Transcript 04. Nursing Diagnosis, Planning Nursing Care

Nursing Diagnosis,
Planning Nursing Care
NURSING DIAGNOSIS
a clinical judgment about individual, family, or community
responses to actual and potential health problems or life
processes
The goal of a nursing diagnosis is to identify actual and potential
responses
PURPOSES OF A NURSING DIAGNOSIS
• 1. Identify how and individual,
group or community responds to
an actual or potential health and
life processes
• 2. Identify factors that contribute
to or cause health problems
(etiology).
• 3. Identify resources or strengths
the individual, group or
community can utilize to prevent
or resolve problems
FORMULATING A NURSING DIAGNOSIS
Composed of 3 parts:
• Problem statement- the client’s response to a problem
• Etiology- what’s causing/contributing to the client’s problem
• Defining Characteristics- what’s the evidence of the problem
• Problem( Diagnostic Label)-based on your assessment of
client…(gathered information), pick a problem from the NANDA
list...
• Etiology- determine what the problem is caused by or related to
(R/T)...
• Defining characteristics- then state as evidenced by (AEB) the
specific facts the problem is based on...
NURSING VS. MEDICAL DIAGNOSIS
• Focus on unhealthy
response to health or illness
• Nurse treats problem within
scope of independent
nursing practice
• May change from day to
day as the patient’s
responses change
▫ Identify disease
▫ Physician directs treatment
▫ Remains the same as long as
the disease is present
MEDICAL DIAGNOSIS
• Identification of a disease condition based on a specific
evaluation of physical signs, symptoms, history, diagnostic
tests, and procedures
• The goals of a medical diagnosis is to identify the cause of a
illness or injury and design a treatment plan
NURSING DIAGNOSIS
• Actual or potential health problems that can be prevented or
resolved by independent nursing interventions
NURSING /MEDICAL DIAGNOSIS
Nursing Diagnosis
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Fear
Altered health maintenance
Knowledge deficit
Pain
Altered tissue perfusion
Medical Diagnosis
▫ Myocardial infarction
EXAMPLE OF NURSING DIAGNOSIS
Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of
knowledge
AEB B/P= 160/90, dietary sodium restrictions not being
observed, and client statements of “ I don’t watch my salt”
“It’s hard to do and I just don’t get it”.
DEVELOPMENT OF NURSING DIAGNOSIS
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Assess the patient
Review data and find actual and potential problems
Use diagnostic reasoning to identify patient needs
Arrange data in clusters or defining characteristics
Use all data available
Reach conclusions for patient needs
Determine Nursing Diagnosis according to NANDA approved diagnoses
COMPONENTS OF A NURSING DIAGNOSIS
• Diagnostic label – name of the nursing diagnosis with descriptors
• Related factors – includes factors which contribute to the problem and are
not the cause ,but are associated with it. THESE ARE NOT MEDICAL
DIAGNOSIS.
• Defining characteristics - Assessment data which supports the nursing
diagnosis
▫ Subjective data – what the patients tells you
▫ Objective data – what you observe or data obtained
• Risk factors – clues which point to potential problems
TYPES OF NURSING DIAGNOSES
• Actual
Imbalanced nutrition; less than body requirements RT chronic diarrhea,
nausea, and pain AEB height 5’5” weight 105 lbs.
• Risk
Risk for falls RT altered gait and generalized weakness
• Wellness
Family coping: potential for growth RT unexpected birth of twins.
LEGAL RAMIFICATIONS OF NURSING
DIAGNOSIS
A nurse
▫ Can only identify problems within the
scope of practice
▫ Cannot diagnose or treat medical
disease
▫ Must identify problems within his/her
scope o practice, abilities and
education
PLANNING
Third step of the Nursing Process
• This is when the nurse organizes a
nursing care plan based on the
nursing diagnoses.
• Nurse and client formulate goals
to help the client with their
problems
• Expected outcomes are identified
• Interventions (nursing orders) are
selected to aid the client reach
these goals.
PLANNING – BEGIN BY PRIORITIZING CLIENT
PROBLEMS
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Prioritize list of client’s nursing diagnoses using Maslow
Rank as high, intermediate or low
Client specific
Priorities can change
PLANNING
DEVELOPING A GOAL AND OUTCOME STATEMENT
• Goal and outcome statements
are client focused.
• Worded positively
• Measurable, specific
observable, time-limited, and
realistic
• Goal = broad statement
• Expected outcome = objective
criterion for measurement of
goal
• Utilize NOC as standard
EXAMPLE
Goal:
Client will achieve therapeutic management of disease
process….
• Outcome Statement:
AEB B/P readings of 110-120 / 70-80 and client statement of
understanding importance of dietary sodium restrictions by
day of discharge.
PLANNING- TYPES OF GOALS
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Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
A short-term goal is a statement written in objective format
demonstrating an expectation to be achieved in resolution of
the nursing diagnosis in a short period of time, usually in a
few hours or days.
A long-term goal is a statement written in objective format
demonstrating an expectation to be achieved in resolution of
the nursing diagnosis over a longer period of time, usually
over weeks or months.
GOALS ARE PATIENT-CENTERED AND
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain
HR<100
Pt will state pain level
is acceptable 6 (0-10)
PLANNING-SELECT INTERVENTIONS
• Interventions are selected and
written.
• The nurse uses clinical
judgment and professional
knowledge to select
appropriate interventions that
will aid the client in reaching
their goal.
