Asthma is a chronic respiratory condition that affects millions of people worldwide. It is a condition that can be managed with proper care and treatment. One of the key components of managing asthma is through nursing diagnosis and care planning.
Nursing diagnosis for asthma is an essential part of the care plan for patients with asthma. It involves identifying the patient’s specific health condition, assessing their symptoms, and formulating a plan of care that is tailored to meet their unique needs.
The nursing diagnosis helps the healthcare team to provide appropriate interventions that will improve the patient’s quality of life and prevent complications.
Nursing diagnosis for asthma includes identifying potential triggers and risk factors that can cause asthma attacks. This helps to develop preventative measures to avoid these triggers and reduce the risk of an asthma attack.
The nursing care plan also includes interventions to manage the patient’s symptoms, such as administering bronchodilators, oxygen therapy, and monitoring the patient’s vital signs. With proper nursing diagnosis and care planning, patients with asthma can lead a healthy and active life.
Understanding Asthma
Asthma is a chronic respiratory disease that affects the airways, making it difficult to breathe. It is characterized by recurrent episodes of wheezing, chest tightness, shortness of breath, and coughing, which can be severe and life-threatening. Asthma can occur at any age and can affect both adults and children.
Definition
Asthma is a chronic disease that affects the airways, causing inflammation and narrowing of the bronchi. This inflammation can cause the airways to become sensitive to various triggers, such as allergens, irritants, and infections, which can cause the airways to narrow further, making it difficult to breathe.
Causes
The exact cause of asthma is unknown, but it is believed to be a combination of genetic and environmental factors. Some common triggers of asthma include allergens (such as pollen, dust mites, and animal dander), irritants (such as cigarette smoke, air pollution, and strong odors), and infections (such as colds and flu).
Symptoms
The symptoms of asthma can vary from person to person, but some common symptoms include wheezing, chest tightness, shortness of breath, and coughing. These symptoms can be mild or severe and can occur at any time, but they are often worse at night or early in the morning. In severe cases, asthma can cause cyanosis, restlessness, and fatigue.
Diagnosis
Diagnosing asthma involves a combination of medical history, physical examination, and lung function tests. Medical history involves asking about symptoms, triggers, and family history of asthma. Physical examination involves checking for signs of asthma, such as wheezing, breath sounds, and chest tightness. Lung function tests, such as spirometry and peak flow, are used to measure the amount of air that can be exhaled from the lungs and the speed at which it is exhaled. Other tests, such as allergy testing and exercise-induced asthma testing, may also be done to determine the cause of asthma.
In conclusion, understanding asthma is crucial in managing this chronic respiratory disease. It is important to identify the triggers of asthma and take steps to avoid them. Treatment options for asthma include asthma medications, such as inhaled corticosteroids, long-acting bronchodilators, and combination inhalers, as well as quick-relief medications, such as short-acting bronchodilators. With proper management, most people with asthma can lead normal, active lives.
Nursing Diagnosis for Asthma
Asthma is a chronic respiratory disease that affects millions of people worldwide. Nursing diagnosis is an important aspect of asthma management. It involves a thorough assessment of the patient’s condition to identify the specific nursing problems that need to be addressed. This section will discuss the nursing diagnosis for asthma, including assessment, nursing diagnosis, planning, implementation, and evaluation.
Assessment
Assessment is the first step in the nursing diagnosis process. The nurse should assess the patient’s respiratory status, including the presence of wheezing, coughing, and rapid breathing. The nurse should also assess the patient’s level of consciousness and ability to communicate. In addition, the nurse should assess for signs of ineffective airway clearance, such as the presence of mucus or secretions in the airways.
Other important assessments include postural drainage, coughing exercises, and hydration. The nurse should also assess for impaired gas exchange and monitor arterial blood gases. Finally, the nurse should assess the patient’s coping behaviors and provide support as needed.
Nursing Diagnosis
Based on the assessment, the nurse can formulate a nursing diagnosis. The nursing diagnosis for asthma may include ineffective airway clearance, impaired gas exchange, and coping behaviors. Ineffective airway clearance is a common nursing diagnosis for asthma patients. It refers to the inability to clear secretions or mucus from the airways, which can lead to airway obstruction and respiratory distress.
Impaired gas exchange is another common nursing diagnosis for asthma patients. It refers to the inability of the lungs to oxygenate the blood adequately, which can lead to hypoxia and respiratory failure. Coping behaviors may also be a nursing diagnosis for asthma patients. It refers to the patient’s ability to cope with the stress and anxiety associated with asthma.
