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Common Nursing Diagnoses and
Interventions in Primary Health Care
for Adults

presented by

Debra Kay Warren

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COMMON NURSING DIAGNOSES AND INTERVENTIONS
IN PRIMARY HEALTH CARE FOR ADULTS

By
Debra Kay Warren

A THEIS

Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing
1998
Major Professor - Rachel Schiffman

ABSTRACT
COMMON NURSING DIAGNOSES AND INTERVENTIONS
IN PRIMARY HEALTH CARE FOR ADULTS
By
Debra Kay Warren

This descriptive, cross sectional study sought to find the most frequently
reported nursing diagnoses and nursing interventions utilized by Advanced
Practice Nursing students in primary health care. Consistency between the
nursing interventions and the nursing diagnoses was also examined. The
framework used was based on Starfield's stmcture-process—outcome model for
evaluating primary care. Records from a pre—existing database held at a
college of nursing Mid-western state university was utilized. The sample
consisted of 1587 cases, a convenience sample, of clients seen by student
Advanced Practice Nurses. The three most frequent nursing diagnoses were:
"Alteration in Comfort", "Appropriate Health Maintenance", and "Knowledge
Deficit". The six most frequent nursing interventions were: "Patient/ Family
Teaching", "Anticipatory Guidance", "Nutritional Counseling", "Counseling",
"Exercise", and "Patient Contracting". Consistency between the nursing
interventions and the nursing diagnoses was not found using the Nursing
Interventions Classifications system. However, consistency was obtained using
Carpenito (1987, 1995). These findings may apply to the majority of the
population residing in the Mid-western region of the country, but cannot be
applied conclusively to the total population due to regional differences.
Implications for this study are discussed relative to APN students, the impact of
these results on APN education and curriculum, and assistance in developing

guidelines for APN practice in primary health care.

TABLE OF CONTENTS

Title Page
Abstract
Table of Contents
Introduction
Statement of the problem .
Research questions
Conceptual Definitions
Nursing diagnosis
Nursing intervention
Primary health care
Conceptual Framework
Structure-process—outcome model (figure 1)
Review of the Literature .
Nursing diagnosis .
Nursing intervention
Nursing diagnosis and intervention consistency
Methods
Research design
Original data collection procedure and recording
Instrument .
Validity of instrument
Operational definitions
Sample
Data analysis

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Procedure for protection of human subjects
Assumptions and limitations

Results and Findings
Nursing diagnoses .

Nursing interventions

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Consistency between nursing interventions and diagnoses 23

Discussion
Conceptual framework
Nursing Diagnoses

Nursing Interventions

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Consistency between nursing interventions and diagnoses 27

Implications
For advanced practice nursing education
For primary health care practice
For further research

Summary

Bibliography

Appendices
A Caseload database instructions
B Caseload data worksheet
C Worksheet codes
D UCRIHS approval letter

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COMMON NURSING DIAGNOSES AND INTERVENTIONS
IN PRIMARY HEALTH CARE FOR ADULTS

Introduction

Due to the increasing emphasis on primary health care and the
decreasing number of resident physicians specializing in general and family
practice, Advanced Practice Nurses (APN) may find themselves in greater
demand to provide primary health care (Beard, Capan, & Mashburn, 1993).
Sixty to eighty percent of activities that are performed by primary care
physicians at this time could be performed by APNs (Beard et al., 1993). The
health care industry is presently focused on cost-effective and high-quality
care (Beard et al., 1993; Swehla, 1988). It has been demonstrated that APNs are
able to provide unique, therapeutic, comprehensive, quality, cost-effective
care (Beard et al., 1993; Callan, 1992; Draye & Pesznecker, 1979; Swehla, 1988).
Part of this unique care includes development of nursing diagnoses and
nursing interventions.

The use of nursing diagnoses allows the APN to identify and document
nursing's unique role in primary health care and direct interventions (Beard
et al., 1993; Bugle, Frisch, & Woods, 1990; Bulechek & McCloskey, 1990;
Carpenito, 1995; McFarland & McFarlane, 1989; Swehla, 1988). The American
Nurses' Association (ANA) and the North American Nursing Diagnosis
Association (NANDA) agree that the "use of [nursing diagnoses] assists the
nurse in assessment and treatment of nursing problems because it provides a
framework, a nursing model, for practice that gives nurses a common frame of
reference" (Bugle et al., 1990, p. 191). Nursing diagnoses offer a clear focus for

development of health goals and nursing interventions (Bulechek &

1

2

McCloskey, 1992b; Carpenito, 1995; Gordon, 1982; McFarland & McFarlane, 1989).
"Nursing diagnoses address the responses of clients, families and of groups to
situations for which the nurse can prescribe interventions for outcome
achievement" (Carpenito, 1995, p. 2). However, there is no research or
documentation known to date on common nursing diagnoses and nursing
interventions used by APNs in primary health care. Most research involving
diagnoses and interventions focuses on individual patient problems or specific
interventions, medical diagnosis, or acute care/hospital settings (Barkauskas,
Chen, Chen, & Ohlson, 1981; Beard et al., 1993; Bugle et al., 1990). It is
imperative that information on common nursing diagnoses and interventions
be researched, discussed, and incorporated into APN education and training.
Statement of the Problem

For students to obtain an accurate depiction of types of patient problems
they will encounter working in a primary health care setting and to learn
what types of interventions will be useful in assisting patients in health
maintenance, common nursing diagnoses and interventions in primary care
need to be studied and documented. It is necessary for educators of Advanced
Practice Nursing students to know this information in order to develop and
evaluate the effectiveness of the curriculum being used. If the curriculum
does not accurately reflect the types of health problems that the Advanced
Practice Nurse will encounter, the education will be less than optimally
effective. If APNs' practices are only seen from the perspective of medical
diagnoses, no recognition of other services provided by APNs will be given,
thus seeing the client only in terms of medical problems (Burns & Thompson,

1984).

3

The purpose of this study was to explore common nursing diagnoses and
common nursing interventions in primary health care reported by APN
students, and to examine the relationship of the interventions to the diagnoses.
Research Qgestions

This study addressed the following questions:

1) What are the three most common nursing diagnoses for

adult clients reported by Advanced Practice Nursing

students in primary care settings?

2) What are the six most common nursing interventions for

adult clients reported by Advanced Practice Nursing

students in primary care settings?

3) Are the nursing interventions consistent with the nursing

diagnoses?

Conceptual Definitions

The two variables that were discussed in this study were nursing
diagnosis and nursing intervention. Both were explored according to the
available literature and are defined in terms of the purpose of this study.
Primary health care was also defined.
Nursing Diagnosis

"Nursing diagnosis and care planning have been an integral part of
nursing education for at least the past decade" (Bugle et al., 1990, 191 ).
According to Bugle, et a1. (1990), nursing diagnoses were introduced in 1953 .
"Early conceptions focused on patient problems or conditions, sometimes
expressed concretely as listings of strengths and liabilities" (Gordon, 1979, p.
487). The idea of classification was introduced in the 19603 (Bugle et al., 1990).

The contemporary emphasis on nursing diagnoses began in the 19708, when

4

nursing discovered the need for a common diagnostic classification system
(Carpenito, 1995; Gordon, 1982; Sparks & Taylor, 1995). Diagnoses were viewed
as "problematic states-of-the -client" (Gordon, 1979, p. 487).

In the 19708, NANDA was developed to standardize the classification of
nursing diagnoses (Bugle et al., 1990). These nursing diagnoses were generally
accepted in the 19808 when the American Nurses' Association (ANA) published
Nursing: A Social Policy Statement, that defined nursing as " the diagnosis and
treatment of human responses to actual or potential health problems " (1980,
p. 9), in which the professional nurse is licensed to "give independent,
professional care" (Bugle et al., 1990, p. 191). The ANA has not offered a new
policy statement since 1980; however, one is currently being drafted.

Gordon, in discussing the general topic of diagnosis, offered two
definitions: (1) "a category name in a classification system" and (2) "a process
leading to a judgement" (1982, p. 12). Feild describes nursing diagnosis as a
"complex judgmental activity which requires the educational and experiential
background of the professional nurse" (1979, p. 499). Gordon's second
definition of diagnosis and Feild's definition of nursing diagnosis state that
diagnosis is an activity or process. In reviewing the literature of the past
three decades, nursing diagnosis is seen as a process. The process in which
nursing diagnosis is a vital component is the nursing process. "Process, by
definition, is dynamic and changing" (Weber, 1979, p. 535). The process of
diagnosis is the process of identifying the health status of a client and
evaluating influencing factors (Gordon, 1982).

