nursing process 1. 2 nursing diagnosis -judgment or conclusion about the risk for-or...
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Nursing process
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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
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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)
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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
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Health Perception-Health Management Pattern
Energy Field Disturbance.
Altered Growth and Development.
Altered Health Maintenance.
Ineffective Management of Therapeutic Regimen: Individual.Health Seeking BehaviorsEffective Management of Therapeutic RegimenRisk for InjuryRisk for diagnosesRisk for SuffocationRisk for PoisoningRisk for TraumaRisk for Peri-operative Positioning Injury
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Nutritional-Metabolic Pattern
Decreased Adaptive Capacity: Intracranial.Ineffective Thermo regulation.Fluid Volume DeficitFluid Volume ExcessAltered Nutrition: Less than body requirementsAltered Nutrition: More than body requirementsIneffective BreastfeedingInterrupted BreastfeedingIneffective Infant Feeding Pattern Impaired SwallowingAltered ProtectionImpaired Tissue IntegrityAltered Oral Mucous MembraneImpaired Skin Integrity.
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Elimination Pattern
Altered Bowel Elimination Constipation Colonic constipationPerceived constipationDiarrheaBowel IncontinenceAltered Urinary Elimination Patterns of Urinary RetentionTotal IncontinenceFunctional IncontinenceReflex IncontinenceUrge IncontinenceStress Incontinence
Risk for constipation
Risk for altered urinary elimination
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Activity- Exercise Pattern
Activity IntoleranceImpaired Gas Exchange in effective Airway ClearanceIneffective Breathing PatternDecreased Adaptive Intracranial CapacityDecreased Cardiac OutputDisuse syndromeDiversional Activity DeficitImpaired Home Maintenance ManagementImpaired Physical MobilityDysfunctional Ventilatory Weaning ResponseInability to Sustain Spontaneous VentilationSelf-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
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Sexuality-Reproduction Pattern
Risk- Diagnoses
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
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Sleep-Rest Pattern
Wellness Diagnoses:
Opportunity to enhance sleep
Risk Diagnoses:
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleeps Pattern Disturbance
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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.
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Cognitive Pattern
*Actual diagnosisAcute confusionChronic ConfusionDecisional ConflictImpaired Environmental Interpretation SyndromeKnowledge Deficit (Specify)Altered Thought ProcessesImpaired Memory
*Wellness Diagnosis:
Opportunity to enhance cognition
*Risk Diagnoses:
Risk for altered thought processes
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Role-Relationship Pattern
*Actual DiagnosesImpaired Verbal CommunicationAltered Family Processes: AlcoholismAnticipatory GrievingDysfunctional Grieving?Altered ParentingParental Role ConflictAltered Role PerformanceImpaired Social Interaction: Social Isolation
*Risk DiagnosesRisk for dysfunctional grieving, High risk for Loneliness. Risk for Altered Parent/Infant/Child Attachment
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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
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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
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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
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**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…
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Nursing Care Plan 1
*Nursing Diagnosis: ALTERED THOUGHT PROCESSES *Definition: A state in which an individual experiences a disruption in cognitive operations and activities
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*Possible Etiologies (related to) • Withdrawal into the self• Underdeveloped ego; punitive superego• Impaired cognition fostering negative
perception of self or the environment
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*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
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*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.
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*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.
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• 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.
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• 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 in terrupt unwanted thoughts. This noise or command dis tracts individual from undesirable thinking that often precedes undesirable emotions or behaviors.
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• Use touch cautiously, particularly if thoughts reveal ideas of persecution. Pts who are suspicious may perceive touch as threatening and may respond with aggression.
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*Desired Patient Outcomes/Discharge Criteria1.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.
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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
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*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
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*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
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*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).
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*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.
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• 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.
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• 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.
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• 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.
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*Desired Patient Outcomes/Discharge Criteria1.Patient has shown a slow, progressive weight gain dur ing hospitalization.
2.Vital signs, blood pressure, and laboratory serum stud ies are within normal limits.
3.Patient is able to verbalize importance of adequate nutrition and fluid intake.
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Nursing Care Plan 3
*Nursing diagnosis: SLEEP PATTERN DISTURBANCE • Definition: Disruption of sleep time which causes
patient discomfort or interferes with desired lifestyle
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*Possible Etiologies (related to) • Depressed mood• Repressed fears• Feelings of hopelessness• Fear of failure• Anxiety, moderate to severe• Hallucinations• Delusional thinking
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*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
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*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.
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*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.
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• 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.
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*Desired Patient Outcomes/Discharge Criteria1.Patient is sleeping 6 to 8 hours per night without med ication.
2.Patient is dealing to fall asleep within 30 minutes of retiring.
3.Patient is dealing with fears and feelings rather than es caping from them through-excessive sleep.