Planning
Once the nursing diagnosis has been established, the nurse can develop a plan of care. The plan of care should be individualized to meet the specific needs of the patient. The nurse should prioritize the nursing interventions based on the severity of the patient’s symptoms.
The plan of care may include postural drainage, coughing exercises, hydration, and oxygen therapy. The nurse may also provide education to the patient and family members on asthma management and medication administration. Referral to a specialist may also be necessary for further evaluation and treatment.
Implementation
Implementation involves putting the plan of care into action. The nurse should administer medications as ordered, monitor the patient’s respiratory status, and provide emotional support to the patient and family members. The nurse should also encourage the patient to participate in self-care activities, such as postural drainage and coughing exercises.
Evaluation
Evaluation is the final step in the nursing diagnosis process. The nurse should evaluate the effectiveness of the plan of care and modify it as needed. The nurse should monitor the patient’s respiratory status and assess for changes in symptoms. The nitric oxide test may be used to assess the effectiveness of medication therapy.
In conclusion, nursing diagnosis is an important aspect of asthma management. It involves a thorough assessment of the patient’s condition to identify the specific nursing problems that need to be addressed. The nursing diagnosis for asthma may include ineffective airway clearance, impaired gas exchange, and coping behaviors. The plan of care should be individualized to meet the specific needs of the patient, and the nurse should prioritize the nursing interventions based on the severity of the patient’s symptoms.
Medications for Asthma
There are several medications available for the management of asthma. These medications can be broadly classified into two categories: quick-relief medications and long-term control medications. Combination inhalers, which contain both quick-relief and long-term control medications, are also available.
Quick-Relief Medications
Quick-relief medications are used for the immediate relief of asthma symptoms. These medications work by relaxing the muscles around the airways, allowing them to open up and making it easier to breathe. The most commonly used quick-relief medication is albuterol, which is a short-acting beta-agonist. Albuterol is usually administered via an inhaler or a nebulizer.
Long-Term Control Medications
Long-term control medications are used to manage asthma symptoms on a regular basis and to prevent asthma attacks. These medications work by reducing inflammation in the airways, which helps to reduce the frequency and severity of asthma symptoms. Inhaled corticosteroids are the most commonly used long-term control medication for asthma. They are usually administered via an inhaler.
Other long-term control medications for asthma include theophylline and leukotriene modifiers. Theophylline is a bronchodilator that works by relaxing the muscles around the airways. Leukotriene modifiers work by blocking the action of leukotrienes, which are chemicals that cause inflammation in the airways.
Combination Inhalers
Combination inhalers contain both quick-relief and long-term control medications. These inhalers are used to manage asthma symptoms on a regular basis and to provide immediate relief of symptoms when needed. Combination inhalers are usually prescribed for people with moderate to severe asthma.
In conclusion, there are several medications available for the management of asthma. Quick-relief medications are used for the immediate relief of symptoms, while long-term control medications are used to manage symptoms on a regular basis and to prevent asthma attacks. Combination inhalers are also available and contain both quick-relief and long-term control medications. The choice of medication will depend on the severity of the asthma and the individual needs of the patient.
Breathing Techniques for Asthma
There are several breathing techniques that can help individuals with asthma manage their symptoms. These techniques can be used in combination with medication and other treatments to help improve breathing and reduce the frequency and severity of asthma attacks.
Pursed-Lip Breathing
Pursed-lip breathing is a technique that involves inhaling through the nose and exhaling through the mouth with pursed lips. This technique can help slow down breathing and prevent the airways from collapsing, making it easier to breathe. It can also help reduce the amount of air trapped in the lungs, which can be especially helpful during an asthma attack.
To perform pursed-lip breathing, individuals should:
- Inhale slowly through the nose for 2 counts.
- Purse the lips together as if blowing out a candle.
- Exhale slowly through the mouth for 4 counts.
This technique can be repeated as needed throughout the day, especially during periods of shortness of breath or wheezing.
Deep Breathing
Deep breathing, also known as belly breathing, is a technique that involves taking slow, deep breaths from the diaphragm. This technique can help improve lung function and reduce stress and anxiety, which can trigger asthma symptoms.
To perform deep breathing, individuals should:
- Sit or lie down in a comfortable position.
- Place one hand on the chest and the other on the belly.
- Inhale slowly through the nose, feeling the belly rise.
- Exhale slowly through the mouth, feeling the belly fall.
This technique can be repeated for several minutes at a time, several times per day.
Diaphragmatic Breathing
Diaphragmatic breathing is a technique that involves breathing from the diaphragm rather than the chest. This technique can help improve lung function and reduce the effort required to breathe, making it easier to manage asthma symptoms.