Various authors have defined nursing diagnosis, trying to encompass
all that a nursing diagnosis involves. Definitions have been reworked and
revised, beginning with the idea that nursing diagnosis was "problematic

states-of-the-patient" (Gordon, 1979, p. 487) to current definitions, that focus

S

on client behavior (Bulechek & McCloskey, 1990; North American Nursing
Diagnosis Association, 1989). Specific authors have revised their definitions
throughout the decades. Carpenito began with the definition a "nursing
diagnosis is a statement describing one specific type of problem or situation
that nurses identify" (1995, p. 6). Now she defines it as "a statement that
describes the human response (health state or actual/ potential altered
interaction pattern) of an individual or group which the nurse can legally
identify and for which the nurse can order the definitive interventions to
maintain the health state or to reduce, eliminate, or prevent alterations" (1 995,
p. S). This second definition allows for client behavior focus, and also states
that nursing activities or interventions are to be derived from the diagnosis.

This type of definition development has become the accepted style of
defining nursing diagnosis over the years, as seen in the following
definitions, which are presented chronologically. In 1 982, the Task Force of
the National Group for the Classification of Nursing Diagnosis-Subcommittee
on the Definition of Nursing Diagnosis devised the definition: "A nursing
diagnosis is a word or phrase summarizing a set of empirical indicators linked
to contributing factors or etiology, when possible, and representing actual or
potential altered patterns of human functioning , which nurses are licensed to
treat" (McFarland & McFarlane, 1989, p. 11).

In 1984, the Fifth National Conference on the Classification of Nursing
Diagnosis offered this definition: "A nursing diagnosis is a clinical judgement
about an individual, family, or community that is derived through a deliberate,
systematic process of data collection and analysis. It provides the basis for
prescriptions for definite therapy for which the nurse is accountable. It is
expressed concisely and includes the etiology of the condition when known"

(McFarland & McFarlane, 1989, p. l 1). Also in 1984, Burns and Thompson

6

defined nursing diagnosis as "the statement of a person's response to a
situation of illness which is actually or potentially unhealthy and which
nursing'intervention can help to change in the direction of health" (p. 411).

NANDA had not officially devised a definition until 1990. NANDA states a
"nursing diagnosis is a clinical judgement about individual, family, or
community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable" (Carpenito, 1995, p. 5).

These definitions are essentially the same; however, they build upon the
previous definitions until the latest definition encompasses the ideas of client
behavior focus, actual vs. potential health problems, client as an individual,
family or community, and how the diagnosis leads to the intervention(8).

For the purpose of this study, an adaptation of the NANDA definition of
nursing diagnosis was used: a nursing diagnosis is a label which represents a
clinical judgement about individual, family, or community responses to actual
or potential health problems/life processes. Nursing diagnoses provide the
basis for selection of nursing interventions to achieve outcomes for which the
nurse is accountable.

Nursing Intervention

Just as the definition of nursing diagnosis has evolved through the
recent history of nursing, so has the definition of nursing intervention. An
organized approach to defining nursing intervention followed development of
nursing diagnoses. Serious study of nursing intervention began to flourish in
the 19808. Bulechek and McCloskey have done much of the leading work
concerning nursing intervention (Bulechek, Carter, McCloskey, & Moorehead,
1995; Bulechek, Cohen, et al., 1991; Bulechek, Cullen, 8: McCloskey, 1991;
Bulechek, Daly, & McCloskey, 1994; Bulechek, Daly, Mass, & McCloskey, 1996;

7

Bulechek, Daly, McCloskey, & Moorehead, 1996; Bulechek, Denehy, McCloskey,
& Titler, 1994; Bulechek & McCloskey, 1990, 19923, 1992b, 1993, 1994a, 1994b,
1996; Bulechek, McCloskey, & Moorehead, 1993; Bulechek, McCloskey, &
Steelman, 1994). Nursing intervention is a component of the nursing process
and is referred to in many definitions of nursing diagnosis.

In nursing interventions, the focus of concern is with nursing actions
(Bulechek & McCloskey, 1990, 1992b; North American Nursing Diagnosis
Association, 1989). In 1989, NANDA briefly defined nursing intervention as
"nurse-initiated treatments in response to nursing diagnoses" (p. 24). In 1985,
Bulechek and McCloskey (1990) defined nursing intervention as an
"autonomous action based on scientific rationale that is executed to benefit the
client in a predicted way related to the nursing diagnosis and the stated goals"
(p. 26). Bulechek and McCloskey (1992b) have since revised their definition to
read: "a nursing intervention is any direct care treatment that a nurse
performs on behalf of a client. These treatments include nurse—initiated
treatments resulting from nursing diagnoses, physician-initiated treatments
resulting from medical diagnoses, and performance of the daily essential
functions for the client who cannot do these" (p. 6). The second definition
allows for the interventions to be mandated by more than the nursing
diagnoses. NANDA has adopted the second definition of nursing intervention
suggested by Bulechek and McCloskey (North American Nursing Diagnosis
Association, 1989).

Buchanan (1994) defined nursing intervention as "nursing actions and
interventions, executed as part of the nursing process, with or for individuals
and families, that are directed at influencing a measurable change in health

status and quality of life" (p. 190). Buchanan (1994) goes on to state that

8

interventions are performed by expert clinicians in response to a diagnosis;
the goal being to promote change in health status and quality of life issues.

For the purpose of this study, an adaptation of Bulechek and McCloskey's
definition of nursing intervention was used: a nursing intervention is any
direct care treatment that a nurse performs on behalf of a client, involving
nurse-initiated treatments resulting from nursing diagnoses.
Primm Health .Care

In relation to nursing diagnosis and nursing intervention, it is
important to define primary health care. Starfield (1992) states "primary care
is distinguished from other types of care by clinical characteristics of patients
and their problems" (p. 7). Primary care involves a large variety of diagnoses,
as well as health promotion, and has a large portion of it's population as
previously established clients (Starfield, 1992; Yedidia, 1981). In the simplest
terms, primary health care is seen as the setting in which the client has first
contact with the health care system (Starfield, 1992; Yedidia, 1981). "It is the
basic level of care provided equally to everyone. It addresses the most common
problems in the community by providing preventative, curative, and
rehabilitive services to maximize health and wellbeing" (Starfield, 1992, p. 4).
Primary health care does not include specialty fields of health care. This study
defined primary health care as: those settings that involve family or general
practices only. Defining primary health care did not include OB-GYN or
internal medicine practices even though some clients use these settings as
their first contact with health care. These settings were viewed as specialty

practices because they address specific areas of health.

9

Conceptual Framework

The conceptual framework that was used in this study is from Starfield
(1992). Starfield adapted Donabedian's Structure-Process—Outcome model for
the purpose of evaluating primary health care. As the title suggests, this model
has three elements: structure, process, and outcome (See figure 1). The focus
of this study was in the process section. However, the entire model will be
examined so as to understand the process component in context. The process
component includes
the actions of diagnosis and intervention, which are the focus of this study.

Starfield (1992) first addresses the element of structure, which involves
nine components: personnel, facilities and equipment, range of services,
organization, management and amenities, continuity, accessibility, financing,
and population eligible. Each component will be briefly reviewed.

Personnel refers to those individuals involved in providing health care
services, such as the APN, and their training. Facilities and equipment involve
the physical elements involved in providing health care: buildings,
instruments and available technology. Management and amenities include the
manner in which care is provided. Range of services refers to the types of
services available. Organization of services describes how the care is provided
and who provides the care. This component also involves how accountability is
determined. Continuity involves the mechanisms that allow for continuity of
health care. Accessibility describes the way in which access of care for the
client is provided, including time, geographical and psychosocial factors.
Financing refers to the arrangements available for payment of services and
how the personnel are paid. Population eligible describes the delineation of

the clients to which these services are provided, including health and

10

 

Personnel
(ADVANCED PRACTICE NURSES)
Facilities and equipment
Range of services
STRUCTURE Organization

Management and amenitites
Continuity

Accessibility

Financing

Population eligible

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Problem recognition

Provision "NURSING DIAGNOSIS

of care “NURSING INTERVENTION

Reassessment LSocial and
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_ _ __ _ _ _ physical
nvironment

 

 

PROCESS F-ersolrs _

P — — - - — —I T

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Utilization
Receipt Acceptance and
of care satisfaction
Understanding

Participation
Activity

OUTCOME Comfort

Perceived well-being
Disease

Achievement
Resilience

 

 

 

 

Longevity

 

 

 

 

Figure 1. Structure — process - outcome model

(Adapted from Starfield, 1992, p. 13)

11

sociodemographic characteristics of the clients. These nine components are
the resources needed to provide services (Starfield, 1992).

