnosis” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “Outcomes Identification” section of this chapter.

Planning

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care.^{American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

The “Planning” component of the nursing process is further described in the “Planning” section of this chapter.

Nursing Care Plans

Creating nursing care plans is a part of the “Planning” step of the nursing process. A nursing care plan is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “Planning” and “Implementing” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association.} Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed.^{American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

The “Implementation” Standard of Professional Practice also includes the subcategories  “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

The “Implementation” component of the nursing process is further described in the “Implementation” section of this chapter.

Evaluation

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.^{American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

The “Evaluation” component of the nursing process is further described in the “Evaluation” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of nursing as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing.  The art of nursing is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} 

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Caring and the Nursing Process

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Successful use of the nursing process requires the development of a care relationship with the patient. A care relationship is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of rapport and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being.^{Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care – registered nurses’ experiences. The Open Journal of Nursing, 7, 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf}  Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} See Figure 4.4^{“hospice-1793998_1280.jpg” by truthseeker08 is licensed under CC0} for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment.^{Watson Caring Science Institute. (n.d.). Watson Caring Science Institute. Jean Watson, PHD, RN, AHN-BC, FAAN, (LL-AAN). https://www.watsoncaringscience.org/jean-bio/}

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

Open Resources for Nursing (Open RN)

Assessment is the first step of the nursing process (and the first Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as, The patient reports. It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary. Primary data is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as secondary data. Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5^{“361341143-huge.jpg” by Monkey Business Images is used under license from Shutterstock.com} for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example. An example of documented subjective data obtained from a patient assessment is, “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6^{“13394660711603.jpg” by CDC/ Amanda Mills is in the Public Domain} for an image of a nurse performing a physical examination.

Example. An example of documented objective data is, “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s medical diagnoses to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate inferences, the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “Communication” chapter of this book.

Physical Examination

A physical examination is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN Nursing Skills textbook with a head-to-toe checklist in Appendix C. Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs) complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs), or measurements such as vital signs and weight may be delegated to trained Unlicensed Assistive Personnel (UAP) when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s Electronic Medical Record (EMR), an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey: Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment: A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment: In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment: Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment: Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes.^{Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.}

Putting It Together

Review Scenario C in the following box  to apply concepts of assessment to a patient scenario.

Open Resources for Nursing (Open RN)

Diagnosis is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Example. In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse clusters data into patterns. Assessment frameworks such as Gordon’s Functional Health Patterns assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns.^{Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.} Concepts related to many of these patterns will be discussed in chapters later in this book.

Example. Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A nursing diagnosis is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.} Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.} Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in Appendix A. For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Nursing Diagnoses vs. Medical Diagnoses

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the human response to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often respond differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example. A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

Patient

The NANDA-I definition of a “patient” includes:

• Individual: a single human being distinct from others (i.e., a person).
• Caregiver: a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family: two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group: a number of people with shared characteristics generally referred to as an ethnic group.
• Community: a group of people living in the same locale under the same governance. Examples include neighborhoods and cities.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

Age

The age of the person who is the subject of the diagnosis is defined by the following terms:^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

• Fetus: an unborn human more than eight weeks after conception, until birth.
• Neonate: a person less than 28 days of age.
• Infant: a person greater than 28 days and less than 1 year of age.
• Child: a person aged 1 to 9 years
• Adolescent: a person aged 10 to 19 years
• Adult: a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult: a person greater than 65 years of age.

Time

The duration of the diagnosis is defined by the following terms:^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

• Acute: lasting less than 3 months.
• Chronic: lasting greater than 3 months.
• Intermittent: stopping or starting again at intervals
• Continuous: uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of Nursing Diagnoses includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

At-Risk Populations are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses:^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

• Problem-Focused
• Health Promotion – Wellness
• Risk
• Syndrome

A problem-focused nursing diagnosis is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.”^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/} To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present. Related factors (also called etiology) are causes that contribute to the diagnosis. Defining characteristics are cues, signs, and symptoms that cluster into patterns.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

A health promotion-wellness nursing diagnosis is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A risk nursing diagnosis is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.”^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/} A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

A syndrome diagnosis is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.”^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the nursing diagnosis and related factors as exhibited by defining characteristics. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis. Defining characteristics is the terminology used for observable signs and symptoms related to a nursing diagnosis.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.} Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient. Related factors is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The PES mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P) – the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (i.e., the etiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S) – defining characteristics manifested by the patient (i.e., the signs and symptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the PES format:

Problem (P) – statement of the patient response (nursing diagnosis)

Etiology (E) – related factors contributing to the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by that patient

Sample Problem-Focused Nursing Diagnosis Statement

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis Excess Fluid Volume. The NANDA-I definition of Excess Fluid Volume is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Example

The  components of a problem-focused nursing diagnosis statement for Ms. J. would be:

(P) Fluid Volume Excess

(E) Related to excessive fluid intake

(S) As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”:^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

Problem (P) – statement of the patient response (nursing diagnosis)

Signs and Symptoms (S) –  the patient’s expressed desire to enhance

Sample Health-Promotion Nursing Diagnosis Statement

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis Readiness for Enhanced Health Management, which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Example

The components of a health-promotion nursing diagnosis for Ms. J. would be:

Problem (P): Readiness for Enhanced Health Management

Symptoms (S): Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

A risk diagnosis consists of the following:

Problem (P) – statement of the patient response (nursing diagnosis)

As Evidenced By – Risk factors for developing the problem

Sample Risk Diagnosis Statement

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of Risk for Falls is “increased susceptibility to falling, which may cause physical harm and compromise health.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Example

The components of a risk diagnosis statement for Ms. J. would be:

Problem (P) – Risk for Falls

As Evidenced By – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

A syndrome statement consists of these items:

Problem (P) – the syndrome

Signs and Symptoms (S) – the defining characteristics are two or more similar nursing diagnoses

Sample Syndrome Diagnosis Statement

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a syndrome. For example, Activity Intolerance is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.” Social Isolation is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named Risk for Frail Elderly Syndrome. This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Example

The components of a syndrome nursing diagnosis for Ms. J. would be:

(P) – Risk for Frail Elderly Syndrome

(S) – The nursing diagnoses of Activity Intolerance and Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day. Prioritization is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7^{“The How To of Prioritization” by Valerie Palarski for Chippewa Valley Technical College is licensed under CC BY 4.0} on The How To of Prioritization.

Maslow’s Hierarchy of Needs is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8^{“Maslow’s hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0} for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example. Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.: Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls, and Risk for Frail Elderly Syndrome. The top priority diagnosis is Fluid Volume Excess because it affects the physiological needs of breathing, homeostasis, and excretion. However, the Risk for Falls diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

Open Resources for Nursing (Open RN)

Outcome Identification is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.} Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals. Goals are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example. Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of Fluid Volume Excess. A broad goal would be, “Ms. J. will achieve a state of fluid balance.”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable. Expected outcomes are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses.^{Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care. Elsevier.}

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic:^{Campbell, J. (2020). SMART criteria. Salem Press Encyclopedia.}

• Specific
• Measurable
• Attainable/Action oriented
• Relevant/Realistic
• Timeframe

See Figure 4.9^{“SMART-goals.png” by Dungdm93 is licensed under CC BY-SA 4.0} for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

Specific

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific: “The patient will increase the amount of exercise.”
• Specific: “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge” is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained.  Refer to Figure 4.10^{“Measurable Outcomes” by Valerie Palarski for Chippewa Valley Technical College is licensed under CC BY 4.0} for examples of verbs that are measurable and not measurable in outcome statements.

See the following examples:

• Not measurable: “The patient will drink adequate fluid amounts every shift.”
• Measurable: “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb.  Refer to Figure 4.11^{“Action Verbs” by Valerie Palarski for Chippewa Valley Technical College is licensed under CC BY 4.0} for examples of action verbs.

See the following examples:

• Not action-oriented: “The patient will get increased physical activity.”
• Action-oriented: “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

See the following examples:

• Not realistic: “The patient will jog one mile every day when starting the exercise program.”
• Realistic: “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

See the following examples:

• Not time limited:  “The patient will stop smoking cigarettes.”
• Time limited: “The patient will complete the smoking cessation plan by December 12, 2021.”

Putting It Together

In Scenario C in Box 4.3,  Ms. J.’s priority nursing diagnosis statement was Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.” An example of an expected outcome meeting SMART criteria for Ms. J. is, “The patient will have clear bilateral lung sounds within the next 24 hours.”

Open Resources for Nursing (Open RN)

Planning is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

After expected outcomes are identified, the nurse begins planning nursing interventions to implement. Nursing interventions are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.} Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?”  There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs.^{Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018). Nursing interventions classifications (NIC) (7th ed.). Elsevier.}

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care. Direct care refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation. Indirect care interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12^{“400845937-huge.jpg” by Flamingo Images is used under license from Shutterstock.com} for an image of a nurse collaborating with the health care team when planning interventions.)

Independent Nursing Interventions

Any intervention that the nurse can independently provide without obtaining a prescription is considered an independent nursing intervention. An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example. Refer to Scenario C  in the “Assessment” section of this chapter. Ms. J. was diagnosed with Fluid Volume Excess. An example of an evidence-based independent nursing intervention is, “The nurse will reposition the patient with dependent edema frequently, as appropriate.”^{Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018). Nursing interventions classifications (NIC) (7th ed.). Elsevier.} The nurse would individualize this evidence-based intervention to the patient and agency policy by stating, “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.^{NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm} A primary health care provider is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example. Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with Fluid Volume Excess. An example of a dependent nursing intervention is, “The nurse will administer scheduled diuretics as prescribed.”

Collaborative Nursing Interventions

Collaborative nursing interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint.^{Vera, M. (2020). Nursing care plan (NCP): Ultimate guide and database. https://nurseslabs.com/nursing-care-plans/#:~:text=Collaborative%20interventions%20are%20actions%20that,to%20gain%20their%20professional%20viewpoint.}

Example. Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with Fluid Volume Excess. An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “The nurse will manage oxygen therapy in collaboration with the respiratory therapist” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.”^{Centers for Medicare and Medicaid Services. (2017). State operations manual: Appendix PP – Guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf} The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.^{The Joint Commission (n.d.). Standards and guides pertinent to nursing practice. https://www.jointcommission.org/resources/for-nurses/nursing-resources/}

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13^{“Figure 3-3. An example of a nursing care plan in an Australian residential aged care home..png” by NurseRecord is licensed under CC BY-SA 4.0} for an image of a standardized care plan.

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal. Appendix B contains a template that can be used for creating nursing care plans.

Open Resources for Nursing (Open RN)

Implementation is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “Diagnosis” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states, “The nurse will ambulate the patient 100 feet three times daily.” However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient.^{Robert Wood Johnson Foundation. (2011, April 28). Nurses are key to improving patient safety. https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html}

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled To Err Is Human: Building a Safer Health System. The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors. To Err Is Human broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system.^{Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25077248/} In 2007 the IOM published a follow-up report titled Preventing Medication Errors and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety.^{Institute of Medicine. (2007). Preventing medication errors. National Academies Press. https://doi.org/10.17226/11623.}

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care.^{Robert Wood Johnson Foundation. (2011, April 28). Nurses are key to improving patient safety. https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html}

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.”^{QSEN Institute. (n.d.). Project overview: The evolution of the quality and safety education for nurses (QSEN) initiative. http://qsen.org/about-qsen/project-overview/} Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps. Quality improvement is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).”^{Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety, 16(1), 2–3. https://doi.org/10.1136/qshc.2006.022046}

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks. Delegation is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.”^{American Nurses Association. (2013). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf} RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

Table 4.7 General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “Basic Concepts” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards 5A Coordination of Care and 5B Health Teaching and Health Promotion.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Coordination of Care includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team. Health Teaching and Health Promotion is defined as, “Employing strategies to teach and promote health and wellness.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Putting It Together

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

Open Resources for Nursing (Open RN)

Evaluation is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.} Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed.^{American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/}

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time  frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Putting It Together

Refer to Scenario C in the “Assessment” section of this chapter and  Appendix C. The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis Fluid Volume Excess, the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

1. The patient will report decreased dyspnea within the next 8 hours.
2. The patient will have clear lung sounds within the next 24 hours.
3. The patient will have decreased edema within the next 24 hours.
4. The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves.” Based on this data, the nurse evaluated the expected outcomes as “Partially Met” and revised the care plan with two new interventions:

1. Request prescription for TED hose from provider.
2. Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis, Risk for Falls, the nurse evaluated the outcome criteria as “Met” based on the evaluation, “The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred.”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

Open Resources for Nursing (Open RN)

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Open Resources for Nursing (Open RN)

Open Resources for Nursing (Open RN)

Advocacy: The act or process of pleading for, supporting, or recommending a cause or course of action.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Art of nursing: Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

At-risk populations: Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Associated conditions: Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

Basic nursing care: Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.^{Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf}

Caring relationship: A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family.^{Walivaara, B., Savenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing care – registered nurses’ experiences. The Open Journal of Nursing, 7, 89-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf}

Client: Individual, family, or group, which includes significant others and populations.^{NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm}

Clinical judgment: The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.^{NCSBN. (n.d.). NCSBN clinical judgment model. https://www.ncsbn.org/14798.htm}

Clinical reasoning: A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. ^{Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.}

Clustering data: Grouping data into similar domains or patterns.

Collaborative nursing interventions: Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

Coordination of care: While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association.}

Critical thinking: Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.^{Klenke-Borgmann, L., Cantrell, M. A. , & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221.}

Cue: Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

Deductive reasoning: “Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Defining characteristics: Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled.^{NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/}

Delegation: The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome.^{American Nurses Association. (2013). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf}

Dependent nursing interventions: Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Direct care: Interventions that are carried out by having personal contact with a patient.

Electronic Medical Record (EMR): An electronic version of the patient’s medical record.

Evidence-Based Practice (EBP): A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Expected outcomes: Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

Functional health patterns: An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

Generalization:  A judgment formed from a set of facts, cues, and observations.

Goals: Broad statements of purpose that describe the aim of nursing care.

Health teaching and health promotion: Employing strategies to teach and promote health and wellness.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Independent nursing interventions: Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Indirect care: Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

Inductive reasoning: A type of reasoning that involves forming generalizations based on specific incidents.

Inference: Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Licensed Practical Nurses or Licensed Vocational Nurses (LPNs/LVNs): Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

Medical diagnosis: A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing: Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Nursing care plan: Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

Nursing process: A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Objective data: Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

Outcome: A measurable behavior demonstrated by the patient that is responsive to nursing interventions.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

PES Statement:  The format of a nursing diagnosis statement that includes:

• Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)
• Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis
• Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Prescription: Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider.^{NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm}

Primary data: Information collected from the patient.

Primary health care provider: Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client.^{NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm}

Prioritization: The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

Quality improvement: The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).”^{Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety, 16(1), 2–3. https://doi.org/10.1136/qshc.2006.022046}

Rapport: Developing a relationship of mutual trust and understanding.

Registered Nurse (RN): A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

Related factors: The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Right to self-determination: Patients have the right to determine what will be done with and to their own person.

Scientific method: Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Secondary data: Information collected from sources other than the patient.

Subjective data: Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as “The patient appears anxious.”

Unlicensed Assistive Personnel (UAP): Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated.^{NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm}

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A national focus on reducing medical errors has been in place since 1999 when the Institute of Medicine (IOM) released a report titled To Err is Human: Building a Safer Health System. This historic report broke the silence surrounding health care errors and encouraged safety to be built into the processes of providing patient care. It was soon followed by the establishment of several safety initiatives by The Joint Commission, including the release of annual National Patient Safety Goals. Additionally, the Quality and Safety Education for Nurses (QSEN) Institute was developed to promote emphasis on high-quality, safe patient care in nursing. This chapter will discuss several safety initiatives that promote a safe health care environment.

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Safety: A Basic Need

Safety is a basic foundational human need and always receives priority in patient care. Nurses typically use Maslow’s Hierarchy of Needs to prioritize urgent patient needs, with the bottom two rows of the pyramid receiving top priority. See Figure 5.1^{“Maslow’s hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0} for an image of Maslow’s Hierarchy of Needs. Safety is intertwined with basic physiological needs.

Consider the following scenario: You are driving back from a relaxing weekend at the lake and come upon a fiery car crash. You run over to the car to help anyone inside. When you get to the scene, you notice that the lone person in the car is not breathing. Your first priority is not to initiate rescue breathing inside the burning car, but to move the person to a safe place where you can safely provide CPR.

In nursing, the concept of patient safety is central to everything we do in all health care settings. As a nurse, you play a critical role in promoting patient safety while providing care. You also teach patients and their caregivers how to prevent injuries and remain safe in their homes and in the community. Safe patient care also includes measures to keep you safe in the health care environment; if you become ill or injured, you will not be able to effectively care for others.

Safe patient care is a commitment to providing the best possible care to every patient and their caregivers in every moment of every day. Patients come to health care facilities expecting to be kept safe while they are treated for illnesses and injuries. Unfortunately, you may have heard stories about situations when that did not happen. Medical errors can be devastating to patients and their families. Consider the true patient story in the following box that illustrates factors affecting patient safety.

The event described in the Josie King story is considered a “never event.” Never events are adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable. In 2007 the Centers for Medicare and Medicaid Services (CMS) discontinued payment for costs associated with never events, and this policy has been adopted by most private insurance companies. Never events are publicly reported, with the goal of increasing accountability by health care agencies and improving the quality of patient care. The current list of never events includes seven categories of events:

• Surgical or procedural event, such as surgery performed on the wrong body part
• Product or device, such as injury or death from a contaminated drug or device
• Patient protection, such as patient suicide in a health care setting
• Care management, such as death or injury from a medication error
• Environmental, such as death or injury as the result of using restraints
• Radiologic, such as a metallic object in an MRI area
• Criminal, such as death or injury of a patient or staff member resulting from physical assault on the grounds of a health care setting

Sentinel Events

Sentinel events are similar to never events but are not necessarily preventable. They are defined as an “unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof.” For example, injury or death from a properly prescribed and administered medication is a sentinel event. The Joint Commission mandates reporting of sentinel events and the performance of a root cause analysis by the health care agency.  Root cause analysis is a structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals. A multidisciplinary team analyzes the sequence of events leading up to the error with the goal of identifying how and why the event occurred. The ultimate goal of root cause analysis is to prevent future harm by eliminating hidden problems within a health care system that contribute to adverse events. For example, when a medication error occurs, a root cause analysis goes beyond focusing on the mistake by the nurse and looks at other system factors that contributed to the error, such as similar-looking drug labels, placement of similar-looking medications next to each other in a medication dispensing machine, or vague instructions in a provider order.

Root cause analysis uses human factors science as part of the investigation. Human factors focus on the interrelationships among humans, the tools and equipment they use in the workplace, and the environment in which they work. Safety in health care is ultimately dependent on humans – the doctors, nurses, and health care professionals – providing the care.

