NANDA Nursing Diagnosis

Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months.  If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain.

Definition Nursing Diagnosis for Acute Pain:

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Nursing Outcomes Client Will:

• Report pain is relieved / controlled.
• Follow prescribed pharmacological regimen.
• Verbalize methods that provide relief.
• Demonstrate use of relaxation skills and diversion activities as indicated for individual situation.

Nursing Priority Nursing Diagnosis for Acute Pain

• To assess etiology/precipitating contributory factors:
• evaluate client’s response to pain:
• assist client to explore methods for alleviation/control of pain

Sample Clinical Applications using Nursing Diagnosis for Acute Pain:

Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia

The purpose of Nursing health assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems

Data from nursing assessment can be classified as subjective and objective.

Subjective data not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. patients health history is an example of subjective data.

Objective data are overt and measurable. Objective data are referred to as signs. Nursing physical examination and diagnostic studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources come from anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective.

Assessment Process, Nursing health Assessment is an ongoing process. Every patient encounter provides you with an opportunity for assessment.

Types of Assessment

Nursing Assessments can be comprehensive or focused. A comprehensive assessment is usually the initial assessment. It is very thorough and includes a detailed health history and physical examination:

comprehensive assessment examines the patient’s overall health status.

focused assessment is problem oriented and may be the initial assessment or an ongoing assessment. focused assessment is frequently performed on an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments. Even when a focused assessment is performed, it is important to look at the entire picture. A problem in one system will affect or be affected by every other system so scan your patient from head to toe and note any changes in other systems. Look for clues or pertinent data that will help you formulate your diagnosis.

Nursing Assessment and Medical Assessment

Medical and nursing assessments should not contradict, each other in promoting the patient’s health and wellness. Often, data obtained through the nursing assessment contribute to the identification of medical problems. By working together in a collaborative relationship, nursing and medicine ensure the best possible care for patients

Health Assessment is not unique to nursing. It is also an integral part of medical practice. The assessment process Could be same for nursing and medical practice, but the outcomes different. The goal of medical practice is to diagnose and treat disease. and The goal of nursing process  is to diagnose and treat human responses to actual or potential health problems. Nursing assessment focuses on physiological and psychological responses and the psychosocial, cultural, developmental, and spiritual dimensions. It identifies patients’ responses to health problems as well as their strengths.  Optimal level of wellness is the Nursing’s aim.

Methods of Collecting Data

• Interviews
• Observation
• Physical Assessment

11 Gordon’s Functional Health Patterns

1. Health Perception Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self-Concept Pattern
8. Role-Relationship Pattern
9. Sexuality-Reproductive
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use.

• Contamination
• Disturbed energy field
• Effective therapeutic regimen management
• Health-seeking behaviors (specify)
• Ineffective community therapeutic regimen management
• Ineffective family therapeutic regimen management
• Ineffective health maintenance
• Ineffective protection
• Ineffective therapeutic regimen management
• Noncompliance (ineffective Adherence)
• Readiness for enhanced immunization status
• Readiness for enhanced therapeutic regimen management
• Risk for contamination
• Risk for infection
• Risk for injury
• Risk for perioperative positioning injury
• Risk for poisoning
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for trauma
• Risk-prone health behavior

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies.  Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

• Adult failure to thrive
• Deficient fluid volume: [isotonic]
• [Deficient fluid volume: hyper/hypotonic]
• Effective breastfeeding [Learning Need]
• Excess fluid volume
• Hyperthermia
• Hypothermia
• Imbalanced nutrition: more than body requirements
• Imbalanced nutrition: less than body requirements
• Imbalanced nutrition: risk for more than body requirements
• Impaired dentition
• Impaired oral mucous membrane
• Impaired skin integrity
• Impaired swallowing
• Impaired tissue integrity
• Ineffective breastfeeding
• Ineffective infant feeding pattern
• Ineffective thermoregulation
• Interrupted breastfeeding
• Latex allergy response
• Nausea
• Readiness for enhanced fluid balance
• Readiness for enhanced nutrition
• Risk for aspiration
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Risk for imbalanced body temperature
• Risk for impaired liver function
• Risk for impaired skin integrity
• Risk for latex allergy response
• Risk for unstable blood glucose

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin).

