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PURPOSE. This paper aims to illustrate the process of theory-based nursing practice by presenting a case study of a clinical nurse specialist's assessment and care of a woman with type 2 diabetes.
DESIGN. Orem's self-car e deficit theory and standardized nursing language, NANDA, NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification), guided assessment and the identification of outcomes and interventions related to the client's management of diabetes.
FINDINGS. Theory-based nursing care and standardized nursing language enhanced the client's ability to self-manage the chronic illness: diabetes.
CONCLUSION. Nursing theory and standardized nursing language enhance communication among nurses and support a client's ability to self-manage a chronic illness.
Search terms: Nursing diagnoses, nursing classifications and nursing outcomes, Orem's self-care deficit theory, standardized nursing language, theory-based nursing practice
Introduction
As the average lifespan is extended, more individuals are coping with chronic illnesses such as diabetes, which has reached epidemic proportions with more than 20 million people in the United States having this diagnosis (Gordois, Scuffham, Shearer, Oglesby, & Tobian, 2003). The American Diabetes Association (ADA) estimates that a million people will be diagnosed of diabetes every year (2004). Long-term complications of diabetes are costly to both the individual and the healthcare system. Over the past decade, diabetes research has focused on pharmacological approaches and lifestyle interventions to the illness (Odegard, Setter, & Iltz, 2006). Recent evidence in the forum of diabetes care revealed a need for healthcare professionals to assess and empower individuals in the self-management of this illness.
For the purposes of this case study, health assessment by nurses was defined by Fuller and Schaller-Ayers (2000) as a process of systematically collecting and analyzing data to make judgments about health and life processes of individuals, families, and communities. In addition, the assessment included the integration of theory, diagnosis, intervention, and outcomes into practice and the use of theory to make decisions related to complex practice problems (Sandstrom, 2006). The plan of care was organized by the use of standardized nursing language, nursing diagnoses (NANDA International, 2007), nursing interventions (McCloskey & Bulechek, 2003), and nursing outcomes (Johnson & Maas, 2004). This provided a framework that is adaptable to specific health situations. A case study of a client with type 2 diabetes was used to illustrate the...