Near Misses

In addition to investigating sentinel events and never events, agencies use root cause analysis to investigate near misses. Near misses are defined by the World Health Organization (WHO) as, “An error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted.” Errors and near misses are rarely the result of poor motivation or incompetence of the health care professional, but are often caused by key contributing factors such as poor communication, less-than-optimal teamwork, memory overload, reliance on memory for complex procedures, and lack of standardization of policies and procedures. In an effort to prevent near misses, medical errors, sentinel events, and never events, several safety strategies have been developed and implemented in health care organizations across the country. These strategies will be discussed throughout the remainder of the chapter.

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Safety strategies have been developed based on research to reduce the likelihood of errors and to create safe standards of care. Examples of safety initiatives include strategies to prevent medication errors, standardized checklists, and structured team communication tools.

Medication Errors

Several initiatives have been developed nationally to prevent medication errors, such as the establishment of a “Do Not Use List of Abbreviations,” a “List of Error-Prone Abbreviations,” “Frequently Confused Medication List,” “High-Alert Medications List,” and the “Do Not Crush List.” Additionally, it is considered a standard of care for nurses to perform three checks of the rights of medication administration whenever administering medication. View more information about these safety initiatives to prevent medication errors using the hyperlinks provided below. Specific strategies to prevent medication errors are discussed in the “Preventing Medication Errors” of the “Legal/Ethical” chapter of the Open RN Nursing Pharmacology textbook. The rights of medication administration are discussed in the “Basic Concepts of Administering Medications” section of the “Administration of Enteral Medications” chapter of the Open RN Nursing Skills textbook.

Checklists

Performance of complex medical procedures is often based on memory, even though humans are prone to short-term memory loss, especially when we are multitasking or under stress. The point-of-care checklist is an example of a patient care safety initiative that reduces this reliance on fallible memory. For example, a surgical checklist developed by the World Health Organization (WHO) has been adopted by most surgical providers around the world as a standard of care. It has significantly decreased injuries and deaths caused by surgeries by focusing on teamwork and communication. The Association of PeriOperative Registered Nurses (AORN) combined recommendations from The Joint Commission and the WHO to create a specific surgical checklist for nurses. See Figure 5.2^{“9789241598590_eng_Checklist.pdf” by WHO is in the Public Domain} for an image of the WHO surgical checklist.

Team Communication

Nurses routinely communicate with multidisciplinary health care team members and contact health care providers to report changes in patient status. Serious patient harm can occur when patient information is absent, incomplete, erroneous, or delayed during team communication. Standardized methods of communication have been developed to ensure that accurate information is exchanged among team members in a structured and concise manner.

ISBARR

A common format for communication between health care team members is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back. See Figure 5.3^{“ISBARR Reference Card” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0} for an image of an ISBARR reference card.

• Introduction: Introduce your name, role, and the agency from which you are calling.
• Situation: Provide the patient’s name and location, why you are calling, recent vital signs, and the status of the patient.
• Background: Provide pertinent background information about the patient such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
• Assessment: Share abnormal assessment findings and your concerns.
• Request/Recommendations: State what you would like the provider to do, such as reassess the patient, order a lab/diagnostic test, prescribe/change medication, etc.
• Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the patient’s chart.

Handoff Reports

Handoff reports are a specific type of team communication as patient care is transferred. Handoff reports are defined by The Joint Commission as, “A transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.” Handoff reports occur during multiple stages of patient care, such as between nurses at the end of shifts, when a patient is transferred from one unit to another within a health care agency, or when a patient is transferred to a different facility. In 2017 The Joint Commission issued a sentinel alert about inadequate handoff communication resulting in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors. Strategies to improve handoff communication, such as bedside handoff report checklists, have been implemented at agencies across the country.

Bedside handoff reports typically occur between nurses during inpatient care as the off-going and the incoming nurses communicate current, up-to-date details about the patient’s care . The report is optimally conducted at the bedside and includes the patient. Family members may be included during the report with the patient’s permission. See the hyperlink below to view a sample bedside shift report checklist from the Agency for Healthcare Research and Quality. Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts, such as current head-to-toe assessment findings to establish baseline status; information about equipment such as IVs, catheters, and drainage tubes; and recent changes in medications, lab results, diagnostic tests, and treatments.

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In addition to implementing safety strategies to improve safe patient care, leaders of a health care agency must also establish a culture of safety. A culture of safety reflects the behaviors, beliefs, and values within and across all levels of an organization as they relate to safety and clinical excellence, with a focus on people. In 2017 The Joint Commission released a sentinel event regarding the essential role of leadership in establishing a culture of safety. Three components of a culture of safety are the following:

• Just Culture: A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless behaviors.
• Reporting Culture: People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses.
• Learning Culture: People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

The American Nurses Association further describes a culture of safety as one that includes openness and mutual respect when discussing safety concerns and solutions without shifting to individual blame, a learning environment with transparency and accountability, and reliable teams. In contrast, complexity, lack of clear measures, hierarchical authority, the “blame game,” and lack of leadership are examples of barriers that do not promote a culture of safety. See the following box for an example of safety themes established during a health care institution’s implementation of a culture of safety.

A strong safety culture encourages all members of the health care team to identify and reduce risks to patient safety by reporting errors and near misses so that root cause analysis can be performed and identified risks are removed from the system. However, in a poorly defined and implemented culture of safety, staff often conceal errors due to fear or shame. Nurses have been traditionally trained to believe that clinical perfection is attainable and that “good” nurses do not make errors. Errors are perceived as being caused by carelessness, inattention, indifference, or uninformed decisions. Although expecting high standards of performance is appropriate and desirable, it can become counterproductive if it creates an expectation of perfection that impacts the reporting of errors and near misses. If employees feel shame when they make an error, they may feel pressure to hide or cover up errors. Evidence indicates that approximately three of every four errors are detected by those committing them, as opposed to being detected by an environmental cue or another person. Therefore, employees need to be able to trust that they can fully report errors without fear of being wrongfully blamed. This provides the agency with the opportunity to learn how to further improve processes and prevent future errors from occurring. For many organizations, the largest barrier in establishing a culture of safety is the establishment of trust. A model called “Just Culture” has successfully been implemented in many agencies to decrease the “blame game,” promote trust, and improve the reporting of errors.

Just Culture

The American Nurses Association (ANA) officially endorses the Just Culture model. In 2019 the ANA published a position statement on Just Culture, stating, “Traditionally, healthcare’s culture has held individuals accountable for all errors or mishaps that befall patients under their care. By contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A Just Culture also recognizes many individual or ‘active’ errors represent predictable interactions between human operators and the systems in which they work. However, in contrast to a culture that touts ‘no blame’ as its governing principle, a Just Culture does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated).”

The Just Culture model categorizes human behavior into three causes of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior.

• Simple human error: A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medication).
• At-risk behavior: An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a bar code scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.
• Reckless behavior: Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk.^{American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf} For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.

These examples show three different causes of medication errors that would result in different consequences to the employee based on the Just Culture model. Under the Just Culture model, after root cause analysis is completed, system-wide changes are made to decrease factors that contributed to the error. Managers appropriately hold individuals accountable for errors if they were due to simple human error, at-risk behavior, or reckless behaviors.

If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes. In the “simple human error” above, system-wide changes would be made to change the label and location of the medication to prevent future errors from occurring with the same medication.

Individuals committing at-risk behavior are held accountable for their behavioral choice and often require coaching with incentives for less risky behaviors and situational awareness. In the “at-risk behavior” example above where the nurse ignored an error message on the bar code scanner, mandatory training on using a bar code scanner and responding to errors would be implemented, and the manager would track the employee’s correct usage of the bar code scanner for several months following training.

If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.^{American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf}In the “reckless behavior” example above, the manager would report the nurse’s behavior to the state’s Board of Nursing with mandatory substance abuse counseling to maintain their nursing license. Employment may be terminated with consideration of patterns of behavior.

A Just Culture in which employees aren’t afraid to report errors is a highly successful way to enhance patient safety, increase staff and patient satisfaction, and improve outcomes. Success is achieved through good communication, effective management of resources, and an openness to changing processes to ensure the safety of patients and employees. The infographic in Figure 5.4 ^{“Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission.}illustrates the components of a culture of safety and Just Culture.

The principles of culture of safety, including Just Culture, Reporting Culture, and Learning Culture are also being adopted in nursing education. It’s understood that mistakes are part of learning and that a shared accountability model promotes individual- and system-level learning for improved patient safety. Under a shared accountability model, students are responsible for the following:

• being fully prepared for clinical experiences, including laboratory and simulation assignments
• being rested and mentally ready for a challenging learning environment
• accepting  accountability for their part in contributing to a safe learning environment
• behaving professionally
• reporting their own errors and near mistakes
• keeping up-to-date with current evidence-based practice
• adhering to ethical and legal standards^{Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11). https://www.ncsbn.org/Barnsteiner_Creating_a_fair_and_just_culture_in_schools_of_nursing.pdf}

Students know they will be held accountable for their actions, but will not be blamed for system faults that lie beyond their control. They can trust that a fair process will be used to determine what went wrong if a patient care error or near miss occurs. Student errors and near misses are addressed based on an investigation determining if it was simple human error, an at-risk behavior, or reckless behavior. For example, a simple human error by a student can be addressed with coaching and additional learning opportunities to remedy the knowledge deficit. However, if a student acts with recklessness (for example, repeatedly arrives to clinical unprepared despite previous faculty feedback or falsely documents an assessment or procedure), they are appropriately and fairly disciplined, which may include dismissal from the program.^{Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11). https://www.ncsbn.org/Barnsteiner_Creating_a_fair_and_just_culture_in_schools_of_nursing.pdf}

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Every year, national patient safety goals are published by The Joint Commission to improve patient safety.National Patient Safety Goals are goals and recommendations tailored to seven different types of health care agencies based on patient safety data from experts and stakeholders. The seven health care areas include ambulatory health care settings, behavioral health care settings, critical access hospitals, home care, hospital settings, laboratories, nursing care centers, and office-based surgery settings. These goals are updated annually based on safety data and include evidence-based interventions. It is important for nurses and nursing students to be aware of the current National Patient Safety Goals for the settings in which they provide patient care and use the associated recommendations.

The National Patient Safety Goals for nursing care settings (otherwise known as long-term care centers) are described in Table 5.5. (Note that the term “bedsore” is used in the last goal. This is a historic term for the current term “pressure injuries.”)

Table 5.5 National Patient Safety Goals for Nursing Care Centers^{The Joint Commission. (n.d.). 2021 National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/}

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“Prevent residents from falling” is one of the National Patient Safety Goals for nursing care centers. Patient falls, whether in the nursing care center, home, or hospital, are very common and can cause serious injury and death. Older adults have the highest risk of falling. Each year, 3 million older people are treated in emergency departments for fall injuries, and over 800,000 patients a year are hospitalized because of a head injury or hip fracture resulting from a fall. Many older adults who fall, even if they’re not injured, become afraid of falling. This fear may cause them to limit their everyday activities. However, when a person is less active, they become weaker, which further increases their chances of falling.^{Centers for Disease Control and Prevention. (2020, October 8). Older adult fall prevention. https://www.cdc.gov/falls/index.html}

Many conditions contribute to patient falls, including the following:^{Centers for Disease Control and Prevention. (2020, October 8). Older adult fall prevention. https://www.cdc.gov/falls/index.html}

• Lower body weakness
• Vitamin D deficiency
• Difficulties with walking and balance
• Medications, such as tranquilizers, sedatives, antihypertensives, or antidepressants
• Vision problems
• Foot pain or poor footwear
• Environmental hazards, such as throw rugs or clutter that can cause tripping

Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling. Many risk factors can be changed or modified to help prevent falls.

The Centers for Disease Control has developed a program called “STEADI – Stopping Elderly Accidents, Deaths & Injuries” to help reduce the risk of older adults from falling at home. Three screening questions to determine risk for falls are as follows:

• Do you feel unsteady when standing or walking?
• Do you have worries about falling?
• Have you fallen in the past year? If yes, how many times? Were you injured?

If the individual answers “Yes” to any of these questions, further assessment of risk factors is performed.^{Centers for Disease Control and Prevention. (2020, October 16). STEADI – Older adult fall prevention. https://www.cdc.gov/steadi/index.html}

Fall Assessment Tools

By virtue of being ill, all hospitalized patients are at risk for falls, but some patients are at higher risk than others. Assessment is an ongoing process with the goal of identifying a patient’s specific risk factors and implementing interventions in their care plan to decrease their risk of falling. Commonly used fall assessment tools used to identify patients at high risk for falls are the Morse Fall Scale and the Hendrich II Fall Risk Model. Read more about these fall risk assessment tools using the hyperlinks provided below. Key risk factors for falls in hospitalized patients are as follows:^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

• History of falls: All patients with a recent history of falls, such as a fall in the past three months, should be considered at higher risk for future falls.
• Mobility problems and use of assistive devices: Patients who have problems with their gait or require an assistive device (such as a cane or a walker) for mobility are more likely to fall.
• Medications: Patients on a large number of prescription medications or patients taking medicines that could cause sedation, confusion, impaired balance, or orthostatic blood pressure changes are at higher risk for falls.
• Mental status: Patients with delirium, dementia, or psychosis may be agitated and confused, putting them at risk for falls.
• Incontinence: Patients who have urinary frequency or who have frequent toileting needs are at higher fall risk.
• Equipment: Patients who are tethered to equipment such as an IV pole or a Foley catheter are at higher risk of tripping.
• Impaired vision: Patients with impaired vision or those who require glasses but who are not wearing them are at a higher fall risk because of their decreased recognition of an environmental hazard.
• Orthostatic hypotension: Patients whose blood pressure drops upon standing often experience light-headedness or dizziness that can cause falls.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Interventions to Prevent Falls

Universal fall precautions are established for all patients to reduce their risk for falling. In addition to universal fall precautions, a care plan is created based on the patient’s fall risk assessment findings to address their specific risks and needs.

Universal Fall Precautions

Falls are the most commonly reported patient safety incidents in the acute care setting. Hospitals pose an inherent fall risk due to the unfamiliarity of the environment and various hazards in the hospital room that pose a risk. During inpatient care, nurses assess their patients’ risk for falling during every shift and implement interventions to reduce the risk of falling. Universal fall precautions have been developed that apply to all patients all the time. Universal fall precautions are called “universal” because they apply to all patients, regardless of fall risk, and revolve around keeping the patient’s environment safe and comfortable.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Universal fall precautions include the following:

• Familiarize the patient with the environment.
• Have the patient demonstrate call light use.
• Maintain the call light within reach. See Figure 5.5^{“Hill-Rom_hospital_bed_TV_remote_control.JPG” by BrokenSphere is licensed under CC BY-SA 3.0.} for an image of a call light.
• Keep the patient’s personal possessions within safe reach.
• Have sturdy handrails in patient bathrooms, rooms, and hallways.
• Place the hospital bed in the low position when a patient is resting. Raise the bed to a comfortable height when the patient is transferring out of bed.
• Keep the hospital bed brakes locked.
• Keep wheelchair wheels in a “locked” position when stationary.
• Keep no-slip, comfortable, and well-fitting footwear on the patient.
• Use night lights or supplemental lighting.
• Keep floor surfaces clean and dry. Clean up all spills promptly.
• Keep patient care areas uncluttered.
• Follow safe patient handling practices.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Interventions Based on Risk Factors

Patients at elevated risk for falling require multiple, individualized interventions, in addition to universal fall precautions. There are many interventions available to prevent falls and fall-related injuries based on the patient’s specific risk factors. See Table 5.6a for interventions categorized by risk factor.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Table 5.6a  Interventions Based on Fall Risk Factors

Scheduled Hourly Rounding

Scheduled hourly rounds are scheduled hourly visits to each patient’s room to integrate fall prevention activities with the rest of a patient’s care. Scheduled hourly rounds have been found to greatly decrease the incidence of falls. See below for a list of activities to complete during hourly rounds. These activities can be completed by unlicensed assistive personnel, nurses, or nurse managers.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Hourly Rounding Protocol.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

• Assess patient pain levels using a pain-assessment scale. (If staff other than a nurse is doing the rounding and the patient is in pain, contact the nurse immediately so the patient does not have to use the call light for pain medication.)
• Put pain medication that is ordered “as needed” on an RN’s task list and offer the dose when it is due.
• Offer toileting assistance.
• Ensure the pCheck that the bed is in the locked position.atient is using correct footwear (e.g., specific shoes/slippers, no-skid socks).
• Place the hospital bed in a low position when the patient is resting; ask if the patient needs to be repositioned and is comfortable.
• Make sure the call light/call bell button is within the patient’s reach and the patient can demonstrate accurate use.
• Put the telephone within the patient’s reach.
• Put the TV remote control and bed light switch within the patient’s reach.
• Put the bedside table next to the bed or across the bed.
• Put the tissue box and water within the patient’s reach.
• Put the garbage can next to the bed.
• Prior to leaving the room, ask, “Is there anything I can do for you before I leave?”
• Tell the patient that a member of the nursing staff (use names on white board) will be back in the room in an hour to round again.

Medications Causing Elevated Risk for Falls

Evaluate medication-related fall risk for patients on admission and at regular intervals thereafter. Add up the point value (risk level) in Table 5.6b for every medication the patient is taking. If the patient is taking more than one medication in a particular risk category, the score should be calculated by (risk level score) x (number of medications in that risk level category). For a patient at risk, a pharmacist should review the patient’s list of medications and determine if medications may be tapered, discontinued, or changed to a safer alternative.^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

Table 5.6b Medications Causing High Risk for Falls^{Agency for Healthcare Research and Quality. (2018, July). Preventing falls in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html}

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Definition of Restraints

Restraints are devices used in health care settings to prevent patients from causing harm to themselves or others when alternative interventions are not effective. A restraint is a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement without the permission of the person. See Figure 5.6^{“PinelRestraint.jpg” by James Heilman, MD is licensed under CC BY-SA 4.0} for an image of a simulated patient with restraints applied.

Restraints include mechanical devices such as a tie wrist device, chemical restraints, or seclusion. The Joint Commission defines chemical restraint as a drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the patient’s ability to appropriately interact with their surroundings that is not standard treatment or dosage for the patient’s condition. It is important to note that the definition states the medication “is not standard treatment or dosage for the patient’s condition.”^{The Joint Commission. https://www.jointcommission.org/} Seclusion is defined as the confinement of a patient in a locked room from which they cannot exit on their own. It is generally used as a method of discipline, convenience, or coercion. Seclusion limits freedom of movement because, although the patient is not mechanically restrained, they cannot leave the area.

Although restraints are used with the intention to keep a patient safe, they impact a patient’s psychological safety and dignity and can cause additional safety issues and death. A restrained person has a natural tendency to struggle and try to remove the restraint and can fall or become fatally entangled in the restraint. Furthermore, immobility that results from the use of restraints can cause pressure injuries, contractures, and muscle loss. Restraints take a large emotional toll on the patient’s self-esteem and may cause humiliation, fear, and anger.

