Nursing Diagnosis

Parts of Diagnosis
Nursing Process:
DETERMINE PT. RESPONSES TO HEALTH PROBLEMS
PROVIDE CARE AT DIFFERENT LEVELS
AIMS ARE PREVENTION & SELF-CARE AS GOALS
Parts of Nursing Diagnosis:
Assessment:
COLLECTION OF DATA
ASKING QUESTIONS
OBSERVING THE PATIENT
GATHERING INFO
PATIENT HX & PHYSICAL
1.Collect Data
2. Validate Data- check it over again!
3. Data organization and Documentation
Diagnosis:
Analysis of data
Steps for Data analysis:
1. Recognize Trend
2. Compare with standards of norms
3. Make reasoned conclusion: This is Nursing DX
Clinical judgment about individual family or community, responses to actual
or potential health problems or life processes
Types:
-actual
-at risk
-wellness
Components:
-Diagnostic label: NANDA approved client related problem. Includes
descriptors
-Related to: contribute to clients problems-directs how to care for pt
Ex) Acute pain related to trauma

-Nursing assessment to support diagnostic statement: as evidenced

by-signs and symptoms pt presents with
Diagnostic label-related to factor- as evidenced by (signs and
symptoms)
Planning and Outcome Identification:
-Establish goals
-Identify outcome criteria to meet pt goals
-determine appropriate nursing goals and interventions, identify priorities of
care
Nursing care plan-Written guideline to direct delivery of holistic care, goal directed
individualized nursing care to clients.
1. Identify goals
2. formulate outcome criteria to see if goals are met- must be measurable use action
verb
Parts: Subject, action verb, performance, time frame measure through outcome
criteria
Implementation:

Do what needs to be done to solve pts problems

Identify what can be delegated
Teach client to meet own needs
Anything a nurse can and is able to do.
Types: Independent-diagnostic (monitor client), therapeutic (actions by
nurse), Teaching, referral
Component of Nursing Intervention: Action Verb, Descriptive qualifiers,
specific time frame
Evaluation:
Measure if goals have been met, and if problem has been solved.
Evaluation done on outcome criteria.
Measure of whether outcomes were met to achieve patient goals, assess if
interventions have assisted in meeting outcome criteria
Outcome criteria can be partially met
Patient Safety
Interventions to Make Home Safe:
Being able to protect pt within home environment from influences that
can increase the risk for harm

Maslows hierarchy of needs:

Pink-Physiological
Scarves-Safety and Security
Belong Love and Belonging
Everywhere-Self Esteem
So-Self Actualization
Accessorize
Basic Human Needs:
O2
Nutrition
Temp and Humidity: 65F to 75F comfort
Hypothermia-Occurs when body is 95 or lower

Core body temperature drops capillaries and cell membranes are

damaged

Abnormal shift of fluid and sodium

Hypovolemic shock and cell necrosis

Hyperthermia

Syndromes include:

Heat cramps with skeletal muscle spasms

Heat exhaustion

Due to loss of electrolytes

Sweating, headache, nausea, dizziness, fainting

Heat stroke

Hypovolemic Shock

Coma

Very high core body temperature-usually 106 if stop sweating it

means they have heat stroke

Porkolathermia-pt becomes temp of room

Types of Environmental Hazards:
1. Physical: MVAs, Poisonings, Falls-Elderly!

How to Decrease Injury:

Adequate lighting , remove obstacles, remove bathroom hazards, provide

security in homes

2. Pathogens: infection control, hand hygiene, immunization

3. Pollution: increases risk of Pulmonary disease
4. Terrorism: Bioterorism, use of biological agents to create fear or threat
Safe management of pts to decrease risk of falls:
Things that increase risks for falls:
-musculoskeletal changes
-nervous system changes
-sensory changes-lack of perception
-GU changes
-Kyphosis
Joint Commission evaluates for acute and long term care facilities
Nursing DX: RISK FOR INJURY related to impaired mobility
Interventions for pt safety:
Take into account:
developmental stage of pt
Lifestyle
Environment
How to prevent falls in hospital:

Support for heavy/debilitated patients

Side rails up unless patient independent

Safety bars in bathroom

Beds and W/C in locked position

Call bell within patient reach

Remove un-needed furniture/equipment

Patient should have footwear with traction

Check legs of assistive devices for rubber covers

Make frequent patient assessments

Restraints:

Hourly Rounding

Restraints
Human, mechanical, &/or physical device use to restrict freedom of patient
movement
Hospital Goals To be a Restraint-Free Environment
Restraint alternatives:
Position tubes, IVs, and catheters out of line of vision
-if pt wanders, eliminate stressors
Restraint assessment:
pt is hot mess->find out why-> try to change environment-> pt harming
others->apply restraint
Types of Restraints:
Patient/Bed Alarms

