Lifenurses » Nursing Theory

Nursing Diagnosis for Acute Pain

Lifenurses — Fri, 11 Jun 2010 03:45:57 +0000

NANDA Nursing Diagnosis for Acute Pain Related factors R/T trauma, injuring agents (biological, chemical, physical, psychological)

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

Nursing Assessment

lifenurses — Wed, 16 Dec 2009 18:22:24 +0000

Nursing health Assessment part of nursing process: Assessment, Nursing diagnosis, Planning, Implementation, Evaluation. Nursing health Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The Nursing assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Nursing Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient

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

Nursing Diagnosis and 11 Gordon's Functional Health Patterns

lifenurses — Fri, 27 Nov 2009 17:01:45 +0000

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

11 Gordon’s Functional Health Patterns

Health Perception Health Management Pattern
Nutritional Metabolic Pattern
Elimination Pattern
Activity Exercise Pattern
Sleep Rest Pattern
Cognitive-Perceptual Pattern
Self-Perception-Self-Concept Pattern
Role-Relationship Pattern
Sexuality-Reproductive
Coping-Stress Tolerance Pattern
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