To perform diaphragmatic breathing, individuals should:
- Sit or lie down in a comfortable position.
- Place one hand on the chest and the other on the belly.
- Inhale slowly through the nose, feeling the belly rise.
- Exhale slowly through the mouth, feeling the belly fall.
This technique can be repeated for several minutes at a time, several times per day.
In conclusion, breathing techniques can be a helpful addition to medication and other treatments for individuals with asthma. Pursed-lip breathing, deep breathing, and diaphragmatic breathing are all effective techniques that can help improve lung function and reduce the frequency and severity of asthma symptoms.
Other Asthma Management Strategies
In addition to medication, there are several other strategies that can help manage asthma symptoms. These strategies include exercise, allergy management, and coping behaviors.
Exercise and Asthma
Regular exercise is important for overall health, but it can be challenging for people with asthma. Exercise-induced asthma is a type of asthma triggered by physical activity. Symptoms include coughing, wheezing, and shortness of breath. However, with proper management, people with asthma can still enjoy physical activity.
Before starting an exercise program, it is important to talk to a healthcare provider. The provider can help determine which activities are safe and provide guidance on how to manage symptoms. Some tips for managing exercise-induced asthma include:
- Using a bronchodilator before exercise
- Warming up before exercise
- Avoiding exercise in cold, dry weather
- Using a scarf or face mask to cover the mouth and nose in cold weather
Allergy Management
Allergies can trigger asthma symptoms, so managing allergies is an important part of asthma management. Allergy testing can help identify the specific allergens that trigger symptoms. Immunotherapy, also known as allergy shots, can help desensitize the body to allergens over time.
Other allergy management strategies include:
- Avoiding allergens as much as possible
- Using air filters and purifiers
- Washing bedding in hot water to kill dust mites
- Keeping pets out of the bedroom
Coping Strategies
Living with asthma can be challenging, so it is important to develop coping strategies. Some coping behaviors that can help include:
- Learning relaxation techniques, such as deep breathing or meditation
- Keeping a journal to track symptoms and triggers
- Joining a support group
- Talking to a mental health professional
By incorporating these strategies into an asthma management plan, people with asthma can improve their quality of life and reduce the frequency and severity of symptoms.
Nursing Diagnosis for Asthma
Nursing Care Plan for Asthma 1
Nursing Diagnosis: Ineffective Airway Clearance related to asthma as evidenced by shortness of breath, wheeze, SpO2 level of 85%, respiratory rate of 25, and productive cough
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range, and verbalize ease of breathing.
Nursing Interventions for Asthma
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess breath sounds via auscultation. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Wheeze is one of the important signs of asthma.
Encourage coughing. Suction secretions as needed. To help clear thick phlegm that the patient is unable to expectorate.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. To increase the oxygen level and achieve an SpO2 value within the target range.
Administer the prescribed asthma medications (e.g. bronchodilators, steroids, or combination inhalers / nebulizers). Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs.
Elevate the head of the bed and assist the patient to assume semi-Fowler’s position. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.
Nursing Care Plan for Asthma 2
Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand secondary to asthma as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will be able to demonstrate active participation in necessary and desired activities and demonstrate an increase in activity levels.
Nursing Interventions for Asthma
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try. To create a baseline of activity levels and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest. To gradually increase the patient’s tolerance to physical activity. To prevent asthma attack by allowing the patient to pace activity and to have rest periods.
Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required. To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.
Nursing Care Plan for Asthma 3
Nursing Diagnosis: Ineffective Breathing Pattern related to inadequate pulmonary ventilation, secondary to asthma, as evidenced by shortness of breath, coughing, cyanosis, nasal flaring, changes in the depth of breathing, excessive use of accessory muscles, presence of respiratory noise, and tachypnea.
Desired Outcomes:
- The patient’s abnormal breathing pattern will be corrected, as evidenced by a normal respiratory pattern, with no evidence of dyspnea noted.
- The nurse will note that the use of diaphragmatic compression is evident, ABG values are within the prescribed ranges, and there is evidence of comfortable breathing, either vocally or by the patient’s conduct.
Nursing Interventions for Asthma
Monitor the patient and take any necessary vital signs readings while he/she is in a state of distress. During the first stage of hypoxia and hypercapnia, the BP, RR, and HR likely elevate. And when the patient’s condition deteriorates to the point where blood pressure and heart rate fall, respiratory failure might occur.
Evaluate the rate, depth, and rhythm of the patient’s breathing. When the patient’s usual breathing pattern or rhythm changes, there is a strong probability that an impending ailment or disease state is developing; in particular, this may be an early warning sign of oncoming respiratory distress.