Alters staff of patient movement

Not considered a restraint

Pressure sensitive

Examples:

Ambularm-goes above knee, measure circumference of

knee, if greater than 45 give large, alarm goes off if pt
moves out of horizontal position

Bed Check

Side rails if all 4 are up, only if fam requests it

Wedge cushion-discourages them from getting up
Wrap around belt- tied to wheel chair, can be released by pt
Applying Restraint:
Check Orders, determine whether consent needed, explain why restraint
needed,assess skin circulation ROM, pad skin and bony prominents covered
by restraint
Belt: put pt in sitting position, put on belt, ask pt to take deep breath so dont crush
them, attach to bed frame
Extremity Restraint: Foam padding applied to wrist, ankles, tie to bed frame
Mitten Restaint: for hands
Elbow restrain: use for stop picking at IV
hook clip at upper end of sleeve, dont tie straps
If combative or compliant remove one restraint at a time.

Record: Type of restraint, time applied, reason applied

Fire Safety:
R-Rescue/ Remove- all pts
A-Alarm activate
C-Contain- close doors, turn of O2
E-Extinguish fire and evacuate
Other hazards in hospital:
Poisonings: Something related to meds, or something pt has ingested
Seizures: Document time in secs, where on body, have suction, O2 on hand,
dont put anything in Pts mouth, dont restrain pt, keep pt on side on floor when
possible, maintain airway
Radiation Hazards: never be in way of X ray
Electrical Hazards
Can be delegated by CNA.
Disaster Nursing:
Event where illness/injury exceed resource capabilities of a community or
hospital
Types:
Multi Casualty Event: Could handle most of casualties but might need another
hospital to help
Mass Casualty-trauma centers play specialized role in disaster
Emergency Management Plan:
Mitigation-determine hazard vulnerability
Preparedness-steps taken to prepare for vulnerabilities
Response-everyone has certain jobs
Recovery-steps to resume essential services and regular function
Disaster Triage Tag System

Class I: emergent Red tag

Class II: can wait a short time for care Yellow tag

Class III: Non-urgent Walking Wounded Green tag

Class IV: pts. expected not to survive Black tag

Personnel Roles & Responsibilities

Hospital Incident Command System (HICS)

Hospital Incident Commander

Primary role

Assumes overall leadership

Medical Command Physician

Determining needs for patient care

Manages use of physician specialists

Triage Officer

MD or ED RN: reviews each patient coming into hospital for

appropriate disposition

Nursing Role

All hospital staff on call

Personal Emergency Preparedness Plan

Organized model for disaster management

Personal plan for:

Child care

Pet care

Older adult care

Have available emergency contact numbers

Personal Readiness Supplies GO BAG

One for home, one for car

Include clothing; basic survival aids

One for each family member, including pets

Post Traumatic Stress Disorder (PTSD)

Psychological condition related to effects of disaster

Characteristics

Recurrent intrusive memories

Hyper arousal

Avoidance of triggers that bring on PTSD symptoms

Triggers

Sounds

Scents

Weather

Images that produce flashbacks

Symptoms

Severe anxiety

Agitation

Fight or Flight response

Higher risk for:

Stress-related illnesses

Maladaptive coping

Sleep disturbances

Alteration in relationships

Emotional Support Principles

Allow patients to ventilate their feelings

Listen & encourage relaxation

Use culturally appropriate proverbs or storytelling to help restore

coping mechanisms

Facilitate community cohesion through recreational activities &

support groups

Pain:

WHATEVER THE PERSON EXPERIENCING THE PAIN SAYS IT IS,

EXISTING WHEREVER THE PERSON SAYS IT DOES. (McCAFFERY, 1979)
SUBJECTIVE

AN UNPLEASANT SENSORY & EMOTIONAL EXPERIENCE ASSOCIATED WITH

ACTUAL OR POTENTIAL TISSUE DAMAGE, OR DESCRIBED IN TERMS OF SUCH
DAMAGE. (IASP, 1979)

Gate Control Theory:

GATE CONTROL THEORY

DEVELOPED BY MELZACK & WALL (1965)