Restraint Guidelines

The American Nurses Association (ANA) has established evidence-based guidelines that state a restraint-free environment is the standard of care. The ANA encourages the participation of nurses to reduce patient restraints and seclusion in all health care settings. Restraining or secluding patients is viewed as contrary to the goals and ethical traditions of nursing because it violates the fundamental patient rights of autonomy and dignity. However, the ANA also recognizes there are times when there is no viable option other than restraints to keep a patient safe, such as during an acute psychotic episode when patient and staff safety are in jeopardy due to aggression or assault. The ANA also states that restraints may be justified in some patients with severe dementia or delirium when they are at risk for serious injuries such as a hip fracture due to falling.

The ANA provides the following guidelines: “When restraint is necessary, documentation should be done by more than one witness. Once restrained, the patient should be treated with humane care that preserves human dignity. In those instances where restraint, seclusion, or therapeutic holding is determined to be clinically appropriate and adequately justified, registered nurses who possess the necessary knowledge and skills to effectively manage the situation must be actively involved in the assessment, implementation, and evaluation of the selected emergency measure, adhering to federal regulations and the standards of The Joint Commission (2009) regarding appropriate use of restraints and seclusion.”^{American Nurses Association. (2012). Position statement: Reduction of patient restraint and seclusion in health care settings. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reduction-of-patient-restraint-and-seclusion-in-health-care-settings/} Nursing documentation typically includes information such as patient behavior necessitating the restraint, alternatives to restraints that were attempted, the type of restraint used, the time it was applied, the location of the restraint, and patient education regarding the restraint.

Any health care facility that accepts Medicare and Medicaid reimbursement must follow federal guidelines for the use of restraints. These guidelines include the following:

• When a restraint is the only viable option, it must be discontinued at the earliest possible time.
• Orders for the use of seclusion or restraint can never be written as a standing order or PRN (as needed).
• The treating physician must be consulted as soon as possible if the restraint or seclusion is not ordered by the patient’s treating physician.
• A physician or licensed independent practitioner must see and evaluate the need for the restraint or seclusion within one hour after the initiation.
• The patient must be continually assessed. Generally, the best practice is every 15 minutes for continued use of the restraint, and in the case of an applied restraint, the restraint should be removed and the area assessed every hour. Some agencies require a 1:1 patient sitter when restraints are applied.
• Each written order for a physical restraint or seclusion is limited to 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, or 1 hour for patients under 9. The original order may only be renewed in accordance with these limits for up to a total of 24 hours. After the original order expires, a physician or licensed independent practitioner (if allowed under state law) must see and assess the patient before issuing a new order.^{HealthPartners. (n.d.). Patients’ bill of rights (federal). https://www.healthpartners.com/care/hospitals/regions/patient-guest-support/federal-rights/}

Side Rails and Enclosed Beds

Side rails and enclosed beds may also be considered a restraint, depending on the purpose of the device. Recall the definition of a restraint as “a device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement or access to movement without the permission of the person.” If the purpose of raising the side rails is to prevent a patient from voluntarily getting out of bed or attempting to exit the bed, then use of the side rails would be considered a restraint. On the other hand, if the purpose of raising the side rails is to prevent the patient from inadvertently falling out of bed, then it is not considered a restraint. If a patient does not have the physical capacity to get out of bed, regardless if side rails are raised or not, then the use of side rails is not considered a restraint.^{The Joint Commission. (2020, June 29). Restraint and seclusion – Enclosure beds, side rails, and mitts. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000001668/}

Hand Mitts

A hand mitt is a large, soft glove that covers a confused patient’s hand to prevent them from inadvertently dislodging medical equipment. Hand mitts are considered a restraint by The Joint Commission if used under these circumstances:

• Are pinned or otherwise attached to the bed or bedding
• Are applied so tightly that the patient’s hands or finger are immobilized
• Are so bulky that the patient’s ability to use their hands is significantly reduced
• Cannot be easily removed intentionally by the patient in the same manner it was applied by staff, considering the patient’s physical condition and ability to accomplish the objective^{The Joint Commission. (2020, June 29). Restraint and seclusion – Enclosure beds, side rails, and mitts. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000001668/}

It is important for the nurse to be aware of current best practices and guidelines for restraint use because they are continuously changing. For example, meal trays on chairs were previously used in long-term care facilities to prevent residents from getting out of the chair and falling. However, by the definition of a restraint, this action is now considered a restraint and is no longer used. Instead, several alternative interventions to restraints are now being used.

Alternatives to Restraints

Many alternatives to using restraints in long-term care centers have been developed. Most interventions focus on the individualization of patient care and elimination of medications with side effects that cause aggression and the need for restraints. Common interventions used as alternatives to restraints include routine daily schedules, regular feeding times, easing the activities of daily living, and reducing pain.^{Raveesh, B. N., Gowda, G. S., & Gowda, M. (2019). Alternatives to use of restraint: A path toward humanistic care. Indian Journal of Psychiatry, 61(Suppl 4), S693–S697. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482675/}

Diversionary techniques such as television, music, games, or looking out a window can also be used to help to calm a restless patient. Encouraging restless patients to spend time in a supervised area, such as a dining room, lounge, or near the nurses’ station, helps to prevent their desire to get up and move around. If these techniques are not successful, bed and chair alarms or the use of a sitter at the bedside are also considered alternatives to restraints.

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To promote safety for patients of all ages, nurses should be knowledgeable about safety risks according to age and developmental stages because the types and frequencies of accidents vary among age groups. Information from the Centers for Disease Control (CDC) regarding safety tips for each age group is summarized in the following subsections.^{Centers for Disease Control and Prevention. (2020, October 8). Parent information. https://www.cdc.gov/parents/index.html}

Infants and Preschoolers

Drowning is the leading cause of death in children aged 1-3 years. Motor vehicle accidents, falls, choking, and accidental poisoning are also safety concerns for this age group. Infants and toddlers are curious, but they lack the judgement to recognize the dangers of their actions, so childproofing the home and providing adult supervision are essential for this developmental age group.^{Centers for Disease Control and Prevention. (2020, October 8). Parent information. https://www.cdc.gov/parents/index.html} See Figure 5.7^{“ARISE Newborn in Car Seat 144049.jpg” by ARISE project is licensed under CC BY 4.0} for an image of an infant car seat used to protect infants in the event of a motor vehicle accident. Nurses help educate parents about the proper use, positioning, and installation of car seats.

School-Aged Children

In children aged 4-11, motor vehicle injuries are a major cause of unintentional injury, along with drowning and poisoning. This age group is more aware of dangers and limitations, but adult supervision is still important. The nurse should educate parents of school-aged children about safety seats, booster seats, or shoulder seat belts while riding in the car.^{Centers for Disease Control and Prevention. (2020, October 8). Parent information. https://www.cdc.gov/parents/index.html}

Bicycle accidents are also a common concern in this age group. Many bike accidents involve the head or face because of the lack of helmet use. Nurses provide health teaching to school-aged children regarding bicycle safety and helmet use. See Figure 5.8^{“539478754.jpg” by thechatat is used under license from Shutterstock.com}  for an image of a girl wearing a bike helmet.

Because this age group is beginning to enjoy more independence, basic instructions and education on how to recognize and respond to potentially dangerous situations with strangers should also be provided. Parents should also be educated about the AMBER alert system that can be activated if a child is missing and believed to be kidnapped or in danger. This AMBER alert system uses the resources of law enforcement and the media to notify the public about a possible abduction or a missing child in danger.^{Amber Alert. https://amberalert.ojp.gov/}

Nurses must also be aware of signs of maltreatment and child abuse because millions of children are affected each year. Child abuse includes physical, sexual, emotional abuse, and neglect. According to the American Academy of Child and Adolescent Psychiatry (AACAP), after abuse or violence, many children develop mental health problems, including depression and posttraumatic stress disorder. These children may also have serious medical problems, learning problems, and problems getting along with friends and family members. Every state has laws that require health care professionals to report suspected child abuse no matter what form this abuse takes.^{American Academy of Child & Adolescent Psychiatry. (2020, April). Trauma and child abuse resource center. https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/Home.aspx}

Adolescents

Motor vehicle accidents are the number one cause of death for adolescents. Teens aged 16-19 are three times more likely to be in a fatal crash than drivers older than age 20. Adolescent males are twice as likely to die in a motor vehicle accident than females of the same age. Texting while driving is a common cause of distracted driving and accidents in adolescents. Because much of an adolescent’s time is spent away from the home, it is difficult for parents to control many of the decisions that adolescents make. Nurses educate teenagers to use seat belts, obey speed limits, and never use a cell phone or text while driving.^{Centers for Disease Control and Prevention. (2020, October 8). Parent information. https://www.cdc.gov/parents/index.html} See Figure 5.9^{“texting-while-driving/man-texting-while-driving-md.jpg” by unknown at QuoteInspector.com is licensed under CC BY-ND 4.0.} for an image reminding teenage drivers to not text and drive.

Traumatic brain injuries (TBI) may occur in this age group due to participation in sports and recreation-related activities. TBI results from a blow, jolt, or hit to the head that causes a disruption in blood function or flow to the brain. Nurses should always be alert for indications of a concussion when a sports injury has occurred. Signs of a concussion requiring immediate medical attention include the following:

• Headache, vomiting, balance problems, fatigue, or drowsiness
• A dazed and confused appearance or difficulty concentrating or remembering; confusion
• Emotional irritability, nervousness, or a change in personality

The CDC has comprehensive information and education materials for parents, coaches, players, and health care providers as part of their “Heads Up” program.^{Centers for Disease Control and Prevention. (2020, November 20). Helmet safety. https://www.cdc.gov/headsup/helmets/index.html}

Substance abuse is another significant concern in the adolescent population and includes substances such as tobacco, alcohol, illicit drugs, prescription medication, over-the-counter medications, and bath salts. The National Institutes of Health provides many resources for educating teens and their parents about substance abuse.^{National Institute on Drug Abuse. (n.d.). NIDA for teens. https://teens.drugabuse.gov/}

Adults

Intimate partner violence and substance abuse are common safety issues in the adult population.

Intimate Partner Violence

Intimate partner violence (IPV) is widespread in the United States and is the most prevalent adult safety issue. Intimate partner violence includes physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners. Victims can be female or male, and sexual orientation can be heterosexual or LGBTQ+. The nurse is often the initial health care professional in contact with a victim of IPV. Prompt recognition of a potential or actual threat to patient and staff safety is crucial. It is often the nurse’s assessment that plays an important role in identifying a patient experiencing IPV. Compassion and understanding are important to show to this vulnerable population. Effective communication is necessary to help victims come forward and share their experiences of abuse. IPV is a complex issue, and the patient may not initially consider leaving the abuser as an option. See Figure 5.10^{“Domestic_violence_free-zone.jpg” by Ben Pollard is licensed under CC BY-SA 2.0} for an image of a sign in a community demonstrating support against domestic violence.

See the following hyperlinks for tools and resources to share with patients experiencing IPV. For example, the Danger Assessment Tool is a self-administered survey that is free to use and is available in several languages.^{Danger Assessment. https://www.dangerassessment.org/DATools.aspx} Nurses can refer patients experiencing IPV to the National Center on Domestic Violence, the Trauma and Mental Health database for resources,^{National Center on Domestic Violence, Trauma & Mental Health. (n.d.). National domestic violence organizations. http://www.nationalcenterdvtraumamh.org/resources/national-domestic-violence-organizations/} and the National Domestic Violence Hotline for free, confidential support.^{National Domestic Violence Hotline. https://www.thehotline.org/} Most importantly, nurses should assist patients experiencing IPV to create a safety plan.

Substance Abuse

Substance abuse is defined by the World Health Organization (WHO) as a maladaptive pattern of using alcohol and/or drugs despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous. Substance abuse continues to be a safety issue that affects adults across all socioeconomic levels. In America over 450,000 people died between 1999 and 2018 as a result of an opioid overdose.^{Centers for Disease Control and Prevention. (2020, December 17). Opioid overdose. https://www.cdc.gov/drugoverdose/} The abuse of prescription pain medication (such as oxycontin and fentanyl) and heroin is a national crisis that plagues social and economic welfare. Substance abuse not only affects an individual, but also causes harm to their family members. Early identification of substance abuse, rehabilitation interventions, and continued support are key for helping the individual, as well as their family members, in the recovery process. See Figure 5.11^{“Heroin syringe” by Thomas Marthinsen is licensed under CC BY-NC-SA 2.0} for an image of a heroin needle found in a community setting.

Older Adults

According to the Centers for Disease Control and Prevention, falls and motor vehicle accidents are leading causes of injury in older adults. However, several other issues pose significant hazards for this population, such as fires, accidental overdosing on medications (due to poor eyesight and confusion), elder abuse, and financial exploitation.^{Centers for Disease Control and Pevention (n.d.) Injury Prevention and Control. https://www.cdc.gov/injury/index.html} In most reported cases of elder abuse, a caregiver or a person in trusted relationship is the perpetrator. For various reasons such as fear and disappointment, most of these cases go unreported. Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and over 19,000 homicides occurred.^{Centers for Disease Control and Prevention (n.d.) Elder Abuse. https://www.cdc.gov/violenceprevention/elderabuse/} Read an example of an older adult experiencing financial exploitation in the following box.

Most victims of elder abuse are frequently seen in the emergency department several times before they are admitted to the hospital. Nurses must be alert to any indications of elder abuse, such as suspicious injuries or behaviors, and report suspected incidents to local adult protective services agencies. Commons signs of elder abuse or maltreatment include the following:^{Nursing Home Abuse Center. (2020, January 8). Signs of elder abuse. https://www.nursinghomeabusecenter.com/elder-abuse/signs/}

• Bruises, cuts, burns, or broken bones that are unexplainable or suspiciously explained
• Malnourishment or weight loss
• Poor hygiene, an unkempt appearance, unclean clothing, or dirty, matted hair
• Foul odor from clothing or body
• Anxiety, depression, or confusion
• Unexplained transactions or loss of money
• Withdrawal from family members or friends

View additional resources related to elder abuse using the hyperlinks in the following box.

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In addition to promoting safety for patients and their families, it is important for nurses to be aware of safety risks in the environments and to take measures to protect themselves. Common safety risks to nurses include sharps injuries, exposure to blood-borne pathogens, lifting injuries, and lack of personal protective equipment (PPE).

Workplace Safety

The World Health Organization (WHO) defines a healthy environment as a place of physical, mental, and social well-being supporting optimal health and safety. The American Nurses Association (ANA) created the Nurses’ Bill of Rights, a document that sets forth seven basic principles concerning expectations for workplace environments. One of the ANA principles states, “Nurses have the right to a work environment that is safe for themselves and their patients.” ^{American Nurses Association. (n.d.). Healthy work environment. https://www.nursingworld.org/practice-policy/work-environment/} Environmental Health is also one of the ANA Standards of Professional Performance. This standard includes “creating a safe and healthy workplace and professional environment.”^{American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.}

Preventing Sharps Injuries and Blood-Borne Pathogen Exposure

Exposure to sharps and blood-borne pathogens is a critical safety issue that nurses face in the workplace.^{American Nurses Association. (n.d.). Healthy work environment. https://www.nursingworld.org/practice-policy/work-environment/}Blood-borne pathogen exposure can cause life-threatening illnesses such as hepatitis B, hepatitis C, and HIV. Regulations and laws, such as the Blood-borne Pathogen Standard from the Occupational Safety and Health Administration (OSHA) and the Needlestick Safety and Prevention Act of 2002, have been effective in significantly reducing sharps injuries and blood exposures among health care workers. Areas covered by these regulations include sharps disposal practices, evaluation and selection of safety-engineered sharps devices and personal protective equipment (PPE), training, record keeping for needlestick injuries, hepatitis B vaccination, and post exposure follow-up. Medical device manufacturers have also played an important role in reducing sharps injury risks to health care workers by developing innovative safety-engineered technology, such as needleless IV access devices.^{American Nurse. (2012, September 11). Moving the sharps safety agenda forward: Consensus statement and call to action. https://www.myamericannurse.com/moving-the-sharps-safety-agenda-forward-consensus-statement-and-call-to-action/} While substantial progress has been made to reduce injuries, preventable sharps injuries and blood exposures continue to occur in health care settings. According to the Centers for Disease Control and Prevention (CDC), around 385,000 sharps-related injuries occur annually among health care workers in hospitals, but it has been estimated that as many as half of injuries go unreported.^{American Nurses Association. (n.d.). Healthy work environment. https://www.nursingworld.org/practice-policy/work-environment/} See Figure 5.12^{“Sharps Container.jpg” by William Rafti of the William Rafti Institute is licensed under CC BY 2.5} of a sharps container used to prevent sharps-related injuries.

If you do experience a sharps injury or are exposed to the blood or other body fluid of a patient, follow agency and school policy and immediately follow these steps:

• Wash needlesticks and cuts with soap and water.
• Flush splashes to the nose, mouth, or skin with water.
• Irrigate eyes with clean water, saline, or sterile irrigants.
• Report the incident to your supervisor.
• Immediately seek medical treatment.^{Centers for Disease Control and Prevention. (2016, October 5). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C. National Institute for Occupational Safety and Health. https://www.cdc.gov/niosh/topics/bbp/emergnedl.html}

Safe Patient Handling

Back injuries and other musculoskeletal disorders can be caused by one bad patient lift or from  the daily wear and tear of manually lifting patients. At least 56% of nurses have reported pain from musculoskeletal disorders that were exacerbated by requirements of their job. Consequences of these injuries can be devastating to nurses and their careers; musculoskeletal injuries related to patient handling are responsible for more lost work time, long-term medical care needs, and permanent disabilities than any other work-related injury. Even using proper body mechanics and the use of gait belts can result in patient handling injuries in nurses and health care workers. The ANA has established safe patient handling and mobility initiatives with the goal of complete elimination of manual patient handling.^{American Nurses Association. (2015, September). Safe patient handling & mobility: Understanding the benefits of a comprehensive SPHM program [Brochure]. https://www.nursingworld.org/~498de8/globalassets/practiceandpolicy/work-environment/health–safety/ana-sphmcover__finalapproved.pdf} See Figure 5.13^{“User-Integra-lifter1.jpg” by Integracp is licensed under CC BY-SA 3.0} for an example of safe patient handling equipment.

Personal Protective Equipment

The Occupational Safety and Health Administration (OSHA) requires employers to provide personal protective equipment (PPE) to their workers and ensure its proper use.^{United States Department of Labor. (n.d.). Personal protective equipment. Occupational Safety and Health Administration. https://www.osha.gov/personal-protective-equipment} In health care settings, the use of PPE includes gloves, gowns, goggles, face shields, and N95 respirators according to a patient’s condition. Health care workers rely on personal protective equipment to protect themselves and their patients from being infected and infecting others. It is vital to follow agency procedures regarding PPE and transmission precautions to avoid exposure to infectious disease. See Figure 5.14^{“Healthcare_workers_wearing_PPE_03.jpg” by Javed Anees is licensed under CC0 1.0} for an image of health care team members wearing PPE. Unfortunately, the COVID-19 pandemic created global shortages of PPE, resulting in many nurses and health care workers being exposed to the fatal disease. The ANA continues to advocate for adequate PPE for nurses in their work environments. Read more about PPE shortages in the hyperlink below.