Determine the degree to which the patient is experiencing anxiety. There may be a sense of panic when the patient is experiencing difficulty breathing adequately. Hence, assessing his/her level of anxiety would be beneficial in mitigating its course or progression.
Listen to the patient’s breathing and note any abnormalities, including any wheezes or stridor. If unusual sounds persist, it could indicate a worsening condition or the emergence of new complications. It should be noted that patients with chronic respiratory issues like asthma may be more susceptible to lung infections (e.g., pneumonia).
Observe any signs and indicators of shortness of breath (dyspnea) that may present as retractions of the chest, excessive use of accessory muscle, and nasal flaring. This is an essential indicator that the patient may be suffering from breathing issues as these are signs of possible respiratory distress. When there is significant inspiratory effort, the breathing pattern is noticeably altered due to difficulty pumping air into and out of the lungs.
Regularly monitor the patient’s oxygen saturation. Oxygen saturation refers to the percentage of blood hemoglobin that is saturated by oxygen. 95-100 percent oxygen saturation is considered normal, and deviations within this baseline level indicate inadequate ventilation. It may arise from several causes, but it is often correlated with asthma if blockages are present (e.g., mucus) in the airway passage.
Regularly monitor the patient’s arterial blood gas (ABG). Individuals who suffer from mild to moderate persistent asthma may be at risk of developing respiratory alkalosis. It is expected that the respiratory rate and depth will rise in the presence of hypoxemia. On the other hand, respiratory acidosis is a concerning finding since it often suggests that respiratory failure is on the way and that mechanical ventilation may be required in the near future.
Require the patient to have a dedicated rest schedule incorporated into his/her daily routine. A common side effect of having an improper breathing pattern is exhaustion due to the additional work required to breathe normally. Metabolic rate and oxygen consumption rise with exercise, and for that reason, periodic rest between care activities should be incorporated.
Suggest to the patient to inhale and exhale via pursed lips. When the patient breathes with his/her lips pursed, he/she is allowing more fresh air to enter the lungs while expelling old air they’ve been holding in.
Encourage calm, deep breathing while staying close to the client. The nurse should inform the patient and any other important individuals that they are closely watching their situation and will intervene if necessary. Having a trusted and reliable person in the room can make the patient feel more secure; hence, reinforcing a support system.
Nursing Care Plan for Asthma 4
Nursing Diagnosis: Anxiety related to uncontrollable status shifts, secondary to asthma as evidenced by shortness of breath, restlessness, uneasiness, tachycardia, continuous requested presence in the room, and tachypnea.
Desired Outcome: The patient will demonstrate effective coping as evidenced by a reported decrease in the degree of anxiety and reduced anxiousness in the form of a calmer demeanor and more cooperative conduct.
Nursing Interventions for Asthma
Observe the patient for symptoms of nervousness or anxiety such as:
● Visible signs of panic attacks
● Trepidation or fearfulness
● Restlessness
● Uneasiness
● Tachycardia
● Hands or feet that are either cold or sweaty
● Dyspnea Asthma may also be exacerbated by anxiety. And when this happens, the patient tends to exhibit a fast, shallow breathing pattern.
Monitor the level of oxygen in the patient’s blood. Oxygen saturation refers to the percentage of blood hemoglobin saturated by oxygen. 95-100 percent oxygen saturation is considered normal. Establishing the oxygen saturation level would provide baseline data on the patient’s risk of developing hypoxia which is often noted in asthma attacks.
Ensure the patient is at ease and comfortable by providing amenities like a quiet, peaceful space and soothing music. Remaining calm and exerting less inspiratory effort makes breathing easier and conserves the patient’s energy equally.
Assist the patient in understanding each step of the process by thoroughly explaining the procedure clearly and concisely. When the treatment plan is more understood, the patient’s anxiety may lessen. Consequently, the patient’s breathing pace is unlikely to change since he/she will be less apprehensive and concerned.
Maintain constant communication with the patient’s family and loved ones to keep them informed of the patient’s improvement. Anxiety can readily be passed on from family members or significant others to the patient. A peaceful and stress-free environment is of utmost importance, especially when the patient is easily perturbed and troubled. Most likely, it would also ease certain risks of complications developing. Hence, disclosing information to family members would help alleviate their fears and anxiety. Making this step contributes to the promotion of a relaxing, stress-free atmosphere.
Assure the patient and anyone involved that he/she will be closely monitored and that immediate intervention will be made. Having a trusted and reliable person in the room can make the patient feel more secure and at ease.