Starfield (1992) explores the process component next. The process
component involves two sections: health care provider activities and client
activities.

The focus of this study was on a section of this component of the model.
The activities for which the health care provider is responsible are problem
recognition, diagnosis, management (or intervention), and reassessment.
Problem recognition involves identification of an actual or potential
alteration in health of an individual person, an entire population, or a
subgroup. Problem recognition must occur if a diagnosis, the second step, is to
be formulated. The APN is trained to identify a need or needs and to create a
diagnosis or diagnoses accordingly. The next step of this process is the
treatment strategy or management plan for the problem. The APN is also
trained to identify ways in which intervention or treatment plans can be
integrated accordingly to the needs of the patient. At this point, the problem
must be reassessed to determine the efficacy and accuracy of the first three
steps: problem recognition, diagnosis, and intervention. Reassessment of the
problem may initiate a new cycle of process of care by the health care
provider. In the case of health promotion and maintenance, areas of strengths
that the client possesses need to be recognized and utilized. Many nursing
diagnoses are health promotion and maintenance oriented, as are many
nursing interventions. The APN is able to identify actual or potential health
problems and create nursing diagnoses and implement nursing interventions
accordingly. The diagnosis and intervention activities (as identified in figure

1) are the focus of this study.

12

The activities for which the client (an individual, population, or
subgroup) is responsible are utilization, acceptance and satisfaction,
understanding, and participation. Utilization involves the choice of using a
health care service and when to do so. Assuming the client chooses to use a
service, that client then must come to an understanding of the service
obtained from the provider. If understanding has occurred, then the client
chooses to accept or not accept the recommended treatment or management
plan offered by the provider. The client may also choose to be or not to be
satisfied with the service. Then the client chooses to participate in the
management plan either fully, partially, or not at all.

Key components concerning these process of care elements of the
client may impact the process of care offered by the health care provider
(Starfield, 1992). The structure of health care and the process of care together
result in the outcome of care. In order to attain the outcome, the structure
must exist and the process (of care) must occur (see figure 1). Starfield (1992)
examines the outcome section of the model last, including seven measurements
of health status: longevity, activity, comfort, perceived well-being, disease,
achievement, and resilience. Each factor is viewed by Starfield as being a
continuum. .

Longevity is viewed as the life expectancy of a client, ranging from
normal life expectancy to death. Activity includes the type of activity in which
a client is able to participate, with the continuum ranging from functional to
disabled. Comfort refers to pain or any other feeling or sensation that may or
may not disrupt pleasure or work, ranging from comfortable to
uncomfortable. Perceived well-being refers to how the client views his/her
own health, ranging from satisfied to dissatisfied. Disease involves actual or

potential health problems, either mental or physical, ranging from not

13

detectable to permanent. Starfield (1992) addresses achievement as "the
positive aspects of health that must be considered in achieving what the World
Health Organization has defined as 'a state of well-being.‘ Achievement
signifies the development or accomplishment and the potential for future
development of better health" (p. 16). The continuum ranges from achieving
to not achieving. Resilience refers to the state of well-being, or the ability to
cope with actual or potential alterations of health, ranging from resilient to
vulnerable (Starfield, 1992).

The structure and process of health care both have a degree of affect on
each of these outcome measurements. The social and physical environment
has an impact on each component of the structure, process and outcome of
care. Societal norms and cultural differences, as well as geographic locations,
are a few examples of environment which affect the structure, process; and
outcome of health care (Starfield, 1992).

In summary, this model nicely reflects how the activities of the APN
relates to the total process of health care. The activities of forming a diagnosis
and planning and implementing interventions are activities for which the
APN is trained and is responsible. A complete structure must be present for the
process of professional care giving to take place, and outcome is achieved as a

result of the process of professional care giving and client activities.

Review of the literature
In reviewing the literature and studies concerning nursing diagnoses
and interventions, no studies were found specifically addressing common
nursing diagnoses and interventions used by APNs in primary health care.
The studies that were obtained concerning the use of nursing diagnoses and

interventions in clinical practices are reviewed. This section is organized

14

according to the conceptual framework variables related to nursing diagnoses,
nursing interventions, and the consistency between nursing diagnoses and
nursing interventions.

Nursing Diagnosis

Many studies concerning nursing diagnosis and nursing intervention
involve a strategy for implementation of nursing diagnoses or nursing
interventions into a particular setting. Many of the studies were limited by the
age of the study (Bruce, 1979; Buchanan, 1994; Feild, 1979; Parker & Rich, 1995;
Weber, 1979). In the literature for commonly used diagnoses in primary health
care, the majority of research studies focused on medical diagnoses, whether
utilized by nurses, nurse practitioners (regardless of specialty), or physicians,
and again most studies were not recent (Barkauskas et al., 1981; Cherkin, Hart,
Rosenblatt, & Schneeweiss, 1983; Draye 8: Pesznecker, 1979; Marshland, Mayo, &
Wood, 1976; "The Nurse Practitioner Survey Results", 1983; Swehla, 1988).

One study discussed the development of a nursing diagnosis
classification system for Pediatric Nurse Practitioners (Burns & Thompson,
1984). This study reviewed the three most commonly occurring medical
diagnoses in the field of pediatrics for Nurse Practitioners. However, this study
did identify that much of a Pediatric Nurse Practitioner's practice focuses on
health promotion which lends itself well to the use of nursing diagnosis and
nursing intervention.

Only one study addressed the issue of commonly used nursing diagnoses
in a primary health care setting (Bugle et al., 1990). The researchers studied
the use of nursing diagnoses in a nurse-managed college health service at a
mid-sized state university. One of the areas the researchers studied was the
most commonly used nursing diagnoses used by the registered nurses, who

were the primary health care providers at this setting. The researchers found

15

that in this health care setting, the most commonly used nursing diagnoses
were "Alteration in Skin Integrity" and "Alteration in Comfort related to
nasal/ sinus congestion". These together comprised 54% of the nursing
diagnoses. "Health Maintenance Management", "Knowledge Deficit related to
treatment of the common cold", and "Alteration in Comfort related to symptoms
other than nasal/ sinus congestion" together comprised 3796 of the nursing
diagnoses; and "Alteration in Elimination: constipation", "Alteration in Sleep
Patterns", "Alteration in Nutrition: less than body requirements", and "Fear
related to exams" together comprised 996 of total nursing diagnoses. This study
is limited in terms of the current study due to the fact that registered nurses,
rather than APNs, were the providers of care. Also, this population was limited
to a specific age group (young adults) and specific living conditions
(dormitory living and daily classes). This situation differs from the general
population, and therefore, the nursing diagnoses were very specific to this
population. The study alluded to the use of nursing interventions, but did not
describe them.

Most of these studies on diagnoses researched specific nursing
diagnoses. One study did address nursing diagnosis use in an advanced practice
nursing specialty; however, it discussed developing a classification system of
nursing diagnoses specific for this specialty, and did not address commonly
occurring nursing diagnoses (Burns & Thompson, 1984). Only one study
researched commonly occurring nursing diagnoses in a non-acute setting, but
was not conducted with APNs, and the common diagnoses could not be
generalized to the entire population (Bugle et al., 1990). None of these studies
addressed the issue of common nursing diagnoses used by APNs in primary
care. The common nursing diagnoses are important to know for students and

educators to understand what kind of needs of the adult client are most likely

16

going to be addressed in practice, and for existing APNs to better equip
themselves for the needs of their adult clients.
Nursing Intervention

In 1992, a research team from the University of Iowa (Iowa
Intervention Project) developed the Nursing Intervention Classification (NIC)
system. This research project was designed to offer a standardized language of
both nurse-initiated and physician-initiated nursing interventions for
general and specialty nursing (Bulechek & McCloskey, 1993, 1994b). The first
version included an alphabetical list of 336 nursing interventions. These
interventions were labeled and validated through expert survey, focus groups
and content analysis. Each intervention included a conceptual definition, a set
of defining activities and background reading on the specific intervention
(Bulechek & McCloskey, 1992a, 1993, 1994a). This system was compared to two
other classification systems (Bulechek et al., 1993). The ANA has endorsed the
NIC system (Bulechek & McCloskey, 1994b).