Patient Scenario

Mr. Olson is a 64-year-old patient admitted to the medical surgical floor with a diagnosis of pneumonia. The patient has severe macular degeneration and limited visual acuity. He is alert and oriented but notes that he has suffered a “few stumbles” at home over the last few weeks. He ambulates without assistance but relies heavily on tactile cues to help provide guidance.

Applying the Nursing Process

Assessment: The nurse notes that Mr. Olson’s macular degeneration and limited visual acuity pose a significant safety risk. He has reported “stumbling” at home and uses tactile cues to establish room boundaries.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Olson.

Nursing Diagnosis: Risk for Injury related to physical barrier associated with alteration in visual acuity.

Overall Goal: The patient will be free from injury or falls.

SMART Expected Outcome: Mr. Olson will be free from injury throughout his hospitalization.

Planning and Implementing Nursing Interventions:

The nurse will provide the patient with education regarding the room layout and tactile boundary cues. The nurse will keep the patient’s room free from clutter and provide appropriate lighting. The nurse will instruct the patient to utilize the call light and request assistance when ambulating throughout the room. The nurse will provide the patient with nonskid footwear to enhance safety during ambulation.

Sample Documentation

Mr. Olson is at risk for injury as a result of his decreased visual acuity and hospitalization in an unfamiliar environment. The patient has been provided education and safety equipment to decrease his risk of injury. The patient has received education regarding the room layout and has been encouraged to request assistance when ambulating about the room.

Evaluation:

During the patient’s hospitalization, Mr. Olson utilizes the recommended safety equipment and requests assistance when ambulating and no falls occurred. SMART outcome was “met.”

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Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Assessing a patient’s risk for falls and planning interventions to prevent falls are common safety strategies completed by nurses. This section uses a patient scenario to demonstrate how to use the nursing process to assess a patient and then create a nursing care plan to prevent falls. Begin by reading the Handoff Report received from the nurse on the previous shift.

Handoff Report

Mr. Moore is a 72-year-old widower recovering in the hospital after sustaining injuries he received from a fall he sustained at home. See Figure 5.15 for an image of Mr. Moore.^{“old-man-1208210_960_720.jpg” by Free-Photos at Pixabay is licensed under CC0} He fractured his right hip and underwent surgical repair two days ago. He is receiving IV fluids and morphine for pain control. He has a history of hypertension and cardiovascular disease. He wears glasses and hearing aids. Per recommendations from the physical therapist, he is able to transfer with one assist with a walker, but is weak on his right side. He has an order to ambulate at least 100 feet four times daily with a wheeled walker. He is 6 feet tall and weighs 165 pounds. Prior to the fall, he lived at home alone independently, and he is looking forward to returning home.

Assessment

The nurse collects the following assessment findings:

• Vital Signs: Blood pressure 90/60, heart rate 56, respiratory rate 18, temperature 37 degrees Celsius, pulse oximetry reading 92%, current pain level 0
• Alert and oriented x 3 to person, place, and time
• Lungs clear
• Cardiovascular Assessment: Heart rate is regular, capillary refill less than 3 seconds in fingers and toes, pedal pulses 2+
• Right lower extremity strength is 1+ (weak)
• Ambulates with walker with assistance; gait is unsteady

Critical Thinking Questions

1. Describe the fall risk factors for Mr. Moore.

2. Use the Morse Fall Risk Assessment tool to assess Mr. Moore’s risk for falling.

Diagnosis

The NANDA-I nursing diagnosis is established: Risk for Falls as evidenced by lower extremity weakness and difficulty with gait.

Outcome Identification

Overall Goal: Mr. Moore will remain free from falls during his hospitalization stay.

SMART Expected Outcomes:

• Mr. Moore will not experience a fall during hospitalization.
• Mr. Moore will correctly use his assistive device (walker) every time he ambulates during hospitalization.

Planning Interventions

The following interventions are planned based on Mr. Moore’s fall risk factors.

• Remove clutter from the floor.
• Provide adequate lighting with a night-light at the bedside.
• Use half side rails to prevent falls from the bed.
• Monitor gait, balance, and fatigue with ambulation and encourage resting as needed.
• Place personal items within easy reach of the patient at the bedside.
• Provide an elevated toilet seat.
• Encourage the use of prescribed glasses and hearing aids when walking.
• Obtain orthostatic blood pressures daily and notify the provider as indicated.
• Ensure the patient wears shoes that fit properly, are fastened securely, and have no-skid soles.
• Suggest home adaptations to improve safety after discharge, such as adjusting the toilet seat height, installing grab bars in the bathroom, and using a rubber mat in the shower.

Critical Thinking Question

3. What additional interventions could be implemented for Mr. Moore to reduce his risk of falls that target his specific risk factors?

Implementation of Interventions

The following day, upon entering the room, you find Mr. Moore has climbed out of bed and is on his way to the bathroom. He states, “I need to go to the bathroom for a bowel movement and didn’t have time to ring the call light and wait.” You assist him with his walker, but he seems unsteady on his feet as he walks toward the bathroom. You’re not sure if he will make it to the toilet without falling. He says, “We need to hurry or I’m not going to make it.”

Critical Thinking Question:

4. What is the best response?

Evaluation

The nurse evaluates Mr. Moore’s progress based on the established expected outcomes:

• Mr. Moore will not experience a fall during hospitalization: Outcome Met.
• Mr. Moore will use his assistive device (walker) correctly during hospitalization: Outcome Partially Met.

Mr. Moore forgets to call for assistance and uses a walker when he needs to go to the bathroom. A “stop” sign has been placed within patient view to remind him to use the call light before getting up. In addition to hourly rounding, toileting will be performed at scheduled intervals every two hours. An icon has been posted on the doorframe to alert staff that the patient is at high risk for falls. In addition to the bed being kept low and locked, a mat will be placed next to the bed at night. If Mr. Moore continues to forget to call for assistance, a bed alarm will be placed to alert staff of movement so that quick assistance can be offered.

 

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At-risk behavior: According to the Just Culture model, an error that occurs when a behavioral choice is made that increases risk where risk is not recognized or is mistakenly believed to be justified.

Chemical restraint: A drug used to manage a patient’s behavior, restrict the patient’s freedom of movement, or impair the patient’s ability to appropriately interact with their surroundings that is not a standard treatment or dosage for the patient’s condition.

Culture of safety: The behaviors, beliefs, and values within and across all levels of an organization as they relate to safety and clinical excellence, with a focus on people.

Handoff reports: A transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.

Healthy environment: A place of physical, mental, and social well-being supporting optimal health and safety.

Human factors: A science that focuses on the interrelationships between humans, the tools and equipment they use in the workplace, and the environment in which they work.

Intimate Partner Violence (IPV): Physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners.

ISBARR: A mnemonic for the components of health care team member communication that stands for Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

Just Culture: A quality of an institutional culture of safety where people feel safe raising questions and concerns and reporting safety events in an environment that emphasizes a nonpunitive response to errors and near misses, but clear lines are drawn between human error, at-risk, and reckless behaviors.

Learning Culture: A quality of an institutional culture of safety where people regularly collect information and learn from errors and successes. Data is openly shared and evidence-based practices are used to improve work processes and patient outcomes.

National Patient Safety Goals: Annual patient safety goals and recommendations tailored for seven different types of health care agencies based on patient safety data from experts and stakeholders.

Near misses: An unplanned event that did not result in a patient injury or illness but had the potential to.

Never events: Adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable.

Reckless behavior: According to the Just Culture model, an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk.

Reporting Culture: A quality of an institutional culture of safety where people realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses.

Restraint: A device, method, or process that is used for the specific purpose of restricting a patient’s freedom of movement without the permission of the person.

Root cause analysis: A structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals.

Scheduled hourly rounds: Scheduled hourly visits to each patient’s room to integrate fall prevention activities with the rest of a patient’s care.

Seclusion: The confinement of a patient in a locked room from which they cannot exit on their own. It is generally used as a method of discipline, convenience, or coercion.

Sentinel event: An unexpected occurrence involving death or serious physiological or psychological injury or the risk thereof.

Simple human error: According to the Just Culture model, this is an error that occurs when an individual inadvertently does something other than what should have been done. Most errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These are managed by correcting the cause, looking at the process, and fixing the deviation.

Substance abuse: A maladaptive pattern of continued use of alcohol or a drug despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous.

Universal fall precautions: A set of interventions to reduce the risk of falls for all patients and focus on keeping the environment safe and comfortable.

Open Resources for Nursing (Open RN)

Cognition is the term used to describe our ability to think. As humans, we are continually receiving input from the world around us and making decisions about how to respond. Some of these decisions are made with awareness, while others are reflexive responses. Infants develop cognitively based on their experiences with their environment. Cognitive processes continue to develop throughout childhood, adolescence, and adulthood as we learn how to adapt and use knowledge to solve problems and reach desired outcomes.

Many factors can influence an individual’s continuously-evolving cognitive function from fetal development through adulthood. For example, diseases and health conditions can impair a person’s cognitive development and functioning during childhood and beyond. Impaired ability to think and make decisions can be temporarily affected by things such as infection, alcohol, drugs and medications, poor oxygenation, stress, or grief. Sensory deficits and sensory overload can also affect the ability to process information. (See the “Sensory Impairments” chapter for more information on this topic.)

Nurses monitor for changes in mental status and report them to health care providers to assist in the diagnosis and treatment for underlying causes of impairment. This chapter will review cognitive development, as well as common acute and chronic cognitive impairments in adults.

Open Resources for Nursing (Open RN)

Before learning about cognitive impairment, it is important to understand the physiological processes of normal growth and development. Growth includes physical changes that occur during the development of an individual beginning at the time of conception. Development encompasses these biological changes, as well as social and cognitive changes that occur continuously throughout our lives. Cognition starts at birth and continues throughout the life span. See Figure 6.1^{“shutterstock_149010437.jpg” by Robert Adrian Hillman is used under license from Shutterstock.com} for an image of the human life cycle.

There are multiple factors that affect human cognitive development. While there are expected milestones along the way, cognitive development encompasses several different skills that develop at different rates. Cognition takes the form of many paths leading to unique developmental ends. Each human has their own individual experience that influences development of intelligence and reasoning as they interact with one another. With these unique experiences, everyone has a memory of feelings and events that is exclusive to them.^{Vallotton, C. D., & Fischer, K. W. (2008). Cognitive development. Encyclopedia of infant and early childhood development. Academic Press. https://doi.org/10.1016/B978-012370877-9.00038-4}

Developmental Stages

As newborns, we learn behavior and communication to help us to interact with the world around us and to fulfill our needs. For example, crying provides communication to cue parents or caregivers about a newborn’s needs. The human brain undergoes tremendous development throughout the first year of life. As infants receive and experience input from the environment, they begin to interact with the individuals around them as they learn and grow.

Jean Piaget, a well-known cognitive development theorist, noted that children explore the world as they attempt to make sense of their experiences. His theory explains that humans move from one stage to another as they seek cognitive equilibrium and mental balance. There are four stages in Piaget’s theory of development that occur in children from all cultures:

• The first stage is the Sensorimotor period. It extends from birth to approximately two years and is a period of rapid cognitive growth. During this period, infants develop an understanding of the world by coordinating sensory experiences (seeing, hearing) with motor actions (reaching, touching). The main development during the sensorimotor stage is the understanding that objects exist and events occur in the world independently of one’s own actions.^{McLeod, S. (2020, December 7). Piaget’s theory and stages of development. SimplyPsychology. https://www.simplypsychology.org/piaget.html} Infants develop an understanding of what they want and what they must do to have their needs met. They begin to understand language used by those around them to make needs met.
• Infants progress from the Sensorimotor period to a Pre-Operational period in their toddler years. This continues through early school age years. This is the time frame when children learn to think in images and symbols. Play is an important part of cognitive development during this period.
• Older school age children (age 7 years to 11 years) enter a Concrete Operations period. They learn to think in terms of processes and can understand that there is more than one perspective when discussing a concept.^{Ginsburg, H. P., & Opper, S. (1988). Piaget’s theory of intellectual development (3rd ed.). Prentice-Hall, Inc.} This stage is considered a major turning point in the child’s cognitive development because it marks the beginning of logical or operational thought.
• Adolescents transition to the Formal Operations stage around age 12 as they become self-conscious and egocentric. As adolescents enter this stage, they gain the ability to think in an abstract manner by manipulating ideas in their head. Moving toward adulthood, this further develops into the ability to critically reason.^{Ginsburg, H. P., & Opper, S. (1988). Piaget’s theory of intellectual development (3rd ed.). Prentice-Hall, Inc.,McLeod, S. (2020, December 7). Piaget’s theory and stages of development. SimplyPsychology. https://www.simplypsychology.org/piaget.html}

Cognitive impairments in children range from mild impairment in these specific operations to profound intellectual impairments leading to minimal independent functioning. Cognitive impairment is a term used to describe impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. The following areas are domains of cognitive functioning:

• Attention
• Decision-making
• General knowledge
• Judgment
• Language
• Memory
• Perception
• Planning
• Reasoning
• Visuospatial^{Schofield, D. W. (2018, December 26). Cognitive deficits. Medscape. https://emedicine.medscape.com/article/917629-overview}

Intellectual disability (formerly referred to as mental retardation) is a diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period. In the United States, the developmental period refers to the span of time prior to the age 18. Children with intellectual disabilities may demonstrate a delay in developmental milestones (e.g., sitting, speaking, walking) or demonstrate mild cognitive impairments that may not be identified until school age. Intellectual disability is typically nonprogressive and lifelong. It is diagnosed by multidisciplinary clinical assessments and standardized testing and is treated with a multidisciplinary treatment plan that maximizes quality of life.^{Schofield, D. W. (2018, December 26). Cognitive deficits. Medscape. https://emedicine.medscape.com/article/917629-overview} See Figure 6.2^{“22605761265_9f8e65a7ad_k.jpg” by Special Olympics 2017 is in the Public Domain} for an image of an adolescent with an intellectual disability participating in a Special Olympics event.

Adults and Older Adults

There are several physical changes that occur in the brain due to aging. The structure of neurons change, including a decreased number and length of dendrites, loss of dendritic spines, a decrease in the number of axons, an increase in axons with segmental demyelination, and a significant loss of synapses. Loss of synapse is a key marker of aging in the nervous system. These physical changes occur in older adults experiencing cognitive impairments, as well as in those who do not.^{Murman, D. L. (2015). The impact of age on cognition. Seminars in Hearing, 36(3), 111–121. https://doi.org/10.1055/s-0035-1555115} See Figure 6.3^{“3546874802_8b4cf9c822_o.jpg” by United Nations Photo is licensed under CC BY-NC-ND 2.0} of an older adult experiencing typical physical changes of aging.

It is a common myth that all individuals experience cognitive impairments as they age. Many people are afraid of growing older because they fear becoming forgetful, confused, and incapable of managing their daily life leading to incorrect perceptions and ageism. Ageism refers to stereotyping older individuals because of their age. Losing language skills, becoming unable to make decisions appropriately, and being disoriented to self or surroundings are not normal aging changes.

Dementia, Delirium, and Depression

If changes in cognition in adults do occur, a complete assessment is required to determine the underlying cause of the change and if it is caused by an acute or chronic condition. For example, dementia is a chronic condition that affects cognition whereas depression and delirium can cause acute confusion with a similar clinical appearance to dementia.

Dementia

Dementia is a chronic condition of impaired cognition, caused by brain disease or injury, and marked by personality changes, memory deficits, and impaired reasoning. Dementia can be caused by a group of conditions, such as Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. Clinical manifestations of dementia include forgetfulness, impaired social skills, and impaired decision-making and thinking abilities that interfere with daily living. It is gradual, progressive, and irreversible.^{Alzheimer’s Association. (2021). https://www.alz.org/} While dementia is not reversible, appropriate assessment and nursing care improve the safety and quality of life for those affected by dementia.

As dementia progresses and cognition continues to deteriorate, nursing care must be individualized to meet the needs of the patient and family. Providing patient safety and maintaining quality of life while meeting physical and psychosocial needs are important aspects of nursing care. Unsafe behaviors put individuals with dementia at increased risk for injury. These unsafe or inappropriate behaviors often occur due to the patient having a need or emotion without the ability to express it, such as pain, hunger, anxiety, or the need to use the bathroom. The patient’s family/caregivers require education and support to recognize that behaviors are often a symptom of dementia and/or a communication of a need and to help them to best meet the needs of their family member.^{Downing, L. J., Caprio, T. V., & Lyness, J. M. (2013). Geriatric psychiatry review: Differential diagnosis and treatment of the 3 D’s – delirium, dementia, and depression. Current Psychiatry Reports, 15(6), 365. https://doi.org/10.1007/s11920-013-0365-4}

Delirium

Delirium is an acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury. Sensory overload, excess stress, and sleep deprivation can also cause delirium. Hospitalized older adults are at increased risk for developing delirium, especially if they have been previously diagnosed with dementia. One third of patients aged 70 years or older exhibit delirium during their hospitalization. Delirium is the most common surgical complication for older adults, occurring in 15 to 25% of patients after major elective surgery and up to 50% of patients experiencing hip-fracture repair or cardiac surgery.^{Marcantonio, E. R. (2017). Delirium in hospitalized older adults. The New England Journal of Medicine, 377(15), 1456–1466. https://doi.org/10.1056/NEJMcp1605501}

The symptoms of delirium usually start suddenly, over a few hours or a few days, and they often come and go. Common symptoms include the following:

• Changes in alertness (usually most alert in the morning and decreased at night)
• Changing levels of consciousness
• Confusion
• Disorganized thinking or talking in a way that do not make sense
• Disrupted sleep patterns or sleepiness
• Emotional changes: anger, agitation, depression, irritability, overexcitement
• Hallucinations and delusions
• Incontinence
• Memory problems, especially with short-term memory
• Trouble concentrating^{MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Feb 12]. Delirium; [reviewed 2016, May 13; cited 2021, Feb 17]. https://medlineplus.gov/delirium.html}

Delirium and dementia have similar symptoms, so it can be hard to tell them apart. They can also occur together.

Nurses must closely monitor the cognitive function of all patients and promptly report any changes in mental status to the health care provider. The provider will take a medical history, perform a physical and neurological examination, perform mental status testing, and may order diagnostic tests based on the patient’s medical history. After the cause of delirium is determined, treatment is targeted to the cause to reverse the effects. See Figure 6.4^{“old-peoples-home-524234_960_720.jpg” by mikegi is licensed under CC0} for an illustration of an older adult experiencing delirium.

