Nursing process 1

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Nursing Diagnosis -Judgment or conclusion about the risk for-or actual-need/problem of the pt. (NANDA format). Nursing Diagnosis: Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures by: Sorting, clustering, analyzing information Identifying potential problems and strengths Writing statement of problem or strength Prioritizing the problems Not a medical diagnosis 3

Diagnostic Statements: Name of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by” Problem: (Risk of infection related to compromised nutrition state) (No AEB) 4

5 Functional Health Pattern (NANDA) Health Perception-Health management pattern Nutritional-Metabolic Pattern Elimination Pattern Activity-Exercise Pattern Sexuality-Reproduction Pattern Sleep-Rest Pattern Sensory-Perceptual Pattern Cognitive Pattern Role-Relationship Pattern Self-Perception-Self- Concept Pattern Coping-Stress Tolerance Pattern Value-Belief Pattern

Health Perception-Health Management Pattern Energy Field Disturbance. Altered Growth and Development. Altered Health Maintenance. Ineffective Management of Therapeutic Regimen: Individual. Health Seeking Behaviors Effective Management of Therapeutic Regimen Risk for Injury Risk for diagnoses Risk for Suffocation Risk for Poisoning Risk for Trauma Risk for Peri-operative Positioning Injury 6

Nutritional-Metabolic Pattern Decreased Adaptive Capacity: Intracranial. Ineffective Thermo regulation. Fluid Volume Deficit Fluid Volume Excess Altered Nutrition: Less than body requirements Altered Nutrition: More than body requirements Ineffective Breastfeeding Interrupted Breastfeeding Ineffective Infant Feeding Pattern Impaired Swallowing Altered Protection Impaired Tissue Integrity Altered Oral Mucous Membrane Impaired Skin Integrity. 7

Elimination Pattern Altered Bowel Elimination Constipation Colonic constipation Perceived constipation Diarrhea Bowel Incontinence Altered Urinary Elimination Patterns of Urinary Retention Total Incontinence Functional Incontinence Reflex Incontinence Urge Incontinence Stress Incontinence Risk for constipation Risk for altered urinary elimination 8

Activity- Exercise Pattern Activity Intolerance Impaired Gas Exchange in effective Airway Clearance Ineffective Breathing Pattern Decreased Adaptive Intracranial Capacity Decreased Cardiac Output Disuse syndrome Diversional Activity Deficit Impaired Home Maintenance Management Impaired Physical Mobility Dysfunctional Ventilatory Weaning Response Inability to Sustain Spontaneous Ventilation Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming, Toileting) Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and Cardiopulmonary. Renal, Gastrointestinal, Peripheral) Disorganized Infant Behavior Risk for Disorganized Infant Behavior Risk for Peripheral Neurovascular Dysfunction Risk for altered respiratory function 9

Sexuality-Reproduction Pattern Risk- Diagnoses Risk for altered sexuality pattern Actual Diagnoses Sexual Dysfunction, Altered Sexuality Patterns 10

Sleep-Rest Pattern Wellness Diagnoses: Opportunity to enhance sleep Risk Diagnoses: Risk for sleep pattern disturbance Actual Diagnosis: Sleeps Pattern Disturbance 11

Sensory-Perceptual Pattern Wellness Diagnosis: Opportunity to enhance comfort level Risk Diagnoses: Risk for pain, Risk for Aspiration Actual Diagnoses: Pain, Chronic Pain and Dysreflexia. 12

Cognitive Pattern *Actual diagnosis Acute confusion Chronic Confusion Decisional Conflict Impaired Environmental Interpretation Syndrome Knowledge Deficit (Specify) Altered Thought Processes Impaired Memory *Wellness Diagnosis: Opportunity to enhance cognition *Risk Diagnoses: Risk for altered thought processes 13

Role-Relationship Pattern *Actual Diagnoses Impaired Verbal Communication Altered Family Processes: Alcoholism Anticipatory Grieving Dysfunctional Grieving? Altered Parenting Parental Role Conflict Altered Role Performance Impaired Social Interaction: Social Isolation *Risk Diagnoses Risk for dysfunctional grieving, High risk for Loneliness. Risk for Altered Parent/Infant/Child Attachment 14