The Iowa Intervention Project team has studied the use of the NIC
system in various areas in nursing: medical-surgical (Barry-Walker,
Bulechek, & McCloskey, 1 994), perioperative (Bulechek, McCloskey, &
Steelman, 1994), long-term (Bulechek, Daly, 8: McCloskey, 1994), cardiac
(Bulechek, Cullen, et al. , 1991), integument care (Bulechek, Cohen, et al.,
1991), delegation of care (Bulechek, Daly, McCloskey, & Moorehead, 1996), and
management (Bulechek et al., 1995). None of these studies discussed primary
health care or APN involvement; each study was acute care oriented or
management of acute care settings.

In attempting to validate the NIC system in clinical settings, the team did
conduct a study using the NIC system in a variety of practices. The nurses

involved were of varying specialties (hospital settings including intensive

17

care and other specialties, and non-hospital settings) and of varying
educational backgrounds (baccalaureate degrees, graduate degrees and/ or
certifications for specialty practice). The researchers found that specialty
practices reported active listening, emotional support, infection control, vital
signs monitoring, infection protection, and medication management as the six
most frequently used nursing interventions. The researchers also reported
that nurses who worked outside hospital settings identified abuse protection,
anticipatory guidance, attachment promotion, reminiscence therapy, and
therapy group as some of their most commonly used nursing interventions
(Bulechek, Denehey, et al., 1994). This study didn't describe "non-hospital"
settings, nor did it specify that APNs were involved in the study.

These NIC studies primarily addressed the use of nursing interventions
by nurses in acute care settings and generally by nurses holding
baccalaureate degrees or less. One study did address nursing intervention use
in non-hospital settings and also included nurses who held special
certifications or graduate level degrees but did not offer information
specifically on primary care settings or APNs. None of these studies addressed
the issue of common nursing interventions used by APNs in primary health
care.

Nursing Diagnosis and Intervegtion Consisteggy

In 1996, the Iowa Intervention Project team published a revision of the
NIC system that also includes a linkage system of nursing interventions to
nursing diagnoses. The team researched 433 nursing interventions that
correlated with 137 nursing diagnoses. This linkage system has been validated
in the research stage and is now being validated in actual clinical practice

(Bulechek, Daly, Maas 8: McCloskey, 1996).

18

In summary, the studies that were obtained concerning the use of
nursing diagnoses and interventions in clinical practices were reviewed. In
reviewing the literature and studies concerning nursing diagnoses and
interventions, no studies were found specifically addressing common nursing
diagnoses and interventions used by APNs in primary health care.

It is evident that research has not addressed the questions of what are
the most commonly occurring nursing diagnoses and the most commonly
occurring nursing interventions reported by APNs in primary health care
settings. As stated previously, these questions are important for education of
the APN, so as to direct curriculum preparation and education of APNs. This
appalling lack of research cannot be beneficial to the nursing profession and
must be addressed. This study was an attempt to begin this process of
documenting what diagnoses and interventions are being used by APN

students in their practices.

Methods

Research Qgsign

This study's research design was descriptive and cross sectional. This
research was a secondary analysis of pre-existing data.
Original Data Collection Procedure and Recording

The original data were collected by APN students in a primary care
nursing masters degree program at a large university in the midwest. Each
APN student was expected to document information for each client or family
visit. A worksheet was provided. Included on this worksheet was a section for
nursing diagnoses and nursing interventions. Students entered codes of

nursing diagnoses and nursing interventions on a bubble sheet worksheet

19

(Appendices A, B, and C) . The completed forms were returned for data entry
and processing.
Instrument

A Caseload Data Worksheet was provided for each student to complete for
each client seen during the entire clinical experience. The worksheet
provided a place to record information concerning client demographics,
reason and type of visit, medical and nursing diagnoses, nursing and
pharmacological interventions, and any type of referral made (Appendix B).
Validity of Instrument

This database was the method of data collection used by the college of
nursing. No traditional validity or reliability testing was established on the
completed caseload worksheet. The tool to collect this data, the Caseload Data
Worksheet, was constructed by the teaching faculty at Michigan State
University; therefore, validity (in terms of the information collected
intending to be reflective of practice) was obtained through expert panel.
Measures to ensure accuracy of the instrument were taken by the college of
nursing though providing instructions for completing the caseload worksheet
(Appendix A).
0 ratio Def‘ ' 'o 8

The nursing diagnoses were those identified by code on the nursing
diagnosis section (item #21) of the caseload data worksheet (Appendix B). A list
of 1 54 coded nursing diagnoses were given to students (Appendix C). The
students were to select up to three nursing diagnoses, by priority, applicable to
the client seen and record the code number for the nursing diagnosis on the
Caseload Data Worksheet. A special code was provided for any case in which a
nursing diagnosis was not applicable. All nursing diagnoses were used in this

study's data, regardless of priority.

20

The nursing interventions were those identified by code on the nursing
interventions section (item #22) of the caseload data worksheet (Appendix B).
The 23 nursing interventions were listed on the Caseload Data Worksheet for
the students to choose according to the nursing intervention(s) provided
during a client visit. The student was to choose the interventions used during
the client visit. A space was provided if a nursing intervention wasn't
applicable. The interventions were not specified to be prioritized, and were not
specified to be correlated with any of the nursing diagnoses.

Seattle

This study was a convenience sample of 1587 cases from the caseload
data base from the spring semester of 1996 through the summer semester of
1997. Students were in either the family track or the gerontology track. The
clinical sites were in rural and urban areas in Michigan. No other
demographic information concerning the clients was obtained. Inclusion
criteria for the sample selection were:

1) Clients seen at a Family or General Practice setting for a

first or return visit regardless of reason for visit,

2) Clients at least 1 8 years of age.

Data Analysis

The records that conformed to sample criteria were the only records
used in this study. In response to the research question of the three most
commonly occurring nursing diagnoses recorded by APN students in primary
health care, these were identified by frequency and percent and rank ordered
by percent. The nursing diagnosis with the highest percentage of occurrence
across all priorities was identified as the most commonly occurring diagnosis.
The diagnosis that had the second highest percentage of occurrence was

viewed as the second most commonly occurring nursing diagnosis. The same

21

process was applied for the third most commonly occurring nursing diagnosis.
The same process of rank order was applied to determine the six most
commonly occurring nursing interventions.

The third research question of consistency between the interventions
and the diagnoses was evaluated through the NIC linkage system (Bulechek &
McCloskey, 1996). The NIC system was used to evaluate whether one or more of
the six nursing interventions were indicated for one of the three nursing
diagnoses.

Procedure for Protection of Human Subjects

This database identified client, student and clinical site by identification
number only. This researcher did not have access to this specific information.
. No direct contact to the subjects was made. The College of Nursing gave
permission for use of this database after UCRIHS approval was obtained (see
Appendix D). Confidentiality was maintained due to the fact that students did
not report patient names to the College of Nursing or record patient names on
the database worksheets. Also, this researcher did not have access to student
identification numbers.

Assum tions d ‘ itations

One assumption this study has made is that the APN students were able to
see clients who were representative of typical clients seen in primary care
settings. Another assumption held was that the data from the caseload
worksheets were correctly entered into the database.

Hungler and Polit (1987), in discussing limitations to secondary data
analysis, state "one always takes a risk of obtaining data that are inaccurate or
erroneous" (p. 175). This limitation may be applied in this case. If a student
didn't complete the worksheet form in it's entirety, it was not entered into the

database. In addition, not every client seen by a APN student was recorded.

22

Another limitation to this study is that regional differences exist in health
care; therefore this study may provide information relative to the midwest

states but may not apply to all states or other countries.

