By Wong, Elizabeth
PURPOSE. In the first of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the North American Nursing Diagnosis Association (NANDA) International ClassificationCritical incident nursing diagnosis (CIND)-defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication. DATA SOURCES. The literature, research studies, and meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article.
DATA SYNTHESIS. The current nursing diagnoses in the NANDA International Classification are inaccurate or inadequate for describing nursing care during lifethreatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life- threatening situations.
CONCLUSIONS. Coining and defining a novel nursing terminology, CIND, for patient care during life-threatening situations are important and fill the gap in the current standardized nursing terminology.
IMPLICATIONS FOR NURSING PRACTICE. Refining the NANDA International Classification will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology: CIND. Parts 2 and 3 of this series will propose additional nursing terminology: critical incident nursing intervention and critical incident control, respectively.
Search terms: Critical incident nursing diagnosis, definition principles, NANDA International Classification, nursing diagnosis, standardized nursing terminology
Introduction
Coining and defining novel nursing terminology to record nursing behaviors inherent in the practice and experience of critical care registered nurses (CCRN) can be a challenging task. The initial impetus for this endeavor was the realization that the current standardized nursing terminology contained in the NANDA International Classification is inadequate or inaccurate for describing nursing diagnoses that may be required during the course of patient care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication to other registered nurses (RNs), the public, and other healthcare professionals.
Historical Overview of Standardized Nursing Terminology
The first nursing textbook written by Nightingale (1969/1860), Notes on Nursing: What It Is and What It Is Not, contains keen, accurate descriptions of nursing behaviors or treatments responsible for returning a patient to wellness. Note that all of the words Nightingale used to define the term observation are different, yet they describe the same nursing behavior. The use of different terms to describe nursing behavior prohibits the clear categorization of these nursing behaviors for purposes of the systematic study, teaching, application, and research of nurses’ contribution to patient care. What was ultimately needed was a standard classification system for nursing practice.
The organization of standardized nursing diagnosis terminology was pioneered in the 1970s by Gebbie and Lavin (1974) in their seminal article “Classifying Nursing Diagnoses.” A prominent group of nurse theorists joined the First Task Force to Name and Classify Nursing Diagnoses in 1977 in order to further develop the work that Gebbie and Lavin began (NANDA International, 2007). The development and construction of the nursing diagnosis classification eventually led to the formation of NANDA in 1982 (NANDA International). As a result of widespread research, testing, acceptance, and expansion of the term nursing diagnosis, NANDA has gained international status and is now known as NANDA International; the NANDA International Classification was accepted by the American Nurses Association in 1987 and the International Council of Nurses in 1989 as the definitive source for nursing diagnoses (Carpenito, 1997).
A literature search was conducted using the keyword “nursing diagnosis.” Over the past three decades 3,412 articles (U.S. National Library of Medicine, 2008) have been written that scrutinize the ability of standardized nursing diagnosis terminology to benefit the practice of nursing. Most recently, Muller-Staub, Lavin, Needham, and van Achterberg (2006) conducted a meta-analysis of 48 nursing articles that specifically examine the effect of nursing diagnoses on the documentation of the quality of nursing assessment; the quality, frequency, accuracy, and completeness of nursing diagnoses; and the coherence among nursing diagnosis, interventions, and outcomes. The conclusion of this meta-analysis was that the use of nursing diagnostics improved the documentation of nursing assessment, the quality of reporting nursing interventions, and the outcomes attained; conversely, deficits were noted in the reporting of signs, symptoms, and etiology. In short, what is apparent from a review of the history of the development of standardized nursing terminology is that such a system is greatly needed, investigation of its accuracy and relevance is ongoing, it has been accepted internationally by the nursing community, it is documented in nursing textbooks, and, finally, it is used to advance the profession of nursing globally for the betterment of patient care.
Some confusion may exist between the terms medical diagnosis, which is defined as “the entire process of identifying the cause of the patient’s illness or discomfort” (Thomas, 1993, p. 531), versus nursing diagnosis, which is defined as “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (Neal, 2007, p. 332). Both medicine and nursing use data collection and data analysis to arrive at a standardized label for a particular cause of the patient’s illness or discomfort. The difference between a medical diagnosis (e.g., congestive heart failure, diabetes mellitus, hypertension) and a nursing diagnosis (e.g., Risk for Falls, Readiness for Enhanced Comfort, or Bathing/Hygiene Self-care Deficit) lies in the object or primary focus of the investigation, the tools and methods of the investigation, and the nature of the conclusion reached (Kelly, 1985).