Self-Perception-Self-Concept Pattern *Actual Diagnoses Anxiety fatigue - Fear - Hopelessness- Powerlessness- Personal Identity. Disturbance - Body Image Disturbance- self Esteem Disturbance. *Risk Diagnoses Risk for hopelessness Risk for body image disturbance Risk for low self esteem 15

Coping-Stress Tolerance Pattern *Actual Diagnoses Impaired Adjustment Ineffective Individual Coping Ineffective Family Coping: Disabling Ineffective Family Coping: Compromised Ineffective Community Coping: Post-Trauma Response, Rape-Trauma Syndrome Relocation and Stress Syndrome. *Risk Diagnoses Risk for ineffective coping (individual, family, or community) Risk for self-harm Risk for self- abuse. Risk for Self-Mutilation Risk for suicide Risk for Violence; Self- directed or directed at others 16

Value-Belief Pattern *Actual Diagnosis Spiritual disturbance (distress of the human spirit). *Risk diagnosis Risk for spiritual distress *Wellness Diagnosis Potential for enhanced spiritual Well- Being 17

**PRACTICAL STEPS Perform assessment Look at the NANDA list Look for the defining characteristics or symptoms from your assessment Look for the related factors - things that cause the symptoms Make the sentence read: NANDA Diagnosis…RT…AEB… 18

Nursing Care Plan 1 *Nursing Diagnosis: ALTERED THOUGHT PROCESSES *Definition: A state in which an individual experiences a disruption in cognitive operations and activities 19

*Possible Etiologies (related to) Withdrawal into the self Underdeveloped ego; punitive superego Impaired cognition fostering negative perception of self or the environment 20

*Defining Characteristics (evidenced by) Inaccurate interpretation of environment Delusional thinking Hypovigilance (lack of attention or concentration) Altered attention span-distractibility Egocentricity Impaired ability to make decisions, problem-solve, reason Negative ruminations 21

*Goals/objectives **Short-Term Goal Patient will recognize and verbalize when interpretations of the environment are inaccurate within 1 week. **Long-Term Goal Patient will experience no delusional or distorted thinking by discharge. 22

*Interventions with Selected Rationales Convey your acceptance of pt’s need for false belief, while letting him know that you don’t share delusion. Positive response would convey to pt. that you accept the delusion as reality. Do not argue to deny belief. Use REASONABLE DOUBT as therapeutic technique: “I find that hard to believe.” An arguing with pt. or denying belief serves no useful purpose; delusional ideas are not eliminated by this approach, and development of trusting relationship may be impeded. 23

Use CONSENSUAL VALIDATION & SEEKING CLARIFICATION technique when communication reflects alteration in thinking. (Ex: “Is it that you mean? “or“ I don’t understand what you mean by that. Would you please explain?”) These techniques reveal to pt. how he is being perceived by others, while responsibility for not understanding is accepted by nurse. Reinforce & focus on reality. Talk about real events & real people. Use real situations & events to divert pt. away from long, purposeless, repetitive verbalizations of false ideas. 24

Give positive reinforcement, as pt. is able to differentiate b/w reality- & nonreality-based thinking. Positive reinforcement enhances self- esteem & encourages repetition of desirable behaviors. Teach pt. to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail. Thought stopping involves using command stop!” or loud noise (ex. hand clapping) to in­terrupt unwanted thoughts. This noise or command dis­tracts individual from undesirable thinking that often precedes undesirable emotions or behaviors. 25

Use touch cautiously, particularly if thoughts reveal ideas of persecution. Pts who are suspicious may perceive touch as threatening and may respond with aggression. 26

*Desired Patient Outcomes/Discharge Criteria 1.Pt’s thinking processes reflect accurate interpretation of environment. 2.Pt is able to recognize negative or irrational thoughts and intervene to stop their progression. 27

Nursing Care Plan 2 *Nursing Diagnosis: ALTERED NUTRITION, LESS THAN BODY REQUIREMENTS *Definition: The state in which an individual experiences an intake of nutrients insufficient to meet metabolic needs 28

*Possible Etiologies (related to) **Inability to ingest food due to: Depressed mood Loss of appetite Energy level too low to meet own nutritional needs Regression to lower level of development Ideas of self-destruction Lack of interest in food 29

*Defining Characteristics (evidenced by) Loss of weight Pale conjunctiva and mucous membranes Poor muscle tone Amenorrhea Poor skin turgor Edema of extremities Electrolyte imbalances Weakness Constipation Anemias 30