Observe the patient and support him/her by suggesting to take a slow, deep breath. To enhance the patient’s health prior to any complications arising and to help him/her progressively calm down.
Suggest relaxation techniques for the patient to employ, such as gradual decrease of muscle tension using progressive muscle techniques, diaphragmatic breathing, pursed-lip breathing, guided imagery, and positive affirmations (e.g., relax, take a deep breath, and let go). Asthma attacks can be triggered by panic episodes brought on by anxiety. Hence, techniques like deep breathing and meditation can help alleviate stress and anxiety.
Nursing Care Plan for Asthma 5
Health-Seeking Behaviors: Prevention of Asthma Attack
Nursing Diagnosis: Health-Seeking Behaviors: Prevention of Asthma Attack related to an expressed desire to avoid and correct situations impetus of asthmatic episodes, as evidenced by an increased interest for better control over health practices, the impact of environmental factors and behavioral factors on health, and an increase in the number of attacks
Desired Outcomes:
- The parents and the patient will communicate their comprehension of the triggering agents that may induce an asthma attack.
- Avoidance strategies will also be communicated effectively.
Nursing Interventions for Asthma
Examine the patient’s medical history for information such as the incidence of respiratory illnesses, triggering determinants, and the kind of therapies or actions taken to improve the patient’s health. Respiratory changes or infections can trigger asthma attacks, and determining its incidence can provide baseline information to keep the patient healthy.
Identify allergies in the patient’s family and what causes an attack, and the behaviors that ensue after the attack. Indicates whether there is a history of reactive airway diseases, eczema, allergic rhinitis, or urticaria within the family. In addition, it is not uncommon to link reactive airway illnesses to asthma, as it is used to describe suspected cases of asthma that have yet to be diagnosed.
Determine if the patient is taking any over-the-counter medications, and if so, what kind they are and what effects they are having. Respiratory infections are often treated with over-the-counter drugs, and acquiring this information would help determine the kind of OTC medications that may interfere with prescribed medications and cause a worsening of the respiratory conditions or attacks.
Inform the patient to maintain a safe distance or keep away from people with respiratory infections. Respiratory infections are infectious, and they could potentiate and trigger asthma attacks. Inhaling aerosolized droplets could be avoided by taking preventative actions such as staying away from those who are unwell.
Encourage the patient to use tissues to cover the mouth while coughing or sneezing and properly dispose of tissues when he/she is done using them. To prevent the spread of bacteria by inhalation of aerosolized droplets.
As a precaution, suggest to parents that they make changes to the patient’s home environment, such as changing filters to reduce exposure to dust and getting rid of common food allergens like peanuts and eggs. To reduce the chance of an attack being triggered.
Explain the disease, its symptoms, as well as probable underlying causes that might trigger an attack. Contains information that can be used to enhance the effectiveness of preventive measures. Adherence to prescribed treatment programs would be improved as patients would find it easier to include something they are familiar with.
Take the time to instruct the patient and parents on correct handwashing procedures and offer time for a follow-up demonstration. Avoids the transmission of pathogens from close contacts, such as touching.
Contact local groups that can support and educate the patient. These organizations provide assistance to families with an asthmatic child or family member.
Other Nursing Diagnosis
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Anna J. Yeo, Elissa Jelalian, Sheryl J. Kopel & Daphne Koinis-Mitchell (2023) Asthma-related lung function and physical activity patterns among children living in urban neighborhoods, Journal of Asthma, 60:7, 1386-1393, DOI: 10.1080/02770903.2022.2149410
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.
Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, asthma, and clinical immunology : official journal of the Canadian Society of Allergy and Clinical Immunology, 14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Walid Al-Qerem, Anan Jarab, Shrouq R. Abu Heshmeh & Jonathan Ling (2023) Variables associated with asthma control among adult patients, Journal of Asthma, 60:7, 1290-1298, DOI: 10.1080/02770903.2022.2144351
Best Nursing Books and Resources
These are the nursing books and resources that we recommend.
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The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care
This is a great reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnosis, it also helps guide the nurse to matching the nursing diagnosis to the patient assessment and diagnosis.
This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
All introductory chapters in this updated version of a ground-breaking text have been completely rewritten to give nurses the knowledge they require to appreciate assessment, its relationship to diagnosis and clinical reasoning, and the goal and use of taxonomic organization at the bedside.
Nursing Care Plans: Nursing Diagnosis and Intervention
Contains more than 200 care plans that adhere to the newest evidence-based recommendations.
Additionally, it distinguishes between nursing and collaborative approaches and highlights QSEN competencies.
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