• Bowel incontinence
• Constipation
• Diarrhea
• Functional urinary incontinence
• Impaired urinary elimination
• Overflow urinary incontinence
• Perceived constipation
• Readiness for enhanced urinary elimination,
• Reflex urinary incontinence
• Risk for constipation
• Risk for urge urinary incontinence
• Stress urinary incontinence
• Total urinary incontinence
• Urge urinary incontinence
• [acute/chronic] Urinary retention

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

• Activity intolerance
• Autonomic dysreflexia
• Decreased cardiac output
• Decreased intracranial adaptive capacity
• Deficient diversonal activity
• Delayed growth and development
• Delayed surgical recovery
• Disorganized infant behavior
• Dysfunctional ventilatory weaning response
• Fatigue
• Impaired spontaneous ventilation
• Impaired bed mobility
• Impaired gas exchange
• Impaired home maintenance
• Impaired physical mobility
• Impaired transfer ability
• Impaired walking
• Impaired wheelchair mobility
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective tissue perfusion
• Readiness for enhanced organized infant behavior
• Readiness for enhanced self care
• Risk for delayed development
• Risk for disorganized infant behavior
• Risk for disproportionate growth
• Risk for activity intolerance
• Risk for autonomic dysreflexia
• Risk for disuse syndrome
• Sedentary lifestyle
• Self-care deficit
• Wandering

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input.

• Acute confusion
• Acute pain
• Chronic confusion
• Chronic pain
• Decisional conflict
• Deficient knowledge
• Disturbed sensory perception
• Disturbed thought processes
• Impaired environmental interpretation syndrome
• Impaired memory
• Readiness for enhanced comfort
• Readiness for enhanced decision making
• Readiness for enhanced knowledge
• Risk for acute confusion
• Unilateral neglect

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation.

• Insomnia
• Readiness for enhanced sleep
• Sleep deprivation

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth.

• Anxiety
• disturbed Body image
• Chronic low self-esteem
• Death anxiety
• Disturbed personal identity
• Fear
• Hopelessness
• Powerlessness
• Readiness for enhanced hope
• Readiness for enhanced power
• Readiness for enhanced self-concept
• Risk for compromised human dignity
• Risk for loneliness
• Risk for powerlessness
• Risk for situational low self-esteem
• Risk for [/actual] other-directed violence
• Risk for [actual/] self-directed violence
• Situational low self-esteem

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships.

• Caregiver role strain
• Chronic sorrow
• Complicated grieving
• Dysfunctional family processes: alcoholism (substance abuse)
• Grieving
• Impaired social interaction
• Impaired verbal communication
• Ineffective role performance
• Interrupted family processes
• Parental role conflict
• Readiness for enhanced communication
• Readiness for enhanced family processes
• Readiness for enhanced parenting
• Relocation stress syndrome
• Risk for caregiver role strain
• Risk for complicated grieving
• Risk for impaired parent/infant/child attachment
• Risk for relocation stress syndrome
• Social isolation

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

• Ineffective sexuality patterns
• Rape-trauma syndrome
• Sexual dysfunction

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies.

• Compromised family coping
• Defensive coping
• Disabled family coping
• Impaired adjustment
• Ineffective community coping
• Ineffective coping
• Ineffective denial
• Post-trauma syndrome
• Readiness for enhanced community coping
• Readiness for enhanced coping
• Readiness for enhanced family coping
• Risk for self-mutilation
• Risk for suicide
• Risk for post-trauma syndrome
• Self-mutilation
• Stress overload

Value-Belief Pattern it’s focused on the person’s values and beliefs.

• Impaired religiosity
• Moral distress
• Readiness for enhanced religiosity
• Readiness for enhanced spiritual well-being
• Risk for impaired religiosity
• Risk for spiritual distress
• Spiritual distress

]]> http://www.lifenurses.com/nursing-diagnosis-and-11-gordons-functional-health-patterns/feed/ 6 http://www.lifenurses.com/nursing-process/ http://www.lifenurses.com/nursing-process/#comments Tue, 10 Nov 2009 16:40:10 +0000 lifenurses http://www.lifenurses.com/?p=58

Nursing Process

The nursing process is a problem solving process consists of elements assessment, planning, implementation, and evaluation. Many a priori assumptions have been identified and studied concern the nursing process approach to patient care that includes decision making as a characteristic of the process. These assumptions are that the nursing process is a holistic, scientific, individualized, problem-solving approach with an emphasis on diagnosing.

Shore (1988) described the nursing process as “combining the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method.”

The nursing process is used by nurses every day to help patients improve their health and assist doctors in treating patients. Nursing requires the use of this process day in and day out. The process is based on theories and practices taught in nursing school. It is a form of problem solving. The nursing process is made up of a series of stages that are used to achieve the objective – the health improvement of the patient. The nursing process can stop at any stage as deemed necessary or can repeat as needed. This process is inclusive of physical health as well as the emotional aspects of patient health.

Nursing knowledge is used throughout the process to formulate changes in approach to the patient’s changing condition. During the process, nurses use this knowledge to identify problems and changes that are occurring to the patient. Caring for a patient requires the nurse to communicate with the patient to determine how they are feeling and gain the results of implemented care from the patient.