*Goals/Objectives **Short-Term Goal Patient will gain 2 Ib per week for the next 3 week. **Long-Term Goal Patient will exhibit no s&s of malnutrition by discharge (ex: electrolytes & blood counts within normal limits; steady wt gain will be demonstrated; constipation will be corrected; pt will exhibit increased energy in participation of activities). 31

*Interventions with Selected Rationales In collaboration with dietitian, determine number of calories required to provide adequate nutrition & realistic weight gain. Ensure that diet includes foods high in fiber to prevent constipation. Encourage pt to increase fluid consumption & physical exercise to promote normal bowel functioning. Depressed pts are particularly vulnerable to constipation due to psychomotor retardation. Constipation is also a common side effect of many antidepressant medications. 32

Keep strict documentation of intake, output, & calorie count. This is necessary to make accurate nutritional assessment & maintain pt’s safety. Weigh pt daily. Weight loss or gain is important assessment information. Determine pt’s likes & dislikes & collaborate with dietitian to provide favorite foods. Pt is more likely to eat foods that he particularly enjoys. 33

Ensure that pt receives small, frequent feedings, including a bedtime snack, rather than three larger meals. Large amounts of food may be objectionable, or even intolerable, to pt. Administer vitamin, mineral supplements & stool softeners or bulk extenders, as ordered. If appropriate, ask family members or significant others to bring in special foods that pt particularly enjoys. 34

Stay with pt during meals to assist as needed and to offer support and encouragement. Monitor laboratory values, & report significant changes to physician. Laboratory values provide objective data regarding nutritional status. Explain importance of adequate nutrition & fluid intake. Pt may have inadequate or inaccurate knowledge regarding contribution of good nutrition to overall wellness. 35

*Desired Patient Outcomes/Discharge Criteria 1.Patient has shown a slow, progressive weight gain dur­ing hospitalization. 2.Vital signs, blood pressure, and laboratory serum stud­ies are within normal limits. 3.Patient is able to verbalize importance of adequate nutrition and fluid intake. 36

Nursing Care Plan 3 *Nursing diagnosis: SLEEP PATTERN DISTURBANCE Definition: Disruption of sleep time which causes patient discomfort or interferes with desired lifestyle 37

*Possible Etiologies (related to) Depressed mood Repressed fears Feelings of hopelessness Fear of failure Anxiety, moderate to severe Hallucinations Delusional thinking 38

*Defining Characteristics (evidenced by) Verbal complaints of difficulty falling asleep Awakening earlier or later than desired Interrupted sleep Verbal complaints of not feeling well rested Remaining awake 30 minutes after going to bed Awakening very early in morning and being unable to go back to sleep Excessive yawning & desire to nap during day Hypersomnia; using sleep as an escape 39

*Goals/Objectives **Short-Term Goal Patient will be able to sleep 4 to 6 hours with the aid of a sleeping medication within 5 days. **Long-Terms Goal Patient will be able to fall asleep within 30 minutes of retiring, and obtain 6 to 8 hours of uninterrupted sleep each night without medication by discharge. 40

*Interventions with Selected Rationales Keep strict records of sleeping patterns. Accurate base line data are important in planning care to assist pt. with this problem. Discourage sleep during day to promote restful sleep at night. Administer antidepressant medication at bedtime so pt does not become drowsy during day. Assist with measures that may promote sleep, such as warm, non-stimulating drinks, light snacks, warm baths, backrubs. 41

Performing relaxation exercises to soft music (or other technique) may be helpful before sleep. Limit intake of caffeinated drinks (tea, coffee, coals). Caffeine is a CNS stimulant that interfere with sleep. Administer sedative meds, as ordered, to assist pt achieve sleep until normal sleep pattern is restored. For pt experiencing hypersomnia, set limits on time spent in room. Plan stimulating diversionary activities on structured, daily schedule. Explore fears & feelings that sleep is helping to suppress. 42

*Desired Patient Outcomes/Discharge Criteria 1.Patient is sleeping 6 to 8 hours per night without med­ication. 2.Patient is dealing to fall asleep within 30 minutes of retiring. 3.Patient is dealing with fears and feelings rather than es­caping from them through-excessive sleep. 43