NANDA International Classification: Evidence of Work in Progress
Retrospective reviews have been written by researchers attempting to classify nursing behaviors from documented descriptions. Meyer and Lavin (2005) examined Nightingale’s observations of nursing behavior and indicate that Nightingale is describing the term vigilance. They maintain that vigilance is the essence of nursing care and define it as “attention to and identification of clinically significant observations, signals, cues; calculation of risk inherent in nursing practice situations; and readiness to act appropriately and efficiently to minimize risks and to respond to threats” (p. 2). Vigilance, the authors contend, is practiced by modern RNs also. A recommendation by the authors has been made that the NANDA International Classification should be expanded to include the novel nursing terminology vigilance under a novel nursing diagnostic label: Surveillance Nursing Diagnosis. Nursing Diagnoses: Definitions and Classification 20072008 contains an entire section outlining the procedure for submitting new nursing diagnoses in article or outline format for review by the NANDA International Diagnostic Review Committee (Neal, 2007).
Principles of Definition
Words or terms may have several meanings and may be confusing to readers and users of those words or terms. Thus, definitions have been developed for each word or term to clarify the meaning to the reader and user. A definition of a word or term is a fundamental means of organizing information. The goal of a definition is to develop a statement that gives an outline and boundaries for the usage of the word or term. Several rules for the development of a definition exist. The word or term being defined, or definiendum, is written followed by the defining expression, or definiens. The definiens has the same or equivalent meaning as the definiendum. Thus, the standard format for a definition is that X means Y and/or Y means X (Bulechek & McCloskey, 1992; Mills, 1991; Snyder, Egan, & Nojima, 1996). The word or term is capitalized when it is used as a proper noun in a sentence.
The development of a term or concept for standardized nursing terminology begins with the nursing diagnosis as the foundation for nursing interventions and nursing outcomes. Lunney (1990, 1998) stresses that accuracy is absolutely essential so that the RN is able to use the nursing diagnostic term to help interpret human behavior and responses in order to guide patient care. Characteristics of the accuracy of a nursing diagnosis encompass the use of patient cues to support the nursing diagnosis. “Accuracy exists when a diagnosis matches the real or true state of the patient, and accuracy reflects a specific state of existence, therefore, diagnoses that do not reflect this state of existence are inaccurate” (Lunney, p. 13). Every effort was made to follow these principles for defining terms when suggesting a novel term to be included in the NANDA International Classification that is the focus of Part 1 of this three-part series. The importance of developing accurate, standardized nursing terminology cannot be overstressed. Safar (1974) reminds us that “investigators at all levels should communicate with each other using the same terminology” (p. 543). Critical Incident Nursing Diagnosis
Registered nurses have been identifying life-saving nursing diagnoses since the advent of modern nursing. Descriptions of patient care scenarios are often used to convey nursing diagnoses and nursing interventions that made the difference between life and death for a patient. In the following example, an RN recounts her ability to recognize important life and death cues and to intervene appropriately:
An elderly patient was transported to the intensive care unit (ICU) from the operating room after undergoing a 4-hr intracranial neurosurgical procedure followed by successful extubation of the trachea. The patient was quietly spontaneously breathing eight breaths per minute while wearing an oxygen mask during transport.
Arrival at the ICU is a hectic period in which the patient is disconnected from the transport monitors and reconnected to the bedside monitors. During this time the elderly patient became apneic due to having a poor respiratory drive with resultant airway obstruction. The CCRN noticed this serious incident. The CCRN stopped what she was doing, reached over, strategically placed her index finger under the patient’s chin, and lifted it. This painful maneuver stimulated the patient and opened the patient’s obstructed airway, hence his breathing resumed.
In the above scenario, the primary and most important nursing diagnosis for this patient was the NANDA International-approved nursing diagnosis: Impaired Spontaneous Ventilation. The NANDA International textbook format of Domain, Class, Nursing Diagnosis, Defining Characteristics, and Related Factors for Impaired Spontaneous Ventilation are shown in Table 1 (Neal, 2007). The Activity/Rest Domain is defined as “the production, conservation, expenditure, or balance of energy resources” (p. 273), while the Cardiovascular/Pulmonary Responses Class is defined as “cardiopulmonary mechanisms that support activity/ rest” (Neal, p. 274). By definition this Domain and Class may be appropriate for certain nursing diagnoses such as Activity Intolerance or Risk for Activity Intolerance, but it may not be a good fit for a nursing diagnosis such as Impaired Spontaneous Ventilation. In the example shown in Table 1 NANDA International classifies non-life- threatening nursing diagnoses along with life-threatening nursing diagnoses. Would an RN, or any outside group, looking up a standardized nursing term to designate or chart a life-threatening event such as apnea consult the Activity/Rest Domain for the appropriate nursing diagnosis? As will be explained in greater detail later, non-life-threatening nursing diagnoses or routine nursing diagnoses are completely separate in importance and priority when compared to life-threatening nursing diagnoses.