General interventions to prevent and treat delirium in older adults are as follows:

• Control the environment. Make sure that the room is quiet and well-lit, have clocks or calendars in view, and encourage family members to visit.
• Ensure a safe environment with the call light within reach and side rails up as indicated.
• Administer prescribed medications, including those that control aggression or agitation, and pain relievers if there is pain.
• Ensure the patient has their glasses, hearing aids, or other assistive devices for communication in place. Lack of assistive sensory devices can worsen delirium.
• Avoid sedatives. Sedatives can worsen delirium.
• Assign the same staff for patient care when possible.^{MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Feb 12]. Delirium; [reviewed 2016, May 13; cited 2021, Feb 17]. https://medlineplus.gov/delirium.html}

Depression

Depression is a brain disorder with a variety of causes, including genetic, biological, environmental, and psychological factors. It is a commonly untreated condition in older adults that can result in impaired cognition and difficulty in making decisions. It is likely to occur in response to major life events involving health and loved ones. Having other chronic health problems, such as diabetes, dementia, Parkinson’s disease, cancer, heart disease, and kidney disease, increases the likelihood for depression in older adults and can cause the loss of their ability to maintain independence.^{Ouldred, E., & Bryant, C. (2008). Dementia care. Part 1: Guidance and the assessment process. British Journal of Nursing, 17(3): 138-145. https://doi.org/10.12968/bjon.2008.17.3.28401} See Figure 6.5^{“man-416470_960_720.jpg” by geralt is licensed under CC0} for an illustration of an older adult experiencing symptoms of depression.

Symptoms of depression include the following:

• Feeling sad or “empty”
• Loss of interest in favorite activities
• Overeating or not wanting to eat at all
• Not being able to sleep or sleeping too much
• Feeling very tired
• Feeling hopeless, irritable, anxious, or guilty
• Aches, pains, headaches, cramps, or digestive problems
• Thoughts of death or suicide^{MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2021, Feb 6]. Depression; [reviewed 2016, Nov 4; cited 2021, Feb 17]. https://medlineplus.gov/depression.html}

Depression is treatable with medication and psychotherapy. However, older adults have an increased risk for suicide, with the suicide rates for individuals over age 85 years the second highest rate overall. Nurses should provide appropriate screening to detect potential signs of depression as an important part of promoting health for older adults.

Comparison of Three Conditions

When an older adult presents with confusion, determining if it is caused by delirium, dementia, depression, or a combination of these conditions can pose many challenges to the health care team. It is helpful to know the patient’s baseline mental status from a family member, caregiver, or previous health care records. If a patient’s baseline mental status is not known, it is an important patient safety consideration to assume that confusion is caused by delirium with a thorough assessment for underlying causes.^{Marcantonio, E. R. (2017). Delirium in hospitalized older adults. The New England Journal of Medicine, 377(15), 1456–1466. https://doi.org/10.1056/NEJMcp1605501} See Table 6.2 for a comparison of symptoms of dementia, delirium, and depression.^{Ouldred, E., & Bryant, C. (2008). Dementia care. Part 1: Guidance and the assessment process. British Journal of Nursing, 17(3): 138-145. https://doi.org/10.12968/bjon.2008.17.3.28401}

Table 6.2  Comparison of Dementia, Delirium, and Depression^{Ouldred, E., & Bryant, C. (2008). Dementia care. Part 1: Guidance and the assessment process. British Journal of Nursing, 17(3): 138-145. https://doi.org/10.12968/bjon.2008.17.3.28401}

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Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks. It is the most common cause of dementia. In most people with Alzheimer’s disease, symptoms first appear in their mid-60s. One in ten Americans age 65 and older has Alzheimer’s disease.^{Alzheimer’s Association. (2021). https://www.alz.org/}

Scientists continue to unravel the complex brain changes involved in the onset and progression of Alzheimer’s disease. It is thought that changes in the brain may begin a decade or more before memory and other cognitive problems appear. Abnormal deposits of proteins form amyloid plaques and tau tangles throughout the brain. Previously healthy neurons stop functioning, lose connections with other neurons, and die. The damage initially appears to take place in the hippocampus and cortex, the parts of the brain essential in forming memories. As more neurons die, additional parts of the brain are affected and begin to shrink. By the final stage of Alzheimer’s, damage is widespread, and brain tissue has shrunk significantly.^{National Institute on Aging. (2019, May 22). Alzheimer’s disease fact sheet. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet} See Figure 6.6^{“Alzheimers_Disease.jpg” by BruceBlaus is licensed under CC BY-SA 4.0 and “24239522109_6b061a9d69_o.jpg” by NIH Image Gallery is licensed under CC0} for an image of the changes occurring in the brain during Alzheimer’s disease.

Symptoms of Early Alzheimer’s Disease

There are ten symptoms of early Alzheimer’s disease:

• Forgetting recently learned information that disrupts daily life. This includes forgetting important dates or events, asking the same questions over and over, and increasingly needing to rely on memory aids (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own. This is different than a typical age-related change of sometimes forgetting names or appointments, but remembering them later.
• Challenges in planning or solving problems. This includes changes in an individual’s ability to develop and follow a plan or work with numbers. For example, they may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before. This is different from a  typical age-related change of making occasional errors when managing finances or household bills.
• Difficulty completing familiar tasks. This includes trouble driving to a familiar location, organizing a grocery list, or remembering the rules of a favorite game. This symptom is different from a typical age-related change of occasionally needing help to use microwave settings or to record a TV show.
• Confusion with time or place. This includes losing track of dates, seasons, and the passage of time. Individuals may have trouble understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there. This symptom is different from a typical age-related change of forgetting the date or day of the week but figuring it out later.
• Trouble understanding visual images and spatial relationships. Vision problems that include difficulty judging distance, determining color or contrast, or causing issues with balance or driving can be symptoms of Alzeheimer’s. This is different from a typical age-related change of blurred vision related to presbyopia or cataracts. (See the “Sensory Impairments” chapter for more information on common vision problems.)
• New problems with words in speaking or writing. Individuals with Alzheimer’s may have trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may struggle with vocabulary, have trouble naming a familiar object, or use the wrong name (e.g., calling a “watch” a “hand-clock”). This is different from a typical age-related change of having trouble finding the right word.
• Misplacing things and losing the ability to retrace steps. A person with Alzheimer’s disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. They may accuse others of stealing, especially as the disease progresses. This is different from a typical age-related change of misplacing things from time to time and retracing steps to find them.
• Decreased or poor judgment. Individuals with Alzheimer’s may experience changes in judgment or decision-making. For example, they may use poor judgment when dealing with money or pay less attention to grooming or keeping themselves clean. This is different from a typical age-related change of making a bad decision or mistake once in a while, like neglecting to change the oil in the car.
• Withdrawal from work or social activities. A person living with Alzheimer’s disease may experience changes in the ability to hold or follow a conversation. As a result, he or she may withdraw from hobbies, social activities, or other engagements. They may have trouble keeping up with a favorite team or activity. This is different from a typical age-related change of sometimes feeling uninterested in family or social obligations.
• Changes in mood and personality. Individuals living with Alzheimer’s may experience mood and personality changes. They can become confused, suspicious, depressed, fearful, or anxious. They may be easily upset at home, with friends, or when out of their comfort zone. This is different from a typical age-related change of developing very specific ways of doing things and becoming irritable when a routine is disrupted.^{Alzheimer’s Association. (2021). https://www.alz.org/}

Three Stages of Dementia

There are three stages of dementia: early, moderate, and advanced. Early stages of dementia include the ten symptoms previously discussed. Patients with moderate dementia require additional assistance with reminders to eat, wash, and use the restroom. They may not recognize family and friends. Behavioral symptoms such as wandering, getting lost, hallucinations, delusions, and repetitive behavior may occur. Patients living at home may engage in risky behavior, such as leaving the house in clothing inappropriate for weather conditions or leaving on the stove burners. Patients with advanced dementia require full assistance in washing, dressing, eating, and toileting. They often have urinary and bowel incontinence. Their gait becomes shuffled or unsteady. There may be increased aggressive behavior, disinhibition, or inappropriate laughing. Eventually they have difficulty eating, swallowing, and speaking, and seizures may develop.^{Ouldred, E., & Bryant, C. (2008). Dementia care. Part 1: Guidance and the assessment process. British Journal of Nursing, 17(3), 138-145. https://doi.org/10.12968/bjon.2008.17.3.28401} See Figure 6.7^{“civilian-service-63616_960_720.jpg” by geralt is licensed under CC0} of a patient with dementia requiring assistance with dressing.

There is no single diagnostic test that can determine if a person has Alzheimer’s disease. Health care providers use a patient’s medical history, mental status tests, physical and neurological exams, and diagnostic tests to diagnose Alzheimer’s disease and other types of dementia. During the neurological exam, reflexes, coordination, muscle tone and strength, eye movement, speech, and sensation are tested.

Mental status testing evaluates memory, thinking, and simple problem-solving abilities. Some tests are brief, whereas others can be more time-intensive and complex. These tests give an overall sense of whether a person is aware of their symptoms; knows the date, time, and place where they are; can remember a short list of words; and if they can follow instructions and do simple calculations. The Mini Mental Status Examination (MMSE) and Mini-Cog test are two commonly used assessments.

During the MMSE, a health professional asks a patient a series of questions designed to test a range of everyday mental skills. The maximum MMSE score is 30 points. A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia. On average, the MMSE score of a person with Alzheimer’s declines about two to four points each year.

During the Mini-Cog, a person is asked to complete two tasks: remember and then later repeat the names of three common objects and draw a face of a clock showing all 12 numbers in the right places with the time indicated as specified by the examiner. The results of this brief test determine if further evaluation is needed. In addition to assessing mental status, the health care provider evaluates a person’s sense of well-being to detect depression or other mood disorders that can cause memory problems, loss of interest in life, and other symptoms that can overlap with dementia.

Diagnostic testing for Alzheimer’s disease may include structural imaging with magnetic resonance imaging (MRI) or computed tomography (CT). These tests are primarily used to rule out other conditions that can cause symptoms similar to Alzheimer’s but require different treatment. For example, structural imaging can reveal brain tumors, evidence of strokes, damage from head trauma, or a buildup of fluid in the brain.^{Alzheimer’s Association. (2021). https://www.alz.org/}

Treatments

While there is no cure for Alzheimer’s disease, there are medications to help lessen symptoms of memory loss and confusion and interventions to manage common symptomatic behaviors.

Medications

The U.S. Food and Drug Administration (FDA) has approved two types of medications, cholinesterase inhibitors and memantine, to treat the cognitive symptoms of Alzheimer’s disease (memory loss, confusion, and problems with thinking and reasoning). As Alzheimer’s progresses, brain cells die and connections among cells are lost, causing cognitive symptoms to worsen. While current medications cannot stop the damage Alzheimer’s causes to brain cells, they may help lessen or stabilize symptoms for a limited time by affecting certain chemicals involved in carrying messages among the brain’s nerve cells. Sometimes both types of medications are prescribed together.

Cholinesterase inhibitors are prescribed to treat early to moderate symptoms of Alzheimer’s disease related to memory, thinking, language, judgment, and other thought processes. Cholinesterase inhibitors prevent the breakdown of acetylcholine, a neurotransmitter that is vital for learning and memory. It supports communication among nerve cells by keeping acetylcholine high and delays or slows the worsening of symptoms. Effectiveness varies from person to person, and the medications are generally well-tolerated. If side effects occur, they commonly include nausea, vomiting, loss of appetite, and increased frequency of bowel movements. These three cholinesterase inhibitors are commonly prescribed:

• Donepezil (Aricept), approved to treat all stages of Alzheimer’s disease
• Galantamine (Razadyne), approved for mild-to-moderate stages
• Rivastigmine (Exelon), approved for mild-to-moderate stages

Memantine (Namenda) and a combination of memantine and donepezil (Namzaric) are approved by the FDA for treatment of moderate to severe Alzheimer’s. Memantine is prescribed to improve memory, attention, reasoning, language, and the ability to perform simple tasks. Memantine regulates the activity of glutamate, a chemical involved in information processing, storage, and retrieval. It improves mental function and the ability to perform daily activities for some people, but it can cause side effects, including headache, constipation, confusion, and dizziness.

Other medications may be prescribed to treat specific symptoms of depression, anxiety, or psychosis. However, the decision to use an antipsychotic drug must be considered with extreme caution. Research has shown that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The FDA has ordered manufacturers to label such drugs with a “Black Box” warning about their risks and a reminder that they are not approved to treat dementia symptoms. Individuals with dementia should use antipsychotic medications only under one of the following conditions:

• Behavioral symptoms are due to mania or psychosis.
• The symptoms present a danger to the person or others.
• The person is experiencing inconsolable or persistent distress, a significant decline in function, or substantial difficulty receiving needed care.

Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible, and nurses should carefully monitor for adverse side effects and report them to the health care provider.^{Alzheimer’s Association. (2021). https://www.alz.org/}

Interventions for Symptomatic Behavior

Many people find the behavioral changes caused by Alzheimer’s disease to be the most challenging and distressing effect of the disease. The chief cause of behavioral symptoms is the progressive deterioration of brain cells. However, medication, environmental influences, and some medical conditions can also cause symptoms or make them worse.

In the early stages of Alzheimer’s disease, people may experience behavior and personality changes, such as irritability, anxiety, and depression. In later stages, other symptoms may occur, including the following:

• Aggression and anger
• Anxiety and agitation
• General emotional distress
• Physical or verbal outbursts
• Restlessness, pacing, or shredding paper or tissues
• Hallucinations (seeing, hearing, or feeling things that are not really there)
• Delusions (firmly held beliefs in things that are not true)
• Sleep issues and sundowning

Sundowning is restlessness, agitation, irritability, or confusion that typically begins or worsens as daylight begins to fade and can continue into the night, making it hard for patients with Alzheimer’s to sleep. Being too tired can increase late-afternoon and early-evening restlessness. Tips to manage sundowning are as follows:^{National Institute on Aging. (n.d.) Tips for Coping with Sundowning. https://www.nia.nih.gov/health/tips-coping-sundowning}

• Take them outside or expose them to bright light in the morning to reset their circadian rhythm.
• Do not plan too many activities during the day. A full schedule can be overtiring.
• Make early evening a quiet time of day. Play soothing music or ask a family member or friend to call during this time.
• Close the curtains or blinds at dusk to minimize shadows and the confusion they may cause.
• Reduce noise, clutter, or the number of people in the room.
• Do not serve coffee, cola, or other drinks with caffeine late in the day.

Aggressive Behaviors

Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While aggression can be hard to cope with, understanding this is a symptom of Alzheimer’s disease and the person with Alzheimer’s or dementia is not acting this way on purpose can help. See Figure 6.8^{“5012292106_507e008c7a_o.jpg” by borosjuli is licensed under CC BY 2.0} for an image of a resident with dementia demonstrating aggressive verbal behavior.

Aggression can be caused by many factors including physical discomfort, environmental factors, and poor communication. If the person with Alzheimer’s is aggressive, consider what might be contributing to the change in behavior.

Physical Discomfort

• Is the person able to let you know that he or she is experiencing physical pain? It is not uncommon for persons with Alzheimer’s or other dementias to have urinary tract or other infections. Due to their loss of cognitive function, they are unable to articulate or identify the cause of physical discomfort and, therefore, may express it through physical aggression.
• Is the person tired because of inadequate rest or sleep?
• Is the person hungry or thirsty?
• Are medications causing side effects? Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions.

Environmental Factors

• Is the person overstimulated by loud noises, an overactive environment, or physical clutter? Large crowds or being surrounded by unfamiliar people — even within one’s own home — can be overstimulating for a person with dementia.
• Does the person feel lost?
• What time of day is the person most alert? Most people function better during a certain time of day; typically mornings are best. Consider the time of day when making appointments or scheduling activities. Choose a time when you know the person is most alert and best able to process new information or surroundings.

Poor Communication

• Are your instructions simple and easy to understand?
• Are you asking too many questions or making too many statements at once?
• Is the person picking up on your own stress or irritability?

Techniques for Response

There are many therapeutic methods for a nurse or caregiver to respond to aggressive behaviors displayed by a person with dementia. The following are some methods that can be used with aggressive behavior:

• Begin by trying to identify the immediate cause of the behavior. Think about what happened right before the reaction that may have triggered the behavior. Rule out pain as the cause of the behavior. Pain can trigger aggressive behavior for a person with dementia.
• Focus on the person’s feelings, not the facts. Look for the feelings behind the specific words or actions.
• Don’t get upset. Be positive and reassuring and speak slowly in a soft tone.
• Limit distractions. Examine the person’s surroundings, and adapt them to avoid future triggers.
• Implement a relaxing activity. Try music, massage, or exercise to help soothe the person.
• Shift the focus to another activity. The immediate situation or activity may have unintentionally caused the aggressive response, so try a different approach.
• Take a break if needed. If the person is in a safe environment and you are able, walk away and take a moment for emotions to cool.
• Ensure safety! Make sure you and the person are safe. If these interventions do not successfully calm down the person, seek assistance from others. If it is an emergency situation, call 911 and be sure to tell the responders the person has dementia that causes them to act aggressively.

When educating caregivers about responding to aggressive behaviors, encourage them to share their experience with others, such as face-to-face support groups, where they can share response strategies they have tried and also get more ideas from other caregivers.

Anxiety and Agitation

A person with Alzheimer’s may feel anxious or agitated. They may become restless, causing a need to move around or pace or become upset in certain places or when focused on specific details. See Figure 6.9^{“old-63622_960_720.jpg” by geralt is licensed under CC0} for an illustration of an older adult feeling the need to move around. Anxiety and agitation can be caused by several medical conditions, medication interactions, or by any circumstances that worsen the person’s ability to think. Ultimately, the person with dementia is biologically experiencing a profound loss of their ability to negotiate new information and stimuli. It is a direct result of the disease. Situations that may lead to agitation can include moving to a new residence or nursing home; changes in environment, such as travel, hospitalization, or the presence of houseguests; changes in caregiver arrangements; misperceived threats; or fear and fatigue resulting from trying to make sense out of a confusing world.

Interventions to prevent and treat agitation include the following:

• Create a calm environment and remove stressors. This may involve moving the person to a safer or quieter place or offering a security object, rest, or privacy. Providing soothing rituals and limiting caffeine use are also helpful.
• Avoid environmental triggers. Noise, glare, and background distraction (such as having the television on) can act as triggers.
• Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation. Make sure the room is at a comfortable temperature. Be sensitive to the person’s fears, misperceived threats, and frustration with expressing what is wanted.
• Simplify tasks and routines.
• Find outlets for the person’s energy. The person may be looking for something to do. Provide an opportunity for exercise such as going for a walk or putting on music and dancing.

Techniques for Response

If a patient with dementia becomes anxious or agitated, consider these potential interventions:

• Back off and ask permission before performing care tasks. Use calm, positive statements, slow down, add lighting, and provide reassurance. Offer guided choices between two options when possible. Focus on pleasant events and try to limit stimulation.
• Use effective language. When speaking, try phrases such as, “May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay with you until you feel better.”
• Listen to the person’s frustration. Find out what may be causing the agitation, and try to understand.
• Check yourself. Do not raise your voice, show alarm or offense, or corner, crowd, restrain, criticize, ignore, or argue with the person. Take care not to make sudden movements out of the person’s view.