Results and Findings

Nursing Diagnoses

The 1587' cases included both first time visits and return visits. Those
cases which were return visits were not differentiated from the first time visit
cases. Of the total number of cases, 1481 cases provided one or more nursing
diagnoses. There were 2,239 diagnoses reported across all three priority
rankings. All diagnoses reported for this study sample were included. The most
commonly occurring nursing diagnosis was "Alteration in Comfort" (not pain)
( n=33 3, 14.996). The second most commonly occurring nursing diagnosis was
"Appropriate Health Maintenance" (£2257, 11.496). The third most commonly
occurring nursing diagnosis was "Knowledge Deficit" (932139596).
Nugsing Interventions

Each of the 1 587 records reported at least one nursing intervention. The
most commonly occurring nursing intervention was "Family/ Patient
Teaching" (95947, 59.796). The second most commonly occurring nursing
intervention was "Anticipatory Guidance" (n=407, 25.696). The third most
commonly occurring nursing intervention was "Nutritional Counseling"
(r1_=172, 10.896). The fourth most commonly occurring nursing intervention
was "Counseling" (n=167, 10.596). The fifth most commonly occurring nursing
intervention was "Exercise" (35164, 10.396).The sixth most commonly

occurring nursing intervention was "Patient Contracting" (g,=93, 5.996).

23

Consistency between Nursing Interventions and Nursing Diagnoses

The results of the data analysis of the third research question was not
defmitive. In the NIC system, the linkage system did not include the diagnoses
"Alteration in Comfort" or "Appropriate Health Maintenance". It did offer the
intervention "Comfort Support through environmental management", "Pain
Management", and "Touch (therapeutic)", but offered no linkage between the
diagnosis of "Alteration in Comfort" with specific interventions. The NIC
system did have a linkage between the diagnosis of "Altered Health
Maintenance" and interventions, and between the diagnosis "Health Seeking
Behavior" and interventions; however, it did not provide any specific linkage
between the diagnosis "Appropriate Health Maintenance" with specific
interventions.

The N IC system did provide a linkage between the diagnosis of
"Knowledge Deficit" with specific interventions. The main intervention
reported was "Family/Patient Teaching". "Exercise" and " Nutrition" were
included within the intervention "Teaching". The intervention "Anticipatory
Guidance" was alluded to through the sub—intervention of "Preparatory
Sensory Information" of the intervention "Family/ Patient Teaching". Based
on the NIC system, poor consistency between nursing interventions and

nursing diagnoses was found.

Discussion
Conceptual Framework
These findings reflect well upon the use of the structure-process-
outcome model in this study. As previously stated, the activities of diagnosing
and implementing interventions are activities for which the APN is

responsible. The APN is trained to identify actual or potential health problems,

24

form an appropriate nursing diagnosis or diagnoses (such as "Alteration in
Comfort", "Appropriate Health Maintenance" and "Knowledge Deficit"),
implement necessary nursing interventions (such as "Family/Patient
Teaching", "Anticipatory Guidance", "Nutritional Counseling", "Counseling, "
"Exercise", and "Patient Contracting"), and reassess the problem or treatment
plan for accuracy and efficacy.

Nursing Diagnoses

It is not surprising that the nursing diagnoses of "Alteration in
Comfort", "Appropriate Health Maintenance" and "Knowledge Deficit" were the
most common nursing diagnoses found. These diagnoses are most likely to be
frequently used in most populations due to the fact that most people seek out
health care because of discomfort or health screening. Also, the APN is seen as
a source of health information of which the client can utilize. Primary health
care involves a variety of diagnoses, including health promotion (Starfield,
1992; Yedidia, 1981). Primary health care "addresses the most common
problems in the community by providing preventative, curative, and
rehabilitative services to maximize health and wellbeing" (Starfield, 1992, p.
4). The APN in primary health care focuses on health promotion as a large
part of the role of nursing, as evident by the APN roles addressed earlier. An
emphasis on health promotion would generally lead to these common
diagnoses, due to the very nature of these diagnoses. Each implies a need for
health promotion or maintenance.

It was very interesting to find low frequencies among these nursing
diagnoses. Even though these were the most frequent diagnoses, the
percentages were small, indicating the variety of diagnoses, some of which
may be similar to the diagnoses identified in this study, however, and may

have been approached differently by each student. Also, a need identified

25

through evaluating these diagnoses is that the diagnoses need qualifiers to
give them merit. Diagnoses are generally written with the main diagnosis
preceding and a qualifier following, for example: "Alteration in Comfort due
to diarrhea" or "Knowledge Deficit due to inability to properly self-administer
an inhaler".

The one study found with common nursing diagnoses in primary care
used by RNs in a college health care setting reported "Alteration in Comfort
related to nasal/ sinus congestion" as one of the most commonly occuring
diagnoses, with "Health Maintenance Management" and "Knowledge Deficit
related to treatment of the common cold" occurring somewhat less (Bugle et al.,
1990). This can be loosely compared with the common nursing diagnoses found
in this study: "Alteration in Comfort" (unspecified), "Appropriate Health
Maintenance", and "Knowledge Deficit" (unspecified). In both the study by
Bugle et al. (1990) and this study, "Alteration in Comfort" was found to be one
of the most frequently used nursing diagnosis. Comparatively, "Health
Maintenance" and "Knowledge Deficit" were found to be a frequently used
nursing diagnoses, but not the most frequently used in both studies.

The study by Burns 8: Thompson (1984) which discussed the
development of a nursing diagnosis classification system for Pediatric Nurse
Practitioners reviewed the common medical diagnoses for the pediatric
population (Burns 8: Thompson, 1 984). However, the study did emphasize the
health promotion that the APN provides to this age group. This can be easily
correlated with the nursing diagnosis of "Appropriate Health Maintenance"
found in this study.

Nugsing Intervegtigns
Similar to the nursing diagnoses found in this study, it is not surprising

that the nursing interventions "Family/ Patient Teaching", "Anticipatory

26

Guidance", "Nutritional Counseling", "Counseling, " "Exercise", and "Patient
Contracting" were the most common interventions found. These interventions
are integral parts of the role of nursing. The ability of an APN to provide these
types of interventions is what creates the uniqueness of nursing. One of the
roles of the APN is that of educator (Given, 1993). "Family/ Patient Teaching"
can be used with all areas of primary health care, as well as health promotion
and maintenance, which directly relates to the APN role of educator.
"Anticipatory Guidance" involves education of the client as well. "Nutritional
Counseling" and "Exercise" are interventions that the APN is equiped and
trained to provide through the APN role of change agent (Given, 1993). The
APN role of counselor (Given, 1993) directly correlates with the intervention
of "Counseling". And the APN role of client advocate (Given, 1993) incorporates
the intervention of "Patient Contracting".

It was interesting to find the high frequency of the intervention of
"Family/ Patient Teaching", as compared to the lower frequencies of the
common nursing diagnoses. This is most likely due to the major role the
educator has in the field of nursing, especially Advanced Practice Nursing.
Similar to the common nursing diagnoses, these most common nursing
interventions also need qualifiers to provide further merit. Specifically, for
example, what was the content of the family or patient teaching?

Similar to the nursing diagnosis literature, only one study addressed
nursing interventions utilized by nurses (with varying educational levels)
practicing in out-of-hospital settings; however, these settings were
unspecified (Bulechek, Denehey, et al., 1994). Of the six interventions
identified by Bulechek, Denehey, et al. (1994), one correlated with the

interventions identified in this study: "Anticipatory Guidance".

27

It was interesting to find that all 1587 cases used at least one nursing
intervention; however, only 1481 cases reported at least one nursing
diagnosis. Two possible reasons may explain the 106 case discrepency. First, it
could be due to student error of not including the nursing diagnosis on the
database worksheet. Second, the nursing interventions could have been
utilized in response to medical diagnoses. If this is the situation, this study's
conceptual definition for nursing intervention needs to be more inclusive of
other sources for diagnoses (ie. medical diagnoses). The conceptual definition
could be redefined to read: a nursing intervention is any direct care
treatment that a nurse performs on behalf of a client, involving nurse-
initiated treatments resulting from diagnoses (nursing or medical).

Nursing interventions utilized by APNs in primary health care address
both nursing and medical problems. As a APN in primary health care, nursing
care and medicine are blended together for appropriate patient care. This
blending adds depth to APN care.

