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 client’s 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
Due to loss of electrolytes
Heat exhaustion
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