If the person’s anxiety or agitation does not improve using these techniques, notify the provider to rule out physiological causes or medication-related side effects.

Hallucinations

When a person with dementia experiences hallucinations, they may see, hear, smell, taste, or feel something that isn’t there. Some hallucinations may be frightening, while others may involve ordinary visions of people, situations, or objects from the past. Alzheimer’s and other dementias are not the only cause of hallucinations. Other causes of hallucinations include schizophrenia; physical problems, such as kidney or bladder infections, dehydration, or intense pain; alcohol or drug abuse; eyesight or hearing problems; and medications. See Figure 6.10^{lewy-body-dementia-2965713_960_720.jpg” by Jetiveri is licensed under CC0} for an illustration of hallucinations experienced by a person with dementia.

If a person with dementia begins hallucinating, notify the health care provider to rule out other possible causes and to determine if medication is needed. It may also help to have the person’s eyesight or hearing checked. If these strategies fail and symptoms are severe, medication may be prescribed. While antipsychotic medications can be effective in some situations, they are associated with an increased risk of stroke and death in older adults with dementia and must be used carefully.

Techniques for Response

When responding to a patient with dementia experiencing hallucinations, be cautious. First, assess the situation and determine whether the hallucination is a problem for the person or for you. Is the hallucination upsetting? Is it leading the person to do something dangerous? Is the sight of an unfamiliar face causing the person to become frightened? If so, react calmly and quickly with reassuring words and a comforting touch. Do not argue with the person about what he or she sees or hears. If the behavior is not dangerous, there may not be a need to intervene.

• Offer reassurance. Respond in a calm, supportive manner. You may want to respond with, “Don’t worry. I’m here. I’ll protect you. I’ll take care of you.” Gentle patting may turn the person’s attention toward you and reduce the hallucination.

• Acknowledge the feelings behind the hallucination and try to find out what the hallucination means to the individual. You might want to say, “It sounds as if you’re worried” or “This must be frightening for you.”

• Use distractions. Suggest a walk or move to another room. Frightening hallucinations often subside in well-lit areas where other people are present. Try to turn the person’s attention to music, conversation, or activities they enjoy.

• Respond honestly. If the person asks you about a hallucination or delusion, be honest. For example, if he or she asks, “Do you see the spider on the wall?,” you can respond, “I know you see something, but I don’t see it.” This way you’re not denying what the person sees or hears and avoiding escalating their agitation.

• Modify the environment. Check for sounds that might be misinterpreted, such as noise from a television or an air conditioner. Look for lighting that casts shadows, reflections, or distortions on the surfaces of floors, walls, and furniture. Turn on lights to reduce shadows. Cover mirrors with a cloth or remove them if the person thinks that he or she is looking at a stranger.

Sundowning

Sundowning is increased confusion, anxiety, agitation, pacing, and disorientation in patients with dementia that typically begins at dusk and continues throughout the night. Although the exact cause of sundowning and sleep disorders in people with Alzheimer’s disease is unknown, these changes result from the disease’s impact on the brain. There are several factors that may contribute to sleep disturbances and sundowning:

• Mental and physical exhaustion from a full day trying to keep up with an unfamiliar or confusing environment.
• An upset in the “internal body clock,” causing a biological mix-up between day and night.
• Reduced lighting causing shadows and misinterpretation is seen, causing agitation.
• Nonverbal behaviors of others, especially if stress or frustration is present.
• Disorientation due to the inability to separate dreams from reality when sleeping.
• Decreased need for sleep, a common condition among older adults.^{Alzheimer’s Association. (2021). https://www.alz.org/}

There are several interventions that nurses and caregivers can implement to help manage sleep issues and sundowning:

• Promote plenty of rest.
• Encourage a regular routine of waking up, eating meals, and going to bed.
• When possible and appropriate, include walks or time outside in the sunlight.
• Make notes about what happens before sundowning events and try to identify triggers.
• Reduce stimulation during the evening hours (e.g., TV, doing chores, loud music, etc.). These distractions may add to the person’s confusion.
• Offer a larger meal at lunch and keep the evening meal lighter.
• Keep the home environment well-lit in the evening. Adequate lighting may reduce the person’s confusion.
• Do not physically restrain the person; it can make agitation worse.
• Try to identify activities that are soothing to the person, such as listening to calming music, looking at photographs, or watching a favorite movie.
• Take a walk with the person to help reduce his or her restlessness.
• Consider the best times of day for administering medication; consult with the prescribing provider or pharmacist as needed.
• Limit daytime naps if the person has trouble sleeping at night.
• Reduce or avoid alcohol, caffeine, and nicotine that can affect the ability to sleep.
• Discuss the situation with the provider when behavioral interventions and environmental changes do not work. Additional medications may be prescribed.

Caregiver Role Strain

Eighty-three percent of the help provided to people living with dementia in their homes in the United States comes from family members, friends, or other unpaid caregivers. Approximately one quarter of dementia caregivers are also “sandwich generation” caregivers — meaning that they care not only for an aging parent, but also for children under age 18. Dementia can take a devastating toll on caregivers. Compared with caregivers of people without dementia, twice as many caregivers of people with dementia indicate substantial emotional, financial, and physical difficulties.^{Alzheimer’s Association. (2021). https://www.alz.org/} See Figure 6.11^{“My_mum_ill_with_dementia_with_me.png” by MariaMagdalens is licensed under CC BY-SA 4.0} of an image of a caregiver daughter caring for her mother with dementia.

The caregivers of patients with dementia frequently report experiencing high levels of stress that often eventually impact their health and well-being. Nurses should monitor caregivers for these symptoms of stress:

• Denial about the disease and its effect on the person who has been diagnosed. For example, the caregiver might say, “I know Mom is going to get better.”
• Anger at the person with Alzheimer’s or frustration that he or she can’t do the things they used to be able to do. For example, the caregiver might say, “He knows how to get dressed — he’s just being stubborn.”
• Social withdrawal from friends and activities. For example, the caregiver may say, “I don’t care about visiting with my friends anymore.”
• Anxiety about the future and facing another day. For example, the caregiver might say, “What happens when he needs more care than I can provide?”
• Depression or decreased ability to cope. For example, the caregiver might say, “I just don’t care anymore.”
• Exhaustion that makes it difficult for them to complete necessary daily tasks. For example, the caregiver might say, “I’m too tired to prepare meals.”
• Sleeplessness caused by concerns. For example, the caregiver might say, “What if she wanders out of the house or falls and hurts herself?”
• Irritability, moodiness, or negative responses.
• Lack of concentration that makes it difficult to perform familiar tasks. For example, the caregiver might say, “I was so busy; I forgot my appointment.”
• Health problems that begin to take a mental and physical toll. For example, the caregiver might say, “I can’t remember the last time I felt good.”

Nurses should monitor for these signs of caregiver stress and provide information about community resources. (See additional information about community resources below.) Caregivers should be encouraged to take good care of themselves by visiting their health care provider, eating well, exercising, and getting plenty of rest. It is helpful to remind them that “taking care of yourself and being healthy can help you be a better caregiver.” It is helpful to teach them relaxation techniques, such as relaxation breathing, progressive muscle relaxation, visualization, and meditation.

Caregivers should also be educated about additional care options, such as adult day care, respite care, residential facilities, or hospice care. Adult day centers offer people with dementia and other chronic illnesses the opportunity to be social and to participate in activities in a safe environment, while also giving their caregivers the opportunity to work, run errands, or take a break. Respite care can be provided at home (by a volunteer or paid service) or in a care setting, such as adult day care or residential facility, to provide the caregiver a much-needed break. If the person with Alzheimer’s or other dementia prefers a communal living environment or requires more care than can be safely provided at home, a residential facility may be the best option for providing care. Different types of facilities provide different levels of care, depending on the person’s needs. Hospice care focuses on providing comfort and dignity at the end of life; it involves care and support services that can be of great benefit to people in the final stages of dementia and their families.

Community Resources

Local Alzheimer’s Association chapters can connect families and caregivers with the resources they need to cope with the challenges of caring for individuals with Alzheimer’s.

• Find a chapter in your community by visiting the Find Your Local Chapter web page.
• The Alzheimer’s Association 24/7 Helpline (800.272.3900) is available around the clock, 365 days a year. Through this free service, specialists and master’s-level clinicians offer confidential support and information to people living with dementia, caregivers, families, and the public.
• The Alzheimer’s Association has a free virtual library web page devoted to resources that increase knowledge about Alzheimer’s and other dementias.^{Alzheimer’s Association. (2021). https://www.alz.org/}

Open Resources for Nursing (Open RN)

This section outlines the steps of the nursing process when providing care for adults with cognitive impairments.

Assessment

Nurses provide care for older adults in a wide variety of settings including acute care facilities, clinics, adult day care facilities, retirement communities, long-term care facilities, private homes, and community-based residential facilities (CBRF). It is vital for nurses to notice any signs of changing mental status based on the patient’s baseline. Any new or sudden changes that indicate possible delirium should be urgently reported to the health care provider for further assessment of potential underlying health conditions. See the following hyperlink to view a delirium evaluation tool used by hospitals.

When assessing an adult patient with a previously diagnosed cognitive impairment, there are several assessments to include on admission. Their medical history should be reviewed and a medication reconciliation completed. A general survey provides a quick, overall assessment of the way an individual interacts with their environment and their overall mobility status. A comprehensive neurological assessment should be performed to establish a patient’s baseline neurological status. After a baseline status is determined, routine focused neurological assessments are performed to monitor for changes, such as asking the patient to state their name, place, and the date, as appropriate.

Additional assessments include functional status and the patient’s ability to perform activities of daily living (ADLs). A decline in the ability to perform self-care and maintain ADLs can affect the individual’s well-being. Functional declines can bring about feelings of inadequacy and lead to depression. The ability to live independently relies on maintenance of self-care skills, including bathing, dressing, and toileting. Other factors that must be considered include the ability to adequately handle finances; maintain a clean, safe environment; and to shop and prepare meals. When deficits in these areas occur, resources should be recommended to assist the individual to meet these needs.

Cognitive changes including disorientation, poor judgment, loss of language skill, and memory impairment should be assessed objectively using standardized tools. Common standardized tools used to assess a patient’s mental status include the Mini Mental State Exam (MMSE) and the Mini-Cog.^{Alzheimer’s Association. (2021). https://www.alz.org/} See Figure 12^{“InterlockingPentagons.svg” by Jfdwolff[2] is licensed under CC BY-SA 3.0} for an image of one of the questions included on the MMSE.

Cultural Considerations

Nurses provide culturally competent care for all individuals. Being aware of personal biases related to ageism and cognitive impairments is necessary when providing care for older adults experiencing confusion, memory deficits, and impaired judgment. Ageism is the stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs. Ageism is widely prevalent and stems from the assumption that all members of a group (i.e., older adults) are the same. Ageism has harmful effects on the health of older adults; research has shown that older adults with negative attitudes about aging may live 7.5 years less than those with positive attitudes. Some of this prejudice arises from observable biological declines and may be distorted by awareness of disorders such as dementia, which may be mistakenly thought to reflect normal aging. Socially ingrained ageism can become self-fulfilling by promoting stereotypes of social isolation, physical and cognitive decline, lack of physical activity, and economic burden in older adults.^{World Health Organization. (2020, November 2). Ageing: Ageism. https://www.who.int/westernpacific/news/q-a-detail/ageing-ageism}

These biases in health care personnel, patients, and family members can prevent early recognition and treatment of health problems like dementia, delirium, and depression.

Diagnoses

Commonly used NANDA-I nursing diagnoses for older adults experiencing cognitive impairment include the following:

• Self-Care Deficit
• Risk for Injury
• Impaired Memory
• Impaired Coping
• Social Isolation

A common NANDA-I diagnosis related to cognitive impairment caused by dementia is Self-Care Deficit, defined as, “The inability to independently perform or complete cleansing activities; to put on or remove clothing; to eat; or to perform tasks associated with bowel and bladder elimination.” An associated condition with this nursing diagnosis is “Alteration in cognitive functioning.”^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.}

An example of a related PES statement is, “Self-Care Deficit related to altered cognitive functioning as evidenced by impaired ability to access the bathroom, to put clothing on lower extremities, and to maintain appearance.”

Outcome Identification

An example of an overall goal for an older adult experiencing cognitive impairment due to dementia is, “The patient will perform self-care activities within the level of their own ability daily.”

An example of a SMART expected outcome for a patient with cognitive impairment resulting in Self Care Deficit is, “The patient will remain free of body odor during their hospital stay.”

Planning Interventions

There are many nursing interventions that can be implemented for older adults with impaired cognitive function based on their individual needs. Interventions focus on maintaining safety, meeting physical and psychological needs, and promoting quality of life. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. For interventions targeted for common symptoms of dementia, see the “Alzheimer’s Disease” section in this chapter. See Table 6.4 for general nursing interventions to implement for patients with cognitive impairments.

Table 6.4 General Nursing Interventions for Cognitive Impairments

Implementing Interventions

When implementing interventions for patients with cognitive impairments, patient safety receives priority. Implement fall precautions, wandering precautions, and environmental safety precautions as appropriate.

Evaluation

It is important to routinely evaluate the effectiveness of customized interventions for patients with cognitive impairments. Review the SMART outcomes established for each specific patient to determine if interventions are effectively promoting safety while also maintaining their physiological and psychological needs and promoting quality of life. Modify the care plan when needed to meet these outcome criteria.

Patient Scenario

Mrs. Vang is an 83-year-old resident that was recently admitted to a long-term memory care facility. She was diagnosed with Alzheimer’s disease last year. She is alert to self but often has periods where she is uncooperative and is unable to follow commands. She has experienced a decline in the ability to provide self-care and wanders and paces at night. She recently fell when wandering outside of her room at night.

Applying the Nursing Process

Assessment: Mrs. Vang is alert to self only and does not follow commands during the assessment. She is unable to provide self-care despite cueing.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Vang:

Nursing Diagnosis: Wandering related to separation from familiar environment as manifested by frequent movement from place to place and pacing.

Overall Goal: The patient will remain safe and free from falls.

SMART Expected Outcome: Mrs. Vang will experience reduced episodes of wandering within 72 hours.

Planning and Implementing Nursing Interventions:

The nurse will provide orientation cues, such as family pictures in the patient room, as appropriate. The nurse will encourage a daily routine by all caregivers to prevent discomfort issues related to thirst, hunger, or lack of sleep. The nurse will encourage patient autonomy and provide choices in decisions as appropriate. The nurse will provide opportunities for reminiscence and cultivate therapeutic communication using touch and validation of emotional communication. The nurse will place a bed alarm to alert staff at night when the patient is getting out of bed. The nurse will implement a wander guard ankle bracelet to notify staff if the patient wanders near an exit door.

Sample Documentation:

Mrs. Vang has impaired thought processes as a result of her Alzheimer’s disease. A care routine has been established. The patient receives appropriate visual cues and reorientation to the environment. Safety interventions have been implemented, and the patient is being monitored for signs of increasing confusion or mental decline.

Evaluation:

Mrs. Vang has remained safe within the care environment and demonstrated no additional decline in thought processes. Her wandering at night has decreased and the bed alarm alerts staff when she gets out of bed.  SMART outcome “met.”

Open Resources for Nursing (Open RN)

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Practice applying concepts related to cognitive impairments to the following patient scenarios:

Scenario A

Clara is a 77-year-old female who is admitted to an inpatient acute care center for scheduled hip-replacement surgery. See Figure 6.13 for an image of Clara.^{“woman-76527_960_720.jpg” by geralt is licensed under CC0} On admission for the surgical procedure, Clara is functionally independent and living at home but reports having some “mild forgetfulness.” The surgery and post-anesthesia recovery period are uneventful, but on postoperative Day 2, she develops severe confusion and agitation.

Critical Thinking Questions

1. What additional assessment data should the nurse collect?
2. Compare/contrast the symptoms of dementia, delirium, and depression. What condition is the patient exhibiting? What are the possible triggers?
3. What are priority nursing interventions for the patient at this time?

Scenario B

Betty is an 82-year-old female resident of a memory care center with a history of moderate Alzheimer’s disease. See Figure 6.14 for an image of Betty in a memory care center.^{“35528913166_1a61470157_h.jpg” by Senior Guidance is licensed under CC BY 2.0} Staff report that she has episodes of anxiety and agitation that can lead to aggressive behaviors such as yelling, cursing, and waving her cane threateningly at staff members.

Critical Thinking Questions

1. What are the typical symptoms of moderate Alzheimer’s disease?
2. What assessments should the nurse perform if Betty exhibits anxiety, agitation, or aggressive behavior?
3. In addition to identifying and eliminating any potential triggers, how should the nurse respond to Betty therapeutically if an episode occurs?
4. What types of medications may be prescribed for Betty to slow the progression of Alzheimer’s disease?

 

Open Resources for Nursing (Open RN)

Adult day centers: Care that offers people with dementia and other chronic illnesses the opportunity to be social and to participate in activities in a safe environment, while also giving their caregivers the opportunity to work, run errands, or take a much-needed break.

Ageism: The stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs.

Alzheimer’s disease: An irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks.

Cognition: A term used to describe our ability to think.

Cognitive impairment: Impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge.

Delirium: An acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury.

Dementia: A chronic condition of impaired cognition, caused by brain disease or injury, marked by personality changes, memory deficits, and impaired reasoning. Dementia can be caused by a group of conditions, such as Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. It is gradual, progressive, and irreversible.

Depression: A brain disorder with a variety of causes, including genetic, biological, environmental, and psychological factors.

Development: Biological changes, as well as social and cognitive changes, that occur continuously throughout our lives.

Growth: Physical changes that occur during the development of an individual beginning at the time of conception.

Hospice care: Care that focuses on providing comfort and dignity at the end of life. It involves care and support services that can be of great benefit to people in the final stages of dementia and to their families.

Intellectual disability: A diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period prior to the age 18.

Respite care: Care provided at home (by a volunteer or paid service) or in a care setting, such as adult day centers or residential facilities, that allows the caregiver to take a much-needed break.

Sundowning: Increased confusion, anxiety, agitation, pacing, or disorientation in patients with dementia that typically begins at dusk and continues throughout the night.

Open Resources for Nursing (Open RN)

Our five basic senses of sight (vision), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory) help us perceive and act in the world around us. See Figure 7.1^{“Five_senses.jpg” by Allan-Hermann Pool is licensed under CC BY-SA 4.0} for an illustration of our five senses.

We may not often consider the importance of our sensory input. As nurses, we especially rely on our senses when providing patient care as we gather assessment data. We ask questions and listen to patient responses, we listen to their heart and lung sounds, we evaluate the appearance of their skin, we may smell an infectious process when changing a wound dressing, and we feel the sensation of pulses when assessing circulation.