Consisgency between Nursing Interventions and Nursing Diagnoses

Concerning the linkage system, it was unexpected to find that the NIC
system did not include two of the three most commonly occurring nursing
diagnoses identified by this study as part of the linkage system. Also, it was
unexpected to find that the NIC system did not offer a single definition of the
interventions "Counseling" and "Exercise". The N IC system claims to be
comprehensive, including "the full range of nursing interventions from
general practice and specialty areas . . . [and] can be used in any practice
setting . . . " (Bulechek 8: McCloskey, 1996, p xiii). However, the NIC system is
actually geared for acute care. This system has a poor adaptation to APN

practice in primary health care.

28

In reviewing nursing diagnoses by Carpenito (1987, 1995), she offered
many interventions. For the diagnosis "Alteration in Comfort", interventions
included or alluded to "Family/ Patient Teaching", "Anticipatory Guidance",
"Nutritional Counseling", "Counseling", "Exercise", and "Patient Contracting".
For the diagnosis "Appropriate Health Maintenance", interventions included
or alluded to " Family/ Patient Teaching", "Anticipatory Guidance", "Nutritional
Counseling", "Counseling", and "Exercise". After reviewing Carpenito a8 a
source for linkage, a strong consistency was found between the nursing
diagnoses and interventions identified in this study.

In using this caseload database, specific limitations were identified.
First, congruency between nursing diagnoses and nursing interventions was
not utilized. Second, congruency between medical diagnoses and nursing
interventions was not identified. Third, qualifiers for nursing diagnoses and
nursing interventions were not recorded. It is the recommendation of this
study that these limitations be corrected through providing opportunity to
demonstrate congruency between nursing diagnoses and nursing
interventions, medical diagnoses and nursing interventions, and provide

opportunity to record nursing diagnosis and nursing intervention qualifiers.

Implications
Fog Advanced Practice Nursing Education
The main implication of this research is to impact APN education. For
APN students to be well equiped to practice in primary health care, they need
to understand a typical client's potential or actual health problems and how to
create an appropriate plan for interventions. The diagnoses and interventions
need to be fully integrated into curriculum, for example, through a specific

nursing diagnosis and intervention course. The diagnoses need to be presented

29

as very common diagnoses in primary health care and specifically studied in
depth. Also, the interventions need to be presented as frequently used
interventions in primary health care and studied in detail. The APN needs to
know when to use these diagnoses and interventions and how to use them
appropriately and effectively. By being aware of this information, the APN
can then practice unique, high-quality care. This type of care can be provided
as a result of the APN fully utilizing the role of nursing through these
diagnoses and interventions. The client benefits by receiving cost-effective,
quality care. The client also benefits by utilizing the APN a8 a source of health
information, thus allowing the client to make appropriate decisions
concerning his/her health.

Educators can use this study's findings to evaluate the effectiveness of
the curriculum for the optimization of APN education. If the curriculum does
not emphasize these diagnoses and interventions, then the APN students are
not receiving an accurate depiction of the types of patient problems, and are
not learning the types of interventions needed to provide quality care.
Specifically, classes can focus on these nursing diagnoses and interventions
throughout the curriculum, and integrate and compare the nursing diagnoses
and interventions with medical diagnoses and interventions. Also, a specific
class on nursing diagnoses and interventions for APNs in primary health care
can be developed to optimize the use of these nursing diagnoses and
interventions by future APNs.

For Primgy Health Qge antice

An implication for the use of this study in primary health care is that
the use of these nursing diagnoses and interventions assist in developing
guidelines for APNs in primary health care. Specifically, the consistency

found between the nursing diagnoses and interventions can be utilized

3O

effectively in practice. If a client has a diagnosis of "Alteration in Comfort",
the intervention(s) of "Family/ Patient Teaching", "Anticipatory Guidance",
"Nutritional Counseling", "Counseling", "Exercise" and/or "Patient
Contracting" can be implemented. And, if a client has a diagnosis of
"Appropriate Health Maintenance", the intervention(s) of "Family/ Patient
Teaching", "Anticipatory Guidance", "Nutritional Counseling", "Counseling",
and/ or "Exercise" could be utilized. Likewise, if a client is diagnosed with
"Knowledge Deficit", then the intervention(s) "Family/ Patient Teaching",
"Anticipatory Guidance", "Nutritional Counseling", and/ or " Exercise" could be
implemented appropriately.

Guidelines can be formed for linking nursing diagnoses, nursing
interventions and outcomes, thus further advancing the APN practice in
primary health care. Also, these guidelines would assist in offering the
primary health care patient the most cost effective, comprehensive, unique,
consistent care available. I
For Further Research

This study focused on adult primary health care nursing diagnoses and
interventions. The rationale for this was that the pediatric population, even
though it is a part of family practice, has specific routine health needs (ie.
health promotion and maintenance diagnoses and interventions) and has
specific health problems which do not typically occur in the adult population.
As a part of the pediatric population, the adolescent population even has it's
own separate set of health needs and problems, thus requiring different
nursing diagnoses and, especially, nursing interventions than the adult
population or the younger pediatric population. Therefore, since the pediatric
population, including adolescents, were not included in this study's sample, it

is recommended that future research focus on common nursing diagnoses and

31

interventions of the pediatric and adolescent populations. The study would
utilize the same database and focus on the age group of 0—18 years.

Another suggested study would be utilizing the same method format as
this study for certified APNs to complete. Since this data was collected by APN
students, it may not reflect true APN practice. This research would ask the
same questions and use the same worksheet to collect information. A
comparison could even be made between the findings of the practicing APN
and this study's findings from APN students.

Also, this method format of data collection could be utilized by other APN
students in other geographical regions of the country. The results could be
compared to the results of this study.

Lastly, it is recommended that the NIC system be made more applicable
to primary health care as well as adapted for APN use. Specifically, it could
include the diagnoses "Alteration in Comfort" and "Appropriate Health
Maintenance" in the linkage system, as well as creating more activities for

interventions which could be readily utilized in primary health care by APNs.

Summary

In summary, the purpose of this study was to explore common nursing
diagnoses and common nursing interventions in primary health care reported
by APN students, and to examine the relationship of the intervention to the
diagnoses. This information was found to be important for students to obtain
an accurate depiction of types of patient problems they may encounter
working in a primary health care setting and to learn what types of
interventions could be useful in assisting patients. This information was also
found to be useful for educators of Advanced Practice Nursing students for

development and evaluation of the effectiveness of the current curriculum.

32
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37

Appendix A

38

MICHIGAN STATE UNIVERSITY
COLLEGE OF NURSING

CASELOAD DATA

The purpose for recording information about the patients and families whom you
areseeingduringyourclinicalexperienceisfourfold. Oneistohelpyouandyour
campusdinicalimmmrevduueyourperfammandmahesuggesdomforodrer
experiencesorchangesinyourclientcareapproach. Thesecondistoprovideyouwith
documentation ofthedepthandbreadth ofyourclinical practice. Many ofyouwillbe
amwmmmmmmmmmimwtnu
usefidmyou.inyournegodafions.1hethirdaspectiswrrianumevduafion.The
faadtyareruponsiblefwdoarmendngdreexbntmwhichwniudumobjecdvaan'.
met. Ammmmm°pmwnmrorinsum,maeam
ofsmdennindrefamflymckamfiomaflagelevdsandmusomenursingdiagnoaa
andinterventionsdealwidrhealthpronrotion. Thenfinallythisdatawilldemonstrate
theaervicetodre"communityprovidedbyMSUgnduatenursingsmdents.

YouwillcodeandrecordyourdataonCaseloadDataFor-ms. Onceyouare
famifiuwiththepmeeasfitshouldonlynkeafewminummcompleteeachcase.
Youcanuseyourwrite-upsuthedatabaseforcompletingthescansheets. Most
students recommend completing the scan sheets while doing write-ups or very soon
after completing the write-up of the client/family visit. A printout with degenptive
statistics will be provided for you and your clinical faculty at the following points in the
semester: '

A. Midterm evaluation-casesentereduptothis point.

Final evaluation - all cases for the semester.

C. At the end of the two clinical courses you will receive a summary printout
with your data from both- courses.

NUR 322 Fall. 1996 $4

39

W

1 Question!
2 Question2
3 Question3
4 Questio‘n4
5 Questionl
6. Question9
7. Question20
8. QuestionZl

Record your MSU student ID number.

The faculty ID number is a unique 3 digit number for each faculty
member. Yotn'coursefacultywillprovidethis information toyou.
Example: 004; 102; 040.