Phases of the nursing process include:

• Assessment of the patient’s needs
• Diagnosis of human response needs that nurses can deal with
• Planning of patient’s care
• Implementation of care
• Evaluation of the success of the implemented care

Nursing Process diagram

Nursing Assessment

Assessment is widely recognized as the first step in the nursing process. Nurses use assessment to determine patients actual and potential needs, the assistance patients require, and the desired outcomes to evaluate the care provided. Process includes using communication and physical assessment skills to establish a relationship and to gather needed information. The important content will vary with the patient but generally includes physical assessment, other diagnostic data, and assessment of the meaning of the health experience, quality of life, symptoms, and cultural factors that may affect health.  Communication is essential in assessment, and is both the means for nurses and patients to influence each other and the process that leads to therapeutic and supportive influences on patients’ health. Patients’ successful communication of their needs to nurses is vital to individualized care. Individualized patient care has been found to produce more favorable outcomes and to reduce the cost of health care (Attree, 2001).

Physical assessment skills are routinely included in nursing curricula. They include (a) a general survey of patients’ appearance and behaviors; (b) assessment of vital signs, temperature, pulse, respiration rates, and blood pressure; (c) assessment of height and weight; and (d) physical examination to assess patients’ structures, organs, and body systems. Physical assessment can be complete, assessing all of the persons’ organs and body systems, or modified to focus only on areas suggested by the persons’ health history or symptoms. Effective assessment is the essential basis for providing effective nursing care.

Nursing Diagnosis

Nursing diagnosis is the second step in the nursing process. It is the judgment made  about the meaning of a cluster of signs and symptoms (defining characteristics) found in the nursing assessment of the patient. Without a nursing diagnosis, a nurse is left rudderless to determine what goals should be set for the patient, what outcomes are desired, or what interventions to choose to meet the goals and resolve the nursing diagnosis.

NANDA, International (2003) defines a nursing diagnosis as a “clinical judgment about individual, family, or community responses to actual or potential health conditions/problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”. There are three types of nursing diagnoses: actual, risk, and wellness.

An actual nursing diagnosis is a human response to health conditions/problems/life processes that exist in individuals, families, or communities. An actual nursing diagnosis is “supported by defining characteristics (manifestations, signs, symptoms) that cluster in patterns of related cues or inferences” (NANDA).

A risk nursing diagnosis describes a human response that may develop in vulnerable individuals, families, or communities. It is “supported by risk factors that contribute to increased vulnerability” (NANDA).

A wellness nursing diagnosis describes a human response that indicates a readiness for enhancement in levels of wellness in the individual, family, or community (NANDA).

The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining characteristics (or cues) as appropriate.

Planning

Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care.

An intervention is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (Dochterman & Bulechek, 2004).

The Nursing Interventions Classification (NIC) is a comprehensive standardized classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice care, to primary care) and all specialties (from critical care to ambulatory care and long-term care). NIC is recognized by the American Nurses Association (ANA).

Nursing Outcomes Classification

The definition of a nursing-sensitive patient outcome is an individual, family or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention(s). Each outcome has an associated group of indicators that are used to determine patient status in relation to the outcome. (Moorhead, Johnson, & Maas, 2004).

The Nursing Outcomes Classification (NOC) is a comprehensive, research-based standard ized classification of patient/client, family, and community outcomes developed to evaluate the effects of nursing interventions across the continuum of care. An outcome is stated as a variable concept representing an individual, family, or community condition that is measurable along a continuum and responsive to nursing interventions.  The outcomes in the classification are grouped into seven domains: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge and Behavior, Perceived Health, Family Health, and Community Health. Within each domain are several classes that contain the outcomes specific to that class. The Nursing Outcomes Classification is the most comprehensive classification of nursing-sensitive patient outcomes currently available for nurses to use with individuals, families, and communities across the care continuum and in specialty practice.

Implementation

Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Legal and ethical concerns related to interventions also must be considered. Before implementing the interventions in Nursing care Plans, the nurse needs to understand the reason for doing each Nursing intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are a) consistent with the established plan of care, b) implemented in a safe and appropriate manner, c) evaluated for effectiveness, and d) documented in a timely manner.

Evaluation

Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s health record.

Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine: a) appropriateness of nursing actions, b) the need to revise interventions, c) development of new client needs, d) the need for referral to other resources, and e) the need to rearrange priorities to meet changing demands of care.

To effectively use the nursing process, the nurse must possess, and be able to apply, certain skills. Particularly important is a thorough knowledge of science and theory, as applied not only in nursing but also in other related disciplines, such as medicine and psychology.