• Interventions should be
examined for feasibility and
acceptability to the client
• Interventions should be
written clearly and
specifically.
TYPES OF INTERVENTIONS
• Independent ( Nurse initiated )- any action the nurse can
initiate without direct supervision
• Dependent ( Physician initiated )-nursing actions requiring
MD orders
• Collaborative- nursing actions performed jointly with other
health care team members
How To Write Effective And Comprehensive Nursing
Interventions
INTERVENTIONS SHOULD BE:
-consistent with the comprehensive plan of care
-concise, clear, specific and exact
-based upon scientific rationales
-individualized for that patient and that situation
-achievable within time and resource constraints
• INTERVENTIONS SHOULD INCLUDE:
-assessment data needed
-specific care or procedures to be performed
-teaching to be done for the patient and family
-independent and collaborative interventions
Case studies to perform nursing diagnosis
1. Betty Williams, a 62-year-old psychologist, is
admitted to the emergency department with
complaints of severe substernal chest pain. Mrs.
Williams states that the pain began after lunch,about
4 hours ago.She initially attributed the pain to
indigestion. She described the pain, which now
radiates to her jaw and left arm, as “really severe
heartburn.” It is accompanied by a “choking
feeling,” severe shortness of breath, and
diaphoresis.The pain is unrelieved by rest,
antacids,or three sublingual nitroglycerin tablets
(0.4 mg). Oxygen is started per nasal cannula at 5
L/min.Central and peripheral intravenous lines are
inserted. A 12-lead ECG and the following labwork
are obtained: cardiac troponins, CK and CK
isoenzymes, ABGs, CBC, and a chemistry panel.
Betty Williams, a 62-year-old…
Morphine sulfate relieves Mrs.Williams’s pain. Mrs. Williams’s
medical history includes type 2 diabetes, angina, and
hypertension. She has a 45-year history of cigarette smoking,
averaging 1.5 to 2 packs per day. Family history reveals that
Mrs.Williams’s father died at age 42 of AMI, and her paternal
grandfather died at age 65 of AMI.Mrs.Williams is taking the
following medications: tolbutamide (Orinase),
hydrochlorothiazide, and isosorbide (Isordil).
Based on ECG changes and cardiac markers, an acute anterior
MI is diagnosed.Mrs.Williams has no contraindications to
thrombolytic therapy and is deemed a good candidate.
Intravenous alteplase (t-PA, Activase) is given by bolus
followed by intravenous infusions of alteplase and heparin.
She is transferred to the coronary care unit (CCU).
Johti Singh is a 39-year-old
2. Johti Singh is a 39-year-old secretary who was admitted to the
hospital with an elevated temperature, fatigue, rapid, labored
respirations; and mild dehydration. The nursing history reveals
that Ms. Singh has had a “bad cold” for several weeks that just
wouldn’t go away. She has been dieting for several months and
skipping meals. Ms. Singh mentions that in addition to her
fulltime job as a secretary she is attending college classes two
evenings a week. She has smoked one package of cigarettes per
day since she was 18 years old. Chest x-ray confirms
pneumonia.
Johti Singh is a 39-year-old…
Physical Examination
Height: 167.6 cm (5′6′′) Weight: 54.4 kg (120 lb)
Temperature: 39.4°C (103°F)Pulse: 68 BPM
Respirations: 24/minute
Blood pressure: 118/70 mm Hg
Skin pale; cheeks flushed; chills; use of accessory
muscles; inspiratory crackles with diminished breath
sounds right base; expectorating thick, yellow sputum
Diagnostic Data Chest x-ray: right lobar infiltration
WBC: 14,000
pH: 7.49 PaCO2: 33 mm Hg HCO3–
: 20 mEq/L
PaO2: 80 mm Hg O2 sat: 88%
Eddie Kratz, age 22
3. Eddie Kratz, age 22, works as a bellman at a large hotel. For
the past year,he has shared a small apartment with Marla
Jones,who is 5 months pregnant with his child.Although he
intends to marry Ms. Jones before the baby is born, he has
continued a previous relationship with a woman named Justine
Simpson. His sexual activities with Ms. Simpson have
increased in frequency as Ms. Jones’s pregnancy has
advanced. Recently Mr. Kratz has noticed a swelling in his
groin and a sore on his penis.
ASSESSMENT
When Mr. Kratz comes to the community clinic, he is
interviewed by the nurse practitioner, Sally Morovitz. She
takes a thorough medical and sexual history, including
questions about drug use, allergies, difficulty with urination,
urinary frequency, itching or discharge from the penis, recent
sexual activities, precautions taken against infection, history of
STIs, and sexual function.
Eddie Kratz, age 22..
She determines that Mr. Kratz has been having unprotected sex
with both Ms. Jones and Ms. Simpson. He believes that Ms.
Jones is not having sex with anyone except him, but he is not
sure. Physical assessment reveals a classic syphilitic chancre
on the shaft of the penis and regional lymphadenopathy. A
specimen of exudate from the chancre is sent for dark field
examination. Ms. Morovitz discusses with Mr. Kratz the
likelihood that he has syphilis and the need to tell both Ms.
Jones and Ms. Simpson so that they can be tested and, if
necessary, treated. Ms. Morovitz also suggests that Mr. Kratz
be tested for HIV since he has been having unprotected sex
with two women, at least one of whom may be sexually active
with other partners. He agrees, and blood is drawn for an
ELISA test. Darkfield analysis of the chancre exudate
confirms the diagnosis of syphilis; the ELISA results are
negative for HIV.