Thepatlentmnumberisafourdigitnumberwhichmasdgnmyour

- case.. Usedrelastfour(4)digitsoftheclient'ssocialaecnritynumber
'astlntelient’sIDnumher. Iftheclientdoesnothaveasoelalaeeurlty

numberassignanumher. Startwithmm. Ifthevisitisafamilyvisit,
codedrepatientmnumberasm.Youwillhavetohepareeordof
clientidartifiationsineeyoushouldasfigndresamenirmbermthe
clientevery‘timeyouuuerdataahoutttntelient

Thefamillenumberisafourdigitnumberwhichmassignbthe
family. Bverymemberofthatfamilyshouldhavethesamefamilym.
Ywmnmduefuekeepareeordofyotufamilymnumbersaswell.

AfteryoumhmhaLeuaoflnwnnasitecodewillbeasslgnedbythe
OfieeomedentainicalPlaeements.Yourindividualcodeswmbe
providedtoyouwithinthefirstzweeltsoftheaemesteronaplacement

sumnurylist.
Entertlteage,ex:2yars-002.

lunsathroughdMedicalDiagnosiscodesareinAppendixB. Assigns
medicaldiagnosisifhisappmpfiatetomevisit,matis,ifdrereasonfor
thevisithastodowithamedialdiagnosisorfifyouplanin
interventionbasedonanenistingornewdiagnosis. Notallvisitswill
haveamedicaldiagnosis. Theseshouldbecodedinpriorityorder.
Mammmmmwmm 111:
WWW

ImnsAthroughC.NursingDiagnosiscodesarelocatedinAppendiaC.
Enterdrecodeasitapparsonthesheet. T'heaeshouldbecodedln
priority order. Itisanticipated thatall visits will haveatleastone
nursing diagnosis. Not all visits will have morethan one nursing

Q

NU! 321 Fall. 1996 SS

9. QuestionZA

10. Question”

11. Question!)

315/1996

Minn!“

4O

omhmmbmummmtfimmm'9h
AppardisD. Theaeeodesareenteredonlylfyoum.dllflt¢°f
discontinuedreclient's medications. “mates-acodebra
initem(b) “W“

fl‘hecodaforovutlrecmter(01‘¢)pharnneologinlml.e.,
mmammummmuwn
Moodesareenteredonlyifyoupreaedbedramordiaeontinuethe
cliqt'smCmedications. Ifyouenteracodefora
ammutypeofpharmacologiewhmmar)

Pabshhlwstofvisitmdrechargebydlehulthpreprovider
whosawtheclient. 'l‘hisisthechargeforthelnovlder'sma'uviees.

Response In (our should read 876-3100.

41

Appendix B

42

MICHIGAN STATE UNIVERSITY
COLLEGE OF NURSING

CASELOAD DATA WORKSHEET

Instructions: Please, use a number 2 lead pencil to fill in the circle that corresponds to your data.

 

s lamlathefiratvlsittotheellnlcalsitaforthiselient: 0v.- Oslo
7. Haveyouasenthiaellenttorheslthearebeiore? Ob 0N0

6. Praeticeaettingloeationlentarcodetromllstl

 

43

9. AgeltaZyeerallnyeersl ldAaelI<2yearallnmonthel

 

   

11. Clientgender: 12. Bacalethnlcltyotcllent:
OFemele OAelen 0mm
Om Oswmm ()th
Ofllepenlc OOtlIertSpeclM '

 

13. Tlmeepentwlthellent:

O 01.20 Mlnutee 0 sun Mlnutee
0 21-40 mm 0 et-roo MM
0 sun m 0 101 e um

14. Primerynaeontorvlelt:

O Aetneproblenufiutvlalt

0 Acute problem. follow up

0 Chronic problem.flretvlelt

0 Chronic problem follow up

0 Health malntenancelpromotlon mll visit

0 Prenatal—routine

0 Screen history & physical (employment. sports. preechool. etc).

OCasemaneoement

15. Vlelteettlngz ~ ltlypeotvlelt:
Galilee/clinic Olloepltel Olndlvlduel
OPrlvatehome OSchooI 00mm
Omanhome Omar- OFamlly
ONurainghome Oman

OPhonecell 0mm

17. Type of mm:

Ommwam
Ommnmammmm
OPartialhlstorylphyeicel
OCompletehlstoryelone
OPertielhlatory

OPertialhistotytphysicelwlthpeMceuem
OPertialphyslcelelone

OConwlete physleslelone
OTelepnoneasseument
OOnlyapeclalaseesementdone

16. lMflmdMMmemMIMmmmwm

ONutrldonslenalysls

Orsmlly Ollisteppreleel
OFinanclslreeourcee OFenlllty
OFunctioneletsnrs OSoclelrasourcea
Ol'lome OSoclelormletun‘ctloning
Omar-3m OMMM
ONOIW

19. lndiceteil'anyoltheeedlepneetieteetswersdonalordered?

 

OM two 0 “mm OW
OCIC Hamlet 0 MSAFP OStrep screen
Ocnem profile 0 OGTI’ OTB sldn ten
OCholeeterol O Other electrolytes O‘l'herapeutie drug tint
O Coomha O PAP smear OThroet/noee mu
Clare 0 Potassium OThyroid panel
OEKG 0 Pregnancy HCG test OTrlglycerldee

OFetel non-eueee test 0 Pregnancy test-urine O'Nmpenoprem
OFSHIUI 0 Pro time OUltrasound
OGlucoee screen 0 PSA OUuthrsl culture

0 Hearing 0 Pulmonary function Olivine anelysialcultlue
Ol-lemocult O Rubelle'titer OVeginal culture

0 Hepatitis panel 0 Sad rate OVlsion

Ol-llv OSerology-VDRUrpr OWet mount

0 Lead levels 0 Serum HOG OX-rey (Specify)
OUpId MI. 0 Sic”. cell 0001.! MD M

ON“ wobble

45

20. latertoliststoentermedlceldlagnosiscodes.

 

 

21. Reterto'liststosntsrnurslng disgnoelscodss:

hPriorltyznureingdx

 

 

 

immmmommmmmmmmmwmmmmmmm

O Anticipatory guidance 0 Humor 0 Sell-Inoculation
O Assertiveness training 0 imagery 0 Sexual counseling
OCasemanagsment ONutritionalcounseling OSmolringcseaatlon
0 Cognitive therapy 0 Patient contracting 0 Stress management
0 Counseling 0 Patient/family teaching 0 Support groups
0 Crisis intervention 0 Relaxation training 0 Therapeutic touch
ETOl-lldrug counseling 0 Reminiscence therapy 0 Values clarlflcmlon
0 Exercise 0 hole supplementation O Other (lasso Ila)

46

l3.- lndicsteALLlntervemiomuesdhaeadoanOMY1nursingdiagnesis

OAntieipetToryguiance
OAeesnlveneeeuslnlng
OCasemsnegsment
OCognltivethsrepy
OCounsailng
OCrlelsmterventlon
0510mm
OEnrcles

M. flehnoflettemcanetcodebrphunueobglcelagmumuhlngsprsscdpuom

 

0W 0W
Imagery O Malena-sling
ONutrltionalcsunssllng O Smldngcsesetion
Patientan 0 Streesmanegamsnt
OPatismflsmilytsaching ,OSupportgroupe
Moretiontrsinlng Q Therapeutictouch
Oleminiscsncetherapy O Valuseclarliieetion
onolswpplsmsntetlon Q outwit-09W
Ilbl‘l'ypeotpharmaeologlemsnagsmem

0 Newprsecrlptlon

0 llaneweadstlngpreecriptiorwefli
0 Changedosaflm

0 Discernlnue

 

47

14b) Wpsofpharmaeologicmanegement

G) New preecrlpdon

0 lanewerrlstlng prescriptiorvrellll
0 Change dosaflraquaney

0 Discontinue

25. Refertollsttomconeetcodetornon-pnscdpdonphannacologlcalaganu.

E

 

(lb) Typeotphanneeologlemanagsment

0 Nonprescription .
Q henswealstlngprsscrlptlorwellll
G Changedoedlregusnw.

Q Discerninue

48

(46) Type of phsnnaeologle management

 

 

@New prescription
@lenewexisting prescripfionlrefill
®Chengedoseflrsqusncy
ODIeoontinue
OOreeelngMoundcare 00mm
0W OPoemraldraInagdpercueeion
OFoot can 0 Suturing
OGelttrslnlng O Suturing removal
Ol-leetlcoldtherapy OWartremoval
Olmmunbstlon injection. 0 Otherikeelflltl
WM 0 Notappllceble
OWW
27. Indicate referrelematle:
OWMMMMMM Owns
OCase manager OOccupetloneltherspy
OClsrgy OPhennaclst
Dental OPnysicaltherapy
ODIabeteeeducetlon OPhysleian-epeclellu
OW ' 0mm
OFostsrcera OPdmsrycemphyslclen
Ollomecare ,OPublle health
" OHomshealthaldaorehoreservlce OSoclalworher
Ol-lospice OSupport group
OLagal OVlsitlng nurse
OLongtarm care OOther (keep list)
OMental health professional ONot applicable

23. lndicatesllsourcssotpaymant.