ESTABLISHED THAT PAIN WAS NOT JUST PHYSIOLOGIC IN NATURE

GATING MECHANISM IN SPINAL CORD

MECHANISM EXISTS FOR ASCENDING & DECENDING STIMULI

NOCICEPTION
ACTIVATION OF PRIMARY AFFERENT NERVES W/ PERIPHERAL TERMINALS THAT
RESPOND DIFFERENTLY TO NOXIOUS STIMULI

FUNCTION PRIMARILY TO SENSE & TRANSMIT PAIN SIGNALS

Trasnduction: stimuli->cell damaged ->release chemicals->nocireceptors activated>AP generated
Transmission: AP continues from site of injury to spinal cord->to brainstem,
thalamus->to cortex for processing
Perception: Conscious experience of pain.
Somatosensory cortex: location of pain
Association cortex-limbic system: determines how you feel about it
When brain perceives pain, inhibitory neurotransmitters released.
Modulation:
-substances inhibit nocicepive impulses
Neuro, GABA, serotonin, endogenous opioids
How to interrupt pathway:
TRANSDUCTION

NSAIDS- decreases stimuli

LOCAL ANESTHETICS-Lidocane

ANTISEIZURE AGENTS-adjuvant with pain meds

CORTICOSTEROIDS-steriods

TRANMISSION

OPIOIDS-morphine, perkaset (oxycodone/acetmephin)

Perception:
Opiods
NSAIDS
Antidepressents
Modulation:
Trycylic Antidepressants

BASED ON UNDERLYING PATHOLOGY: PAIN SOURCES (Iggy p. 38; Table 5-5)

NOCICEPTIVE PAIN

SOMATIC

VISCERAL

NEUROPATHIC PAIN

BASED ON DURATION (Iggy; Table 5-3; p 36):

ACUTE

CHRONIC

CANCER

NON-CANCER

Neuropathic Pain: CAUSED BY DAMAGE TO NERVE CELLS OR ABNORMAL

PROCESSING OF SENSORY INPUT, sharp burning sensation
Nociceptive: Visceral- not well localized
Somatic-aching or throbbing, well localized
Hygiene:
Bed Baths: drape bath blanket over pt, take off clothes, raise hed of bed 30 to
45 degrees, place
One toel over pts stomach, one under head, form mit, wash eyes first then
head, and body
Arms-move in distal to proximal direction
-record procedure, how it was tolerated, condition of skin, participation
Medication Administration:
6 rights:
Med, Dose, PT, Route, time, document
Administer Oral Meds:
Discuss purpose, action, adverse effects
-administer in sitting or lying position
-place med cup on level surface, read eye level at meniscus
Orally Disinegrating Meds:
-place med on top of pts tongue
Buccal Meds: on side of mouth
Powdered: mix with liquids at bedside
Eye drops: when applying eye drops that have systemic effects, apply pressure on
nasolacrimal duct for 30 to 60 seconds
MDI- assess respiratory sounds, shake 5 to 6 times, tilt head back slowly 3 to 5 secs,
exhale slowly through nose
Wait 20 to 30 seconds with inhalation of same med.
Wait 2 to 5 mins of different med.

3 Types of Injections:
Intradermal: PPD testing
Tuberculin Syringe
Needle length- 3/8 to 5/8 of an in
Guage: 26 to 27
Less than .1ml per injection
5 to 15 degrees
If cant use forarm, use upperback
Subcutaneuous Injections:
Upper arm, abdomen, anterior of thighs
45 angle skinny people, 90 degree fat
to 5/8 an in
25 to 27 guage
Intramuscular1 to 1.5 in
20 to 25 gauge
90 degree dont forget to aspirate
-Ventrogluteal, vastus lateralis, deltoid
PPE:
Don: Cap, Gown, mask, goggles, gloves
Dough: gloves, goggles, gown, mask
Transfer Techniques:
Moving Pt onto stretcher:
Support the patients head as you remove the pillow.
Cross the patients arms over his or her chest.
Lower the side rails of the bed. To place a slide board under the patient,
position two nurses on the side of the bed to which the patient will be turned.
Position the third nurse on the other side of the bed. Fanfold the draw sheet on
both sides.On the count of three, turn the patient onto his or her side toward the
two nurses. Turn the patient as a single unit, with a smooth, continuous motion.
Place the slide board under the draw sheet. Gently roll the patient back onto the
slide board.
Moving Pt to wheel chair:

Position the wheelchair at a 45-degree angle to the bed on the same side on the patients stronger
side. Secure the wheels by pushing the handles forward on the locks above the wheel rims.Raise
the footrests and swing the leg rests outward on the wheelchair. You may remove the leg rests
before transferring the patient to avoid trips and falls. Sit the patient up on the side of the bed by
doing the following: With the patient supine, raise the head of the bed 30 degrees. Turn the
patient onto his or her side facing you, on the side of bed on which the patient will be sitting.
Stand opposite the patients hips. Turn diagonally, so that you face the patient and the far corner
of the foot of the bed.