When an individual experiences sensory impairment because of the loss of one or more senses or is affected by the amount of stimuli (too much or too little), their ability to safely function is impacted. Nurses identify patients’ sensory impairments and implement interventions to improve their safety, functioning, and quality of life. The nurse’s goal is to provide support and dignity to individuals and their families by using strategies and resources that will help them to engage with their surroundings and others to the best of their ability.

This chapter will review common sensory impairments and related nursing care.

Open Resources for Nursing (Open RN)

Interpreting Sensations

Before learning about sensory function, it is important to understand how the nervous system works. An intact nervous system is necessary for information to be delivered from the environment to the brain to trigger responses from the body. For neurons to transmit these messages, they are in the form of an action potential. Sensory receptors perceive a stimulus and then change the sensation to an electrical signal so that it can be transmitted to the brain and then out to the body. For example, a pain receptor perceives pain as your hand touches a hot tray. The signal is transmitted to the brain where it is interpreted, and then signals are quickly sent to the hand to pull away from the hot stimuli.^{This work is a derivative of StatPearls by Gadhvi & Waseem and is licensed under CC BY 4.0}

Our bodies interpret sensations through a process using reception, perception, and reaction. Reception is the first part of the sensory process when a nerve cell or sensory receptor is stimulated by a sensation. Sensory receptors are activated by mechanical, chemical, or temperature stimuli. In addition to our five senses, we also have somatosensation. Somatosensation refers to sensory receptors that respond to stimuli such as pain, pressure, temperature, and vibration. It also includes vestibular sensation, a sense of spatial orientation and balance, and proprioception, the sense of the position of our bones, joints, and muscles. Although these sensory systems are all very different, they share a common purpose. They change a stimulus into an electrical signal that is transmitted in the nervous system.^{This work is a derivative of Sensory Processes by Lumen Learning and is licensed under CC BY-SA 4.0}

The sensory receptors for each of our senses work differently from one another. Light receptors, sound receptors, and touch receptors are each activated by different stimuli with specialized receptor specificity. For example, touch receptors are sensitive to pressure but do not have sensitivity to sound or light. Nerve impulses from sensory receptors travel along pathways to the spinal cord or directly to the brain. Some stimuli are also combined in the brain, such as our sense of smell that can affect our sense of taste.^{This work is a derivative of Sensory Processes by Lumen Learning and is licensed under CC BY-SA 4.0}

As an individual becomes aware of a stimulus and it is transmitted to the brain, perception occurs. Perception is the interpretation of a sensation. All sensory signals, except olfactory system input, are transmitted to the thalamus and to the appropriate region of the cortex of the brain. The thalamus, which is in the forebrain, acts as a relay station for sensory and motor signals. When a sensory signal leaves the thalamus, it is sent to the specific area of the cortex that processes that sense.^{This work is a derivative of Sensory Processes by Lumen Learning and is licensed under CC BY-SA 4.0} However, conditions that affect a person’s consciousness also affect the ability to perceive and interpret stimuli.

Reaction is the response that individuals have to a perception of a received stimulus. The brain determines what sensations are significant because it is impossible to react to all stimuli that are constantly received from our environment. A healthy brain maintains a balance between sensory stimuli received and those reaching awareness. However, sensory overload can occur if the amount of stimuli the brain is receiving is overwhelming to an individual. Sensory deprivation can also occur if there are insufficient sensations from the environment.^{This work is a derivative of Sensory Processes by Lumen Learning and is licensed under CC BY-SA 4.0}

Sensory Impairment

Alterations in sensory function include sensory impairment, sensory overload, and sensory deprivation. Sensory impairment includes any type of difficulty that an individual has with one of their five senses. When an individual experiences loss of a sensory function, such as vision, the way they interact with the environment is affected. For example, when an individual gradually loses their vision, their reliance on other senses to receive information from the environment is often enhanced.

Safety is always a nursing consideration for a patient with a sensory impairment. Intact senses are required to make decisions about functioning safely within the environment. For example, an individual who has impaired hearing may not be able to hear a smoke alarm and requires visual indicators when the alarm is triggered.

Sensory impairments are very common in older adults. Most older adults develop impaired near vision called presbyopia. See Figure 7.2^{“Pesto ingredients – blurred.jpg” by Colin is licensed under CC BY-SA 4.0} for an image of simulated presbyopia.

Deficits in taste and smell are also prevalent in this age group. Additionally, kinesthetic impairment (an altered sense of touch) can occur in adults as young as 55. Kinesthetic impairment can cause difficulty in daily functioning, such as buttoning one’s shirt or performing other fine motor tasks. These sensory losses can greatly impact how older adults live and function.^{Correia, C., Lopez, K. J., Wroblewski, K. E., Huisingh-Scheetz, M., Kern, D. W., Chen, R. C., Schumm, L. P., Dale, W., McClintock, M. K., & Pinto, J. M. (2016). Global sensory impairment in older adults in the United States. Journal of the American Geriatrics Society, 64(2), 306–313. https://doi.org/10.1111/jgs.13955}

Vision Impairments

Several types of visual impairments commonly occur in older adults, including macular degeneration, cataracts, glaucoma, diabetic retinopathy, and presbyopia. See Table 7.2 for more information about each of these visual conditions.

Table 7.2 Common Visual Conditions

Hearing Loss and Ear Problems

Approximately one third of individuals aged 70 and older have hearing loss. Good hearing depends on a series of events that change sound waves in the air into electrical signals. The auditory nerve conducts these electrical signals from the ear to the brain through a series of steps. The structures of the ear, such as the tympanic membrane and cochlea, must be intact and functioning appropriately for conduction of sound to occur. Age-related hearing loss (presbycusis) gradually occurs in most individuals as they age.^{National Institute on Deafness and Other Communication Disorders. (2018, July 17). Age-related hearing loss. https://www.nidcd.nih.gov/health/age-related-hearing-loss} Typically, low-pitched sounds are easiest to hear, but it often becomes increasingly difficult to hear normal conversation, especially over loud background noise. Hearing aids are commonly used to enhance hearing. See Figure 7.3^{“Traditional_hearing_aids.jpg” by ikesters is licensed under CC BY-SA 2.0} for an image of common hearing aids used to treat hearing loss.

Hearing loss can be caused by other factors in addition to aging. A build-up of ear wax in the ear canal can cause temporary hearing loss. Sounds that are too loud or long-term exposure to loud noises can cause noise-induced hearing loss. For example, a loud explosion or employment using loud machinery without ear protection can damage the sensory hair cells in the ear. After these hair cells are damaged, the ability to hear is permanently diminished. Tinnitus, a medical term for ringing in the ears, can also occur. Some medications, such as high doses of aspirin or loop diuretics, can cause toxic effects to the sensory cells in the ear and lead to hearing loss or tinnitus.^{National Institute on Deafness and Other Communication Disorders. (2018, July 17). Age-related hearing loss. https://www.nidcd.nih.gov/health/age-related-hearing-loss,American Speech-Language-Hearing Association. (n.d.). Causes of hearing loss in adults. https://www.asha.org/public/hearing/causes-of-hearing-loss-in-adults/} In addition to hearing loss, ear problems can also cause problems with balance, dizziness, and vertigo due to vestibular dysfunction.

Kinesthetic Impairments

Kinesthetic impairments, such as peripheral neuropathy, affect the ability to feel sensations. Symptoms of peripheral neuropathy include sensations of pain, burning, tingling, and numbness in the extremities that decrease a person’s ability to feel touch, pressure, and vibration. Position sense can also be affected and makes it difficult to coordinate complex movements, such as walking, fastening buttons, or maintaining balance when one’s eyes are closed. Peripheral neuropathy is caused by nerve damage that commonly occurs in patients with diabetes mellitus or peripheral vascular disease. It can also be caused by physical injuries, infections, autoimmune diseases, vitamin deficiencies, kidney diseases, liver diseases, and some medications.^{National Institute of Neurological Disorders and Stroke. (2020, March 16). Peripheral neuropathy fact sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Peripheral-Neuropathy-Fact-Sheet}

Life Span Considerations

Impaired sensory functioning increases the risk for social isolation in older adults. For example, when individuals are not able to hear well, they may pretend to hear in an attempt to avoid embarrassment when asking for the information to be repeated. They may begin to avoid noisy environments or stop participating socially in conversations around them.

Infants and children are also at risk for vision and hearing impairments related to genetic or prenatal conditions. Early determination of sensory impairments is crucial so that problems can be addressed with accommodations to minimize the impact on a child’s development. For example, a screening hearing test is completed on all newborns before discharge to evaluate for hearing impairments that can affect their speech development.

Sensory Overload and Sensory Deprivation

Stimuli are continually received from a variety of sources in our environment and from within our bodies. When an individual receives too many stimuli or cannot selectively filter out meaningful stimuli, sensory overload can occur. Symptoms of sensory overload include irritability, restlessness, covering ears or eyes to shield them from sensory input, and increased sensitivity to tactile input (i.e., scratchy fabric or sensations of medical equipment).^{Watson, K. (2018, September 27). What is sensory overload? https://www.healthline.com/health/sensory-overload#causes} Sensory overload affects an individual’s ability to interpret stimuli from their environment and can lead to confusion and agitation. See Figure 7.4^{“Sensory_Overload.jpg” by Stewart Black is licensed under CC BY 2.0} of an image of a patient reacting to sensory overload.

The health care environment with its frequent noisy alarms, treatments, staff interruptions, and noisy hallway conversations can cause sensory overload for patients. Individuals have different tolerances for the amount of stimuli that will affect them adversely. Tolerance to stimuli is impacted by factors such as pain, stress levels, sleep patterns, physical health, and emotional health. When sensory overload occurs in a hospitalized patient, it can lead to delirium and acute confusion. It is important for the nurse to limit unnecessary awakenings and interactions with the health care team members when a patient is experiencing sensory overload.

Conversely, symptoms of sensory deprivation may occur when there are a lack of stimuli. People experiencing sensory deprivation often report perceptual disturbances such as hallucinations. Symptoms of sensory deprivation can mimic delirium, so it is important for a nurse to further investigate new perceptual disturbances.^{Mason, O., & Brady, F. (2009). The psychotomimetic effects of short-term sensory deprivation. The Journal of Nervous and Mental Disease, 197(10), 783-785. https://doi.org/10.1097/nmd.0b013e3181b9760b}

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This section outlines the steps of the nursing process when providing care for individuals with altered sensory function in any setting.

Assessment

When assessing a patient for sensory impairments, it is important to first establish a therapeutic relationship. Individuals may be hesitant to discuss sensory problems. By establishing a good rapport, patients are more likely to share their sensory concerns and effects on functioning. The health history should include questions regarding current status of sensory function, as well as risk for development of sensory impairment. For example, medications that can be ototoxic should be considered a risk factor for hearing impairment. Additionally, opioids and sedatives depress the central nervous system and can impair stimuli perception and reaction. Techniques to identify deficits in vision, hearing, smell, taste, and sensation are used during the physical exam. Read additional information about assessment techniques using the following hyperlinks.

There are several factors to consider when assessing a patient’s sensory functioning, such as age, their perception of the impairment, and the impact of the sensory impairment on their daily functioning. Age is an important consideration because many sensory functions can be affected by the aging process. However, it should not be assumed that all sensory problems are a normal part of the aging process. It is important to assess the patient’s perception of sensory impairment and its impact on their functioning, as well for any changes in recent behavior, mental status, emotional status, or cognitive function changes. For example, individuals experiencing hearing loss may be more irritable or anxious and avoid social gatherings due to their hearing impairment. If a patient is experiencing confusion, it is important to evaluate underlying factors that can cause confusion.

The environment is also an important consideration when assessing an individual’s sensory functioning. It is important to understand the patient’s daily activities and their ability to perform them; their work and living environment; their use of protective equipment, such as ear protection when working with loud equipment; and their adherence with routine screenings, such as vision and hearing exams. Individuals with sensory impairments are at increased risk for falls and injury, so it is important to encourage basic safety features in the environment, including adequate lighting, availability of handrails and grab bars, hazard-free walkways, and appropriate settings on water heater controls.

When sensory impairments are identified, they should be documented in the patient’s chart and communicated to collaborative team members working with the individual. For example, when an individual has a hearing impairment, it is important to consider their alternative communication needs. They may use lipreading and require face-to-face views when communicating. The use of assistive devices for sensory functioning, such as glasses and hearing aids, should also be documented and communicated. It is important to ensure proper functioning of the devices for optimal patient outcomes. In fact, a hospitalized older adult is at greater risk for developing delirium when their typical glasses and hearing aids (i.e., their “eyes and ears”) are not available, causing sensory deprivation.

See Table 7.3a for a comparison of expected versus unexpected findings on assessment, including those that require notification of the health care provider.

Table 7.3a Expected Versus Unexpected Findings

Diagnoses

Commonly used NANDA-I nursing diagnoses for patients experiencing alterations in sensory function include the following:^{Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 114, 393.}

• Risk for Injury
• Risk for Falls
• Impaired Verbal Communication
• Social Isolation

A common NANDA diagnosis related to sensory alterations is Risk for Injury, which is defined as, “Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.” “Alteration in sensation” is an associated condition for this nursing diagnosis. For risk diagnoses, there are no related factors (etiological factors) because you are identifying a vulnerability in a patient for a potential problem that is not yet present. Additionally, the nurse cannot resolve sensory alteration, so it should not be listed as a related factor to which interventions are directed. Instead, the phrase “as evidenced by” is used to refer to the evidence of risk that exists.

Therefore, a sample NANDA-I diagnosis in current PES format would be as follows: “Risk for Injury as evidenced by alteration in vision.”

Outcomes

An overall goal for a patient at risk for injury related to alteration in sensation is as follows:

• The patient will remain free from injury.

An example of a “SMART” expected outcome for a patient with impaired vision is as follows:

• The patient will be able to verbalize the layout of the room within four hours of admission.

Planning Interventions

There are many nursing interventions that can be implemented for individuals with impaired sensory function. To assist patients to communicate effectively and to promote their quality of life, it is important for the nurse to customize appropriate interventions based on their individual needs. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. See Table 7.3b for basic nursing interventions to implement for a variety of sensory alterations.^{Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier. pp. 115-117.}

Table 7.3b Nursing Interventions to Address Sensory Alterations^{Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier. pp. 115-117.}

Standards of Care

National Patient Safety Goals established by The Joint Commission include prevention of falls. Appropriately assessing the risk of falls for patients with sensory impairments and implementing effective nursing interventions to prevent falls help to meet this standard of care.^{The Joint Commission. (n.d.). 2021 National patient safety goals. https://www.jointcommission.org/standards/national-patient-safety-goals/}

Evaluation

Evaluate a patient’s progress toward the expected outcomes established. Include safety, functioning, ability to communicate, and satisfaction with quality of life when evaluating the effectiveness of interventions. Determine if changes in the plan of care are needed to better meet the needs of the individual.

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Review how to apply the nursing process for a patient with impaired sensation in the following scenario.

Patient Scenario

Mr. Mitchell, age 87, is accompanied to the primary care clinic with his daughter Elise. See Figure 7.5^{“man-old-confused-angry-thinker-street-in-the-age-people-tourists.jpg” by unknown is in the Public Domain} for a simulated image of Mr. Mitchell. Elise tells the nurse that her father has been increasingly withdrawn and she has difficulty getting in contact with him during the week by phone. She is concerned that he is experiencing depression. Mr. Mitchell is alert, well-groomed, and smiling. As the nurse begins the initial assessment interview, it is noted that Mitchell smiles and nods a lot, but does not answer direct questions appropriately. Elise has shared that she has not noted problems with her father’s ability to care for himself; he is paying his own bills and orders groceries online for delivery.

When questioned further about his answers, Mr. Mitchell admits that he is unsure what was asked of him. He is embarrassed about this and avoids asking people to repeat themselves. He also explains that his father had a hearing device, and it always “rang loudly” so he has not considered this option.

The nurse performs a whisper test and discovers he is unable to report any of the six words whispered behind him. She notes that Mr. Mitchell is interested in improving his ability to hear and participate in conversations with others.

Applying the Nursing Process

Assessment: The nurse performs a whisper test and discovers he is unable to report any of the six words whispered behind him. He is interested in improving his ability to hear and participate in conversations with others.

Based on the interview and assessment information, the following nursing care plan is created for Mr. Mitchell.

Nursing Diagnosis: Readiness for Enhanced Communication as evidenced by expressed desire to enhance hearing and communication.

Overall Goal: The patient will experience enhanced communication with improved hearing.

SMART Expected Outcome: Mr. Mitchell will attend an appointment arranged with an audiologist within two weeks.

Planning and Implementing Nursing Interventions

The nurse provides education about available hearing devices and encourages the patient to attend an appointment with an audiologist. While speaking to the patient, she faces him directly and provides good lighting so that he can read her lips. She shuts the door to the exam room to provide a quiet environment and uses short, simple sentences. She does not interpret nodding to indicate understanding. She shares her assessment findings with the provider and requests a referral to an audiologist and then assists the patient in making the appointment. She asks the patient and his daughter if they have any questions before they leave the clinic.

Sample Documentation

During the intake interview, the patient did not answer questions inappropriately or did not answer at all. Exhibited embarrassment when asking people to repeat their statements. Daughter states, “He is becoming increasingly withdrawn.” Ear canals are clear without cerumen present. Unable to report six out of six words during the whisper test. Provided brief explanation of new technology available for hearing loss while standing directly in front of the patient, and he appeared to be able to slightly read lips. Encouraged consultation with an audiologist and notified the provider of assessment findings. Appointment made with the audiologist and communicated place, date, and time to the patient and his daughter.

Evaluation

During the next clinic appointment in two weeks, Mr. Mitchell is wearing a hearing aid device and answers questions appropriately. He reports that he has been attending more social events “now that I can hear better.” The SMART outcome was “met.”

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Cataracts: Opacity of the lens of the eye that causes clouded, blurred, or dim vision. Cataracts can be removed with surgery that replaces the lens with an artificial lens.

Diabetic retinopathy: A complication of diabetes mellitus due to damaged blood vessels in the retina. If found early, treatments, such as laser treatment that can help shrink blood vessels, injections that can reduce swelling, or surgery, can prevent permanent vision loss.

Glaucoma: Gradual loss of peripheral vision caused by elevated intraocular pressure that leads to progressive damage to the optic nerve.

Kinesthetic impairment: An altered sense of touch that can cause difficulty in performing fine motor tasks.

Macular degeneration: Loss of central vision with symptoms such as blurred central vision, distorted vision that causes difficulty driving and reading, and the requirement for brighter lights and magnification for close-up visual activities.

Perception: The interpretation of sensation during the sensory process.

Presbycusis: Age-related hearing loss.

Presbyopia: The impairment of near vision and accommodation as the lens of the eye gradually becomes thicker and loses flexibility as a person ages.

Proprioception: The sense of the position of our bones, joints, and muscles.

Reaction: The response that individuals have to a perception of a received stimulus.

Reception: The initial part of the sensory process when a nerve cell or sensory receptor is stimulated by a sensation.

Sensory deprivation: A condition that occurs when there is a lack of sensations due to sensory impairments or when the environment has few quality stimuli.