OhspaIdmanegadhsalthplenIescHMO.PPO.Caplmsdl
OMediceid

OMadlcare

OPrlvatalnswsnce

OCI-IAMPUS

QPrlvatepaytasiorseMee
QChlldren'sSpsclalHaalthCareCervlossml
DWI-906M

 

49

29. lndlcetelevelofvleltlrelenoeewleacedeel

0 Brief“... ”MlflmJflfl

O MWlemmm)mmtz .
O Umlud (evaluation of almple W cable) cam 09213
O Expanded (multiple and/or compile-m) aazoe. ewe

O Comprehenelve: lhlgh complexity) m. .0218

31. mme

32. Swamlwelofreapomlblllw:

O nmlndbymdemmwnmmedehyw

O ammwmmmmmm

O nmimwmmmwmcmm

O HMMWMWMWMMQWUMOVGON

50

Appendix C

51

Nursing Dx 92-93

Nursing Diagnosis Codes
1992-1993
1.93-1094
Muslim
Activity intolerance
Activity intolerance, potential
Activity tolerance
Adjustment, impaired
Airway clearance, ineffective
Altered protection
Anxiety
Anxiety, anticipatory
Anxiety, mild
Anxiety, moderate
Anxiety, severe
Aspiration: potential for
Attachment, weak mother(parent)/infant
Bladder elimination, adequate
Body image, positive
Body image disturbance
Body image, realistic
Body temperature, potential altered
Bowel incontinence
Bowel elimination, adequate
Breastfeeding: effective
Breastfeeding: ineffective
Breathing pattern, ineffective
Cardiac functioning, effective
Cardiac output, decreased
Cognitive impairment, potential
Conflict, dependence/independence, unresolved
Comfort, adequate '
Comfort, altered (pg; pain)
Communication, impaired: verbal
Constipation, colonic
Constipation, perceived
Constipation, intermittent pattern
Coping avoidance
Coping, defensive
Coping, effective family
Coping, effective individual
Coping, family: potential for growth
Coping, ineffective family: compromised
Coping, ineffective family: disabling
Coping, ineffective individual
Crisis resolution, effective
Decisional conflict
Decubitus ulcer

1

52

Nursing Dx 92-93 2

Denial, ineffective

Depression, reactive (situational)

Developmental progression, efficient

Diarrhea

Disuse syndrome, potential

Diversional activity, deficit

Dysreflexia

Exercise level appropriate

Family processes productive

Family functioning, satisfactory

Family process, altered

Fatigue

Fear

Fluid intake, adequate

Fluid volume, adequate

Fluid volume deficit, actual 1 (failure of regulatory
mechanism)

Fluid volume deficit, actual 2 (active loss of body
fluid)

Fluid volume deficit, potential

Fluid volume excess ‘

Gas exchange, impaired

Grieving, anticipatory

Grieving, dysfunctional

Growth and development, altered

Growth and development altered: communication skills

Growth and development altered: self-care skills

Growth and development altered: social skills

Health maintenance, altered

Health maintenance, appropriate

Health management deficit: total

Health management deficit (specific)

Health seeking behaviors (specific)

Home maintenance management, effective

Home maintenance management, impaired

Hopelessness

Hyperthermia '

Hypothermia

Immune response, effective

Incontinence, functional

Incontinence, reflex

Incontinence, stress

Incontinence, total

Incontinence,urge

Infection, potential for

Injury, potential for: (poisoning: suffocation: trauma)

Joint contractures, potential

Knowledge deficit

Hemory deficit, uncompensated short term

Hobility level adequate

Nobility, impaired physical

Noncompliance

Noncompliance, potential

Nutrition, alteration in: less than body requirement (or
nutritional deficit)

53

Nursing Dx 92-93

Nutrition, alteration in: more than body requirement (or

exogenous obesity)

Nutrition, alteration in: potential forcmore than body

requirement (or potential obesity)
Nutritional status, optimal
Pain
Pain, chronic
Pain, self-management deficit
Oral mucous membrane, altered
Parental role conflict
Parenting, altered
Parenting, potential for altered
Personal identity disturbance
Physical fitness, optimal
Post trauma response

Potential for successful satisfaction of developmental

needs
Powerlessness
Rape trauma syndrome
Rape trauma syndrome: compound reaction
Rape trauma syndrome: silent reaction
Respiratory function, effective
Role performance, disturbance
Self bathing-hygiene deficit
Self-care, independence
Self-care deficit, total
Self-concept, positive
Self dressing-grooming deficit
Self feeding deficit
Self toileting deficit
Self-esteem disturbance
Self-esteem, chronic low
Self-esteem, situational low
Self esteem, positive
Sensory functioning adequate
Sensory deficit, uncompensated (specific)

Sensory-perceptual alteration: input deficit (or

sensory deprivation)

Sensory-perceptual alteration: input excess (or

Sensory overload)
Sexual dysfunction
Sexual function adequate
Sexual expression appropriate
Sexuality patterns, altered

Skin integrity adequate to support body requirements

Skin integrity, impaired

Skin integrity, impaired: potential
Sleep pattern disturbance

Sleep pattern, adequate

Social interaction, impaired

Social interaction, satisfactory
Social isolation

Spiritual distress

Swallowing, impaired

Trauma, potential for

54

Nursing Dx 92-93 4

86 Thermoregulation, ineffective

8? Thought process, alteration in

88 Tissue integrity, impaired . .

89 Tissue perfusion, alteration in: cerebral,
cardiopulmonary, renal

9O Unilateral neglect

91 Urinary elimination, altered patterns

92 Urinary retention

93 - Violence, potential for

9/3/92 c:a:\caseload\ncodes92.alf

55

Appendix D

 
  
  
   
   

saw
“I; sum-1m

.“hm
~e~~
fit.

-I.”
M“

MICHIGANSTATE
UNIV ensu'rv

July 11, 1991

1o: IschelF . Schiffman
A230 Life Sciences

as: use: 91-630
TIM: omens sonsrwo DIM” AID WINS IN
"V1810 m: IA Y TH
carsooev: 3:19,
APPROVAL OATS: 00/97
The university Co-ittee onusearch Involving n-sn ect'e' (scam)

review of this roject ison complete. I am pleased to se thstthe
riggtgt.‘ s31 .rtgogi to obtain magi: consent‘ws risty

ro me rop .
gher:fore, them Wspproved this project mend anyrev rev’geions listed

lawman: We roval is valid for one calendar with
.. M m

the t:e‘pp tlpaip‘iuroval’mdste eshown above. mnmtigatore plm
fore (soil osed “viz”; rows?- let or ”when a
”£36.“ certificst Therein ion
of four-such sible. Investigators

wishinatocontinna roectbeyondths timeneedtosubnitit
again orcowlete tflew,

amsrowsc nurse nut ev ”dimoftgem mm x: “mum“. .g .

the time og‘renewel shamanml mpg
send.. an tten 1:”.01 at to Ithe o tear. “159 t evi ed
approvalmand referencmthe project's Ill O ‘W. fmIncl:

requeetsdeecr tionofthechangeand revised
gem-eta, consent forms P orsadverti ements an?!“ applicable.

work, dtgthgr :goghnfgélnoti“ l i) of robm
(uneebect edade efectsh calm“. e22“ lv-ing m.-

infgmrmsti g: Madicatingh greater risk to MM: 02c?” than
the human e s
existedwhen waspreviously reviewed soda pproved.

be of fut 1 a,
(31-, 3”,“.0‘W“ mm mcugi 2193?. not hesitate to contact us