Even the definition of Impaired Spontaneous Ventilation does not appear to be accurate or adequate, as NANDA International defines the standardized nursing term impaired as “damaged or weakened” (Neal, 2007, p. 260). Weak ventilations may not necessarily be life- threatening, and the standardized nursing term “damaged ventilations” does not make sense. The label does not appear to be an intuitive good fit for the definition. Life-threatening nursing diagnoses require their specific designation so that they may be researched, taught, and applied clinically. Thus, the novel nursing terminology, CIND, defined as the recognition of an acute life- threatening event that occurs as a result of disease, surgery, treatment, or medication, should be included in the NANDA International Classification.
Proposal for the Inclusion of CIND in the NANDA International Classification
Lash (1978) conducted a review of the definitions of nursing diagnoses in journals published from 1956 through 1978 and determined that there were six common characteristics:
1. A nursing diagnosis is made by a professional nurse.
2. A nursing diagnosis is a summary statement.
3. A nursing diagnosis is derived from patient data.
4. A nursing diagnosis is about health problems.
5. A nursing diagnosis is about a therapeutic decision amenable to a nursing intervention.
6. A nursing diagnosis is the necessary base for nursing care. (p. 334).
The novel term, CIND, fulfills all six characteristics outlined by Lash. For example, the RN recognizes a life-threatening situation as a result of disease, surgery, treatment, or medication, using clinical assessment skills derived from patient data. Following the nursing diagnosis, the RN makes a therapeutic decision that results in a nursing intervention that attempts to reverse the life- threatening situation. In addition, life-threatening nursing diagnoses should be separated from non-lifethreatening or routine nursing diagnoses, with the placement of life-threatening nursing diagnoses in the Safety/Protection Domain. The current Safety/ Protection Domain is shown in Table 2, and the proposed novel Safety/ Protection Domain is shown in Table 3.
Implications
The issue of improving the quality of care that RNs deliver has gained national momentum. In 2007, the Joint Commission and Accreditation of Healthcare Organizations launched a research project aimed at collecting data on 12 nursing-sensitive performance measures (Joint Commission, 2008). The first nursingsensitive performance measure is “death among surgical in-patients with treatable serious complications; failure-to-rescue.” Unfortunately, the research project does not stipulate which are “treatable serious complications.” Being able to recognize or conduct a nursing diagnosis of a “treatable serious complication” is an important first step for an RN to perform in this schema and a critical example of where standardized nursing terminology is required. Including the novel nursing terminology, CIND, in the NANDA International Classification would be an aid in this research.
Summary
Maas, Hardy, and Craft (1990) stated that “for the science of a practice discipline to progress, the concepts that describe subject matter of the field must be identified, defined, and empirically validated” (p. 24). This article has presented the initial steps in this process, which are identifying and defining an important concept, CIND, and its inclusion in NANDA International Classification is urged. Refining the NANDA International Classification will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel term: CIND.
Acknowledgment. The author would like to thank Jennifer Briseno, RN, BSN, Lynne M. Scott, RN, MSN, CCRN, CCNS, Cecelia L. Crawford, RN, MSN, Raoul J. Burchette, MA, MS, and Lorys Oddi, EdD, RN, Distinguished Teaching Professor Emerita, Northern Illinois University, for their advice and critique during the preparation of this manuscript.
Table 1. NANDA International-Approved Diagnosis: Impaired Spontaneous Ventilation ((c)NANDA International)
Domain: Activity/Rest: The production, conservation, expenditure, or balance of energy resources
Class: Cardiovascular/Pulmonary Responses: Cardiopulmonary mechanisms that support activity/rest Approved Nursing Diagnoses:
Decreased Cardiac Output
Impaired Spontaneous Ventilation
Ineffective Breathing Pattern
Activity Intolerance
Risk for Activity Intolerance
Dysfunctional Ventilatory Weaning Response
Ineffective Tissue Perfusion (specify type: renal, cerebral, Cardiopulmonary, gastrointestinal, peripheral)
Approved Nursing Diagnosis:
Impaired Spontaneous Ventilation: Decreased energy reserves result in an individual’s inability to maintain breathing adequate to support life.