Sensory impairment: Any type of difficulty that an individual has with one of their five senses or sensory function.

Sensory overload: A condition that occurs when an individual receives too many stimuli or cannot selectively filter meaningful stimuli.

Somatosensation: Sensory receptors that respond to specific stimuli such as pain, pressure, temperature, and vibration; includes vestibular sensation and proprioception.

Tinnitus: Hearing ringing in the ears.

Vestibular sensation: A sense of spatial orientation and balance.

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Sufficient oxygenation is vital to maintain life. When prioritizing nursing interventions, we often refer to using the “ABCs,” an acronym used to signify the importance of maintaining a patient’s airway, breathing, and circulation. Several body systems work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately oxygenate tissues. It is important that all parts of the system work together to ensure that oxygen is delivered appropriately to tissues within each system. Any alteration in these systems can have catastrophic implications on a patient’s health. First, the airway must be open and clear. The chest and lungs must mechanically move air in and out of the lungs. The bronchial airways must be open so that air can reach the alveoli, where the exchange of oxygen and carbon dioxide occurs. The heart must effectively pump oxygenated blood from the lungs and through the systemic arteries. There must be adequate amounts of hemoglobin in the blood to sufficiently carry the oxygen molecules to the tissues. However, several medical conditions such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart disease, and anemia can impair the body’s ability to effectively complete this oxygenation process.^{This work is a derivative of Nursing Skills by Open RN licensed under CC BY 4.0} This chapter will review these basic concepts related to oxygenation and apply the nursing process to patients who are experiencing alterations in oxygenation.

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Several body systems contribute to a person’s oxygenation status, including the respiratory, cardiovascular, and hematological systems. These systems are reviewed in the following sections.

Respiratory System

The main function of our respiratory system is to provide the body with a constant supply of oxygen and to remove carbon dioxide. To achieve these functions, muscles and structures of the thorax create the mechanical movement of air into and out of the lungs called ventilation. Gas exchange occurs at the alveolar level where blood is oxygenated and carbon dioxide is removed, which is called respiration. Several respiratory conditions can affect a patient’s ability to maintain adequate ventilation and respiration, and there are several medications used to enhance a patient’s oxygenation status. Use the following hyperlinks to review information regarding the anatomy and physiology of the respiratory system, common respiratory conditions, and classes of respiratory medications.

Cardiovascular System

In order for oxygenated blood to move from the alveoli in the lungs to the various organs and tissues of the body, the heart must adequately pump blood through the systemic arteries. The amount of blood that the heart pumps in one minute is referred to as cardiac output. The passage of blood through arteries to an organ or tissue is referred to as perfusion. Several cardiac conditions can adversely affect cardiac output and perfusion in the body. There are several medications used to enhance a patient’s cardiac  output and maintain adequate perfusion to organs and tissues throughout the body. Use the following hyperlinks to review information regarding the anatomy and physiology of the cardiovascular system, common cardiac disorders, and various cardiovascular system medications.

Hematological System

Although the bloodstream carries small amounts of dissolved oxygen, the majority of oxygen molecules are transported throughout the body by attaching to hemoglobin within red blood cells. Each hemoglobin protein is capable of carrying four oxygen molecules. When all four hemoglobin structures contain an oxygen molecule, it is referred to as “saturated.”^{This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction} See Figure 8.1^{“2322_Fig_23.33-a.jpg” by OpenStax is licensed under CC BY 3.0} for an image of hemoglobin protein within a red blood cell with four sites for carrying oxygen molecules.

When oxygenated blood reaches tissues within the body, oxygen is released from the hemoglobin, and carbon dioxide is picked up and transported to the lungs for release on exhalation. Carbon dioxide is transported throughout the body by three major mechanisms: dissolved carbon dioxide, attachment to water as HCO3-, and attachment to the hemoglobin in red blood cells.^{This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction} See Figure 8.2^{“2325_Carbon_Dioxide_Transport.jpg” by OpenStax is licensed under CC BY 3.0} for an illustration of carbon dioxide transport.^{This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction}

Measuring Oxygen, Carbon Dioxide, and Acid Base Levels

Because the majority of oxygen transported in the blood is attached to hemoglobin, a patient’s oxygenation status is easily assessed using pulse oximetry, referred to as SpO2. See Figure 8.3^{“OxyWatch_C20_Pulse_Oximeter.png” by Thinkpaul is licensed under CC BY-SA 3.0} for an image of a pulse oximeter. This reading refers to the amount of hemoglobin that is saturated. The target range of SpO2 for an adult is 94-98%.^{This work is a derivative of StatPearls by Patel, Miao, Yetiskul, and Majmundar and is licensed under CC BY 4.0} For patients with chronic oxygenation conditions such as COPD, the target range for SpO2 is often lower at 88% to 92%. Although SpO2 is an efficient, noninvasive method for assessing a patient’s oxygenation status, it is not always accurate. For example, if a patient is severely anemic, the patient has a decreased amount of hemoglobin in the blood available to carry the oxygen, which subsequently affects the SpO2 reading. Decreased perfusion of the extremities can also cause inaccurate SpO2 levels because less blood delivered to the tissues causes a false low SpO2. Additionally, other substances can attach to hemoglobin such as carbon monoxide, causing a falsely elevated SpO2.

A more specific measurement of oxygen and carbon dioxide in the blood is obtained using an arterial blood gas (ABG). ABG results are often used for patients who have deteriorating or unstable respiratory status requiring emergency treatment. An ABG is a blood sample that is typically drawn from the radial artery by a respiratory therapist. ABG results indicate oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen in the arterial blood is referred to as PaO2. PaO2 measures the pressure of oxygen dissolved in the arterial blood and how well oxygen is able to move from the lungs into the blood. The normal PaO2 level of a healthy adult is 80 to 100 mmHg. The PaO2 reading is more accurate than a SpO2 reading because it is not affected by hemoglobin levels. The partial pressure of carbon dioxide in the arterial blood is the PaCO2 level. The PaCO2 level measures the pressure of carbon dioxide dissolved in the blood and how well carbon dioxide is able to move out of the body. It is typically used to determine if sufficient ventilation is occurring at the alveolar level. The normal PaCO2 level of a healthy adult is 35-45 mmHg. The normal range of pH level for arterial blood is 7.35-7.45, and the normal range for the bicarbonate (HCO3-) level is 22-26. The SaO2 level is also calculated in ABG results, which is the calculated arterial oxygen saturation level.^{This work is a derivative of StatPearls by Castro and Keenaghan and is licensed under CC BY 4.0}

Hypoxia and Hypercapnia

Hypoxia is defined as a reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia. Hypoxemia is a specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2) indicated in an arterial blood gas (ABG) result.

Early signs of hypoxia are anxiety, confusion, and restlessness. As hypoxia worsens, the patient’s level of consciousness and vital signs will worsen with an increased respiratory rate and heart rate and decreased pulse oximetry readings. Late signs of hypoxia include bluish discoloration of the skin and mucous membranes called cyanosis. See Figure 8.4^{“Cynosis.JPG” by James Heilman, MD is licensed under CC BY-SA 3.0} for an image of cyanosis.

Hypercapnia, also referred to as hypercarbia, is an elevated level of carbon dioxide in the blood. This level is measured by the PaCO2 level in an ABG test and is indicated when the PaCO2 level is greater than 45. Hypercapnia is caused by hypoventilation or when the alveoli are ventilated but not perfused. In a state of hypercapnia, the accumulation of carbon dioxide in the blood causes the pH of the blood to drop, leading to a state of respiratory acidosis. You can read more about respiratory acidosis in the “Acid-Base Balance” section of the “Fluids and Electrolytes” chapter. Patients with hypercapnia have symptoms such as tachycardia, dyspnea, flushed skin, confusion, headaches, and dizziness. If the hypercapnia develops gradually over time, symptoms may be mild or may not be present at all. Hypercapnia is managed by addressing its underlying cause. A noninvasive positive pressure device such as a BiPAP may be used to help eliminate the excess carbon dioxide, but if this is not sufficient, intubation may be required.^{This work is a derivative of StatPearls by Patel, Miao, Yetiskul, and Majmundar and is licensed under CC BY 4.0} You can read more about BiPAP devices and intubation in the “Oxygen Therapy” chapter in Open RN Nursing Skills.

It is important for a nurse to recognize early signs of respiratory distress and report changes in patient condition to prevent respiratory failure. See Table 8.2a for symptoms and signs of respiratory distress.^{This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0}

Table 8.2a Symptoms and Signs of Respiratory Distress

Treating Hypoxia and Hypercapnia

Hypoxia and/or hypercapnia are medical emergencies and should be treated promptly by calling for assistance as indicated by agency policy.

Failure to initiate oxygen therapy when needed can result in serious harm or death of the patient. Although oxygen is considered a medication that requires a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations as part of the nurse’s response to the “ABCs,” a common abbreviation for airway, breathing, and circulation. Most agencies have a protocol in place that allows nurses to apply oxygen in emergency situations and obtain the necessary order at a later time.^{This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0}

In addition to administering oxygen therapy, there are several other interventions a nurse can implement to assist an hypoxic patient. Additional interventions used to treat hypoxia in conjunction with oxygen therapy are outlined in Table 8.2b.

Table 8.2b Interventions to Manage Hypoxia

Enhanced Breathing and Coughing Techniques

In addition to oxygen therapy and the interventions listed in Table 8.2b, there are several techniques a nurse can teach a patient to use to enhance their breathing and coughing. These techniques include pursed-lip breathing, incentive spirometry, coughing and deep breathing, and the huffing technique. Additionally, vibratory positive expiratory pressure (PEP) therapy can be incorporated in collaboration with a respiratory therapist.

Pursed-lip Breathing

Pursed-lip breathing is a technique that decreases dyspnea by teaching people to control their oxygenation and ventilation. See Figure 8.5^{“v4-460px-Live-With-Chronic-Obstructive-Pulmonary-Disease-Step-8.jpg” by unknown is licensed under CC BY-SA 3.0. Access for free at https://www.wikihow.com/Live-With-Chronic-Obstructive-Pulmonary-Disease} for an illustration of pursed-lip breathing. The technique teaches a person to inhale through the nose and exhale through the mouth at a slow, controlled flow. This type of exhalation gives the person a puckered or pursed-lip appearance. By prolonging the expiratory phase of respiration, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled. This subsequently reduces air trapping that commonly occurs in conditions such as chronic obstructive pulmonary disease (COPD). Pursed-lip breathing relieves the feeling of shortness of breath, decreases the work of breathing, and improves gas exchange. People also regain a sense of control over their breathing while simultaneously increasing their relaxation.^{This work is a derivative of StatPearls by Nguyen and Duong and is licensed under CC BY 4.0}

Incentive Spirometry

An incentive spirometer is a medical device commonly prescribed after surgery to expand the lungs, reduce the buildup of fluid in the lungs, and prevent pneumonia. See Figure 8.6^{“Incentive Spirometer.png” by BruceBlaus is licensed under CC BY-SA 4.0} for an image of a patient using an incentive spirometer. While sitting upright, if possible, the patient should  place the mouthpiece in their mouth and create a tight seal with their lips around it. They should breathe in slowly and as deeply as possible through the tubing with the goal of raising the piston to their prescribed level. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. The patient should attempt to hold their breath for as long as possible (at least 5 seconds) and then exhale and rest for a few seconds. Coughing is expected. Encourage the patient to expel the mucus and not swallow it. This technique should be repeated by the patient 10 times every hour while awake.^{Cleveland Clinic. (2018, May 2). Incentive spirometer. https://my.clevelandclinic.org/health/articles/4302-incentive-spirometer} The nurse may delegate this intervention to unlicensed assistive personnel, but the frequency in which it is completed and the volume achieved should be documented and monitored by the nurse.

Using an incentive spirometer can feel monotonous to patients, resulting in the lack of performing this important activity to prevent pneumonia. It is helpful to  encourage patients to create easy reminders to complete the activity. For example, many patients watch television. Create the reminder to use the incentive spirometer each time they view a commercial. This is a helpful trigger to use the incentive spirometer frequently.

Coughing and Deep Breathing

Coughing and deep breathing is a breathing technique similar to incentive spirometry but no device is required. The patient is encouraged to take deep, slow breaths and then exhale slowly.  After each set of breaths, the patient should cough. This technique is repeated 3 to 5 times every hour.

Huffing Technique

The huffing technique is helpful to teach patients who have difficulty coughing. Teach the patient to inhale with a medium-sized breath and then make a sound like “ha” to push the air out quickly with the mouth slightly open.

Vibratory PEP Therapy

Vibratory Positive Expiratory Pressure (PEP) Therapy uses handheld devices such as flutter valves or Acapella devices for patients who need assistance in clearing mucus from their airways. These devices require a prescription and are used in collaboration with a respiratory therapist or advanced health care provider. To use vibratory PEP therapy, the patient should sit up, take a deep breath, and blow into the device. A flutter valve within the device creates vibrations that help break up the mucus so the patient can cough and spit it out. Additionally, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled. See the supplementary video below regarding how to use the flutter valve device.

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Now that we have discussed various concepts related to oxygenation and hypoxia, we will explain how a nurse uses the nursing process to care for patients with alterations in oxygenation.

Assessment

When assessing a patient’s oxygenation status, there are several subjective and objective assessments to include.

Subjective Assessment

The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath or difficulty breathing. Patients can be asked to rate their dyspnea on a scale of 0-10, similar to using a pain rating scale.^{Registered Nurses’ Association of Ontario. (2005). Nursing care of dyspnea: The 6th vital sign in individuals with chronic obstructive pulmonary disease. https://rnao.ca/bpg/guidelines/dyspnea} The feeling of dyspnea can be very disabling for patients. There are many interventions that a nurse can implement to help improve the feeling of dyspnea and, thus, improve a patient’s overall quality of life.

It is also important to ask patients if they are experiencing a cough. If a cough is present, determine if sputum is present, and if so, the color and amount of sputum. Sputum is mucus and other secretions that are coughed up from the mouth. The body always produces mucus to keep the delicate tissues of the respiratory tract moist so small particles of foreign matter can be trapped and forced out, but when there is an infection in the lungs, an excess of mucus is produced. The body attempts to get rid of this excess by coughing it up as sputum. The color of a patient’s sputum can provide cues for underlying medical conditions. For example, sputum caused by a respiratory infection is often yellow or green and often referred to as purulent sputum.^{Barrel, A. (2017, August 13). What is a sputum culture test? MedicalNewsToday. https://www.medicalnewstoday.com/articles/318924#what-is-a-sputum-culture-test} See Figure 8.7^{“Sputnum.JPG” by Zhangmoon618 is licensed under CC0} for an image of purulent sputum.

Patients should be asked if they are experiencing chest pain. Chest pain can occur with several types of respiratory and cardiac conditions, some which are emergent. If the patient reports chest pain, first determine if it is an emergency by asking questions such as:

• “Does it feel like something is sitting on your chest?”
• “Is the pain radiating into your jaw or arm?”
• “Do you feel short of breath, dizzy, or nauseated?”

If any of these symptoms are occurring, seek emergency medical assistance according to agency policy. If it is not a medical emergency, perform a focused assessment on the chest pain, including onset, location, duration, characteristics, alleviating or aggravating factors, radiation, and if any treatment has been used for the pain.^{A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Chest Pain; [updated 2020, August 4]. https://medlineplus.gov/ency/article/003079.htm}

Objective Assessment

Focused objective assessments for a patient experiencing decreased oxygenation include assessing airway, evaluating respiratory rate and heart rate, analyzing pulse oximetry readings, and auscultating lung sounds for adventitious sounds.

Signs of cyanosis or clubbing should be noted. Clubbing is the enlargement of the fingertips that occurs with chronic hypoxia such as in chronic obstructive pulmonary disease (COPD) or congenital deficits in pediatric patients. See Figure 8.8“Acopaquia.jpg” by Desherinka is licensed under CC BY-SA 4.0 for an image of clubbing.

Another sign of chronic hypoxia that often occurs in patients with chronic obstructive pulmonary disease (COPD) includes an increased anterior-posterior chest diameter, often referred to as a barrel chest. A barrel chest results from air trapping in the alveoli. See Figure 8.9^{“Normal A-P Chest Image.jpg” and “Barrel Chest.jpg” by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0} for an image of a barrel chest.

Diagnostic Tests and Lab Work

Diagnostic tests and lab work are based on the patient’s medical condition that is causing the decreased oxygenation. For example, patients with a productive cough may have a chest X-ray or sputum culture ordered, and patients experiencing respiratory distress often have arterial blood gas (ABG) tests performed.

A chest X-ray is a fast and painless imaging test that uses certain electromagnetic waves to create pictures of the structures in and around the chest. This test can help diagnose and monitor conditions such as pneumonia, heart failure, lung cancer, and tuberculosis. Health care providers also use chest X-rays to see how well certain treatments are working and to check for complications after certain procedures or surgeries. Chest X-rays are contraindicated during pregnancy.^{National Heart, Lung, and Blood Institute. (n.d.) Chest x-ray. https://www.nhlbi.nih.gov/health-topics/chest-x-ray,A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Chest x-ray; [updated 2020, August 4]. https://medlineplus.gov/ency/article/003804.htm} See Figure 8.10^{“Chest Xray PA 3-8-2010.png” by Stillwaterising is licensed under CC0} for an image of a chest X-ray.

A sputum culture is a diagnostic test that evaluates the type and number of bacteria present in sputum. The patient is asked to cough deeply and spit any mucus that comes up into a sterile specimen container. The sample is sent to a lab where it is placed in a special dish and is watched for two to three days or longer to see if bacteria or other disease-causing germs grow.^{A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Routine sputum culture; [updated 2020, Aug 4]. https://medlineplus.gov/ency/article/003723.htm} See Figure 8.11^{“m241-8 Blood agar culture of sputum from patient with pneumonia. Comprimised host. Colonies of Candida albicans and pseudomonas aeruginosa (LeBeau)” by Microbe World is licensed under CC BY-NC-SA 2.0} for an image of a sputum culture.

For patients experiencing respiratory distress, arterial blood gas (ABG) tests are often ordered. Additional details about ABG tests are discussed in the “Oxygenation Basic Concepts” section of this chapter, as well as in the “Acid-Base Balance” section of the “Fluid and Electrolytes” chapter. See Table 8.3a for a summary of normal ranges of ABG values in adults.

Table 8.3a  Normal Ranges of ABG Values in Adults

Diagnoses

Commonly used NANDA-I nursing diagnoses for patients experiencing decreased oxygenation and dyspnea include Impaired Gas Exchange, Ineffective Breathing Pattern, Ineffective Airway Clearance, Decreased Cardiac Output, and Activity Intolerance. See Table 8.3b for definitions and selected defining characteristics for these commonly used nursing diagnoses.^{Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, p. 230.} Use a current, evidence-based nursing care plan resource when creating a care plan for a patient.

Table 8.3b NANDA-I Nursing Diagnoses Related to Decreased Oxygenation and Dyspnea