Nursing Diagnosis, Planning Nursing Care

1. Nursing Diagnosis, Planning Nursing Care

2. 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

3. 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

4. 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

5. 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...

6. 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

7. 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

8. NURSING DIAGNOSIS • Actual or potential health problems that can be prevented or resolved by independent nursing interventions

9. NURSING /MEDICAL DIAGNOSIS Nursing Diagnosis • Fear • Altered health maintenance • Knowledge deficit • Pain • Altered tissue perfusion Medical Diagnosis • Myocardial infarction

10. 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”.

11. DEVELOPMENT OF NURSING DIAGNOSIS • 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

12. 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

13. TYPES OF NURSING DIAGNOSES • ActualImbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs. • RiskRisk for falls RT altered gait and generalized weakness • WellnessFamily coping: potential for growth RT unexpected birth of twins.

14. 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

15. 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.

16. PLANNING – BEGIN BY PRIORITIZING CLIENT PROBLEMS • Prioritize list of client’s nursing diagnoses using Maslow • Rank as high, intermediate or low • Client specific • Priorities can change

17. PLANNINGDEVELOPING 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

18. 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.

19. PLANNING- TYPES OF GOALS • Short term goals • Long term goals • Cognitive goals • Psychomotor goals • Affective goals

20. 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.

21. 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)

22. 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.

23. 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

24. 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

25. 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.

26. 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).

27. 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.

28. 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%

29. 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.

30. 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.