Defining Characteristics:
Apprehension
Decreased cooperation
Decreased dissolved oxygen
Decreased oxygen saturation
Decreased tidal volume
Dyspnea
Increased heart rate
Increased metabolic rate
Increased dissolved carbon dioxide
Increased restlessness
Increased use of accessory muscles
Related Factors:
Metabolic factors
Respiratory muscle fatigue
Table 2. Current Structure of Safety/Protection Domain ((c) NANDA International)
Domain: Safety/Protection: Freedom from danger, physical injury, or immune system damage; preservation from loss; and protection of safety and security
Class 1: Infection
Class 2: Physical Injury
Class 3: Violence
Class 4: Environmental Hazards
Class 5: Defensive Processes
Class 6: Thermoregulation
Table 3. Proposed Novel Safety/Protection Domain With Altered Definition, Life-Threatening Event Class, and Critical Incident Nursing Diagnoses Included
Domain: Safety/Protection: Freedom from danger, physical injury, or immune system damage; preservation from loss of life; and protection of safety and security
Class 1: Life-threatening events
Class 2: Infection
Class 3: Physical Injury
Class 4: Violence
Class 5: Environmental Hazards
Class 6: Defensive Processes
Class 7: Thermoregulation
Class 1: Life-threatening Events: Any acute change in physiology that threatens life and results in a critical incident
Critical Incident Nursing Diagnosis: an acute lifethreatening event that occurs as a result of disease, surgery, treatment, or medication
Defining Characteristics:
Airway-Obstruction
Regurgitation and aspiration
Breathing-All respiratory arrests
Respiratory rate
Respiratory rate > 36
Circulation-All cardiac arrests
Pulse rate
Pulse rate > 140
Systolic blood pressure
Neurology-Sudden fall in level of consciousness
(Fall in Glasgow Coma Scale score of > 2 points) Repeated or prolonged seizures
Hemorrhage
References
Bulechek, G. M., & McCloskey, J. C. (1992). Defining and validating nursing interventions. Nursing Clinics of North America, 27, 289-299.
Carpenito, L. J. (1997). Nursing diagnosis: Application to clinical practice (7th ed.). New York: Lippincott.
Gebbie, K., & Lavin, M. A. (1974). Classifying nursing diagnoses. American Journal of Nursing, 74, 250-253.
Joint Commission. (2008). Nursing sensitive performance measures. Retrieved on January 30, 2008, from www.jointcommission.org/ performancemeasurement/measurereservelibrary/nqf_nursing.htm
Kelly, M. A. (1985). Nursing diagnosis source book. East Norwalk, CT: Appleton-Century-Crofts.
Lash, A. A. (1978). A re-examination of nursing diagnosis. Nursing Forum, 4, 333-343.
Lunney, M. (1990). Accuracy of nursing diagnoses: Concept development. Nursing Diagnosis, 1,12-17.
Lunney, M. (1998). Accuracy of nurses’ diagnoses: Foundation of NANDA, NIC, and NOC. Nursing Diagnosis, 9, 83-85.
Maas, M. L., Hardy, M. A., & Craft, M. (1990). Some methodologic considerations in nursing diagnosis research. Nursing Diagnosis, 1, 24-30.
Meyer, G., & Lavin, M. A. (2005). Vigilance: The essence of nursing. Online Journal of Issues in Nursing, 23,1-15. Retrieved January 30, 2008, from http://nursingworld.org/mainmenucategories/ AN Amarketplace/ANAperiodicals/ojin/tableof contents/ volume82003/ num3sep30_2003/vigilancetheessenceofnursing.aspx
Mills, W. C. (1991). Nursing diagnosis: The importance of a definition. Nursing Diagnosis, 2, 3-8.
Muller-Staub, M., Lavin, M. A., Needham, L, & van Achterberg, A. T. (2006). Nursing diagnoses, interventions and outcomesapplication and impact on nursing practice: Systematic review. Journal of Advanced Nursing, 56, 514-531.
NANDA International. First task force to name and classify nursing diagnoses. Retrieved June 30, 2007, from http:// www.nanda.org/ html/historyl .html
Neal, M. C. (2007). Nursing diagnosis: Definitions and classification 2007-2008. Philadelphia: NANDA International.
Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York: Dover Publications. (Original work published in 1860).
Safar, P. (1974). Critical care medicine-quo vadis? Critical Care Medicine, 2,1-5.
Snyder, M., Egan, E. C., & Nojima, Y. (1996). Defining nursing interventions. Image, Journal of Nursing Scholarship, 28,137-141.
Thomas, C. L. (Ed.). (1993). Taber’s cyclopedic medical dictionary (18th ed.). Philadelphia: F. A. Davis.
U.S. National Library of Medicine. (2008). Nursing diagnosis citations. Retrieved June 30, 2007, from http://www. ncbi.nlm.nih.gov/sites/extrez
Elizabeth Wang, CRNA, MSN, is a Clinical CRNA, Kaiser Permanente Woodland Hills Medical Center, Woodland Hills, CA.
Author contact: [email protected]
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