Nursing Diagnosis

Nursing Diagnosis

• A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes
• Provides basis for nursing interventions
• 4 types:
  • Actual (3-part statement)
  • Risk/High-risk
  • Health promotion and wellness (readiness for enhanced)
  • Syndrome

Common Nursing Diagnoses

• Pain related to hesitancy in taking prescribed pain medication because of fear of addiction
• Acute confusion related to adverse reaction to medication
• Ineffective health maintenance related to not receiving recommended preventive care
• Deficient knowledge related to effects of anticoagulant medication on clotting mechanism
• Noncompliance related to forgetfulness
• Risk for injury related to side effects of drug
• Ineffective self-health management related to lack of finances or health care coverage to purchase medications
• Readiness for enhanced knowledge related to medication schedule and medication side effects

Planning

• Formulated to meet patient’s needs
• Patient goals not nursing goals
• SMART
• Maslow’s Hierarchy of Needs
• NCP to critical pathways
• Standardized, automated care plan with standards, interventions, goals, and outcome
• Evidence-based medicine

Planning - Pharmacology

• Identification of therapeutic intent of medication
• Identification of common adverse effects that require education
• Identification of dosage and route of administration
• Scheduling of administration
• Teaching patient to keep written records
• Education as needed about techniques of self-administration

Implementation

• Carrying out plan of care
• Meeting the needs of the patient, providing safety, monitoring for complications, ongoing-assessment
• 3 actions:
  • Dependent
  • Interdependent
  • Independent

Implementation - Pharmacology

• Selection of correct supplies
• Verification of aspects of the medication
• Premedication assessment
• Administration
• Education (noncompliance)
• Inclusion of a family member:
  • Act as a psychological support
  • Actually administer all or part of therapy
  • Observe effectiveness and S/E
  • Implement other changes or preparation

Evaluation

• Determining whether expected outcomes were met
• Involves patient and SO
• Provides means for input of new significant data

Evaluation - Pharmacology

• On-going assessment to patient’s response to medications, signs and symptoms, therapeutic effects

Patient Education

• Domains of learning:
  • Cognitive domain
  • Affective domain
  • Psychomotor domain

Cognitive Domain

• Thinking portion and incorporation of experiences
• Formulating new meanings

Affective Domain

• Feelings and beliefs on what has been understood
• Value of medication

Psychomotor Domain

• Learning of new procedure or skill
• Demonstration of procedure

Patient Teaching

• General
• Side effects
• Self-administration
• Diet
• Cultural considerations

Principles of Teaching and Learning

• Carries legal implications
• Basic patient right
• Involves establishing goals with patient and family
• Focus the learning
• Consider learning styles
• Organize teaching sessions and materials (teach back)
• Motivates individual to learn
• Determine readiness to learn
• Space the content
• Use repetition to enhance learning
• Consider education level
• Incorporate culture and ethnic diversity

Strategies for Health Teaching

• Teach appropriate use of the internet
• Encourage adherence
• Communicate goals and expectations

Discharge Planning and Teaching

• Summary statement of patient’s unmet needs
• Explain proper method of taking prescribed medication
• Stress need of punctuality
• Teach storage of medication
• Provide written instructions (large bold letters)
• Identify anticipated therapeutic response
• Instruct how to monitor response to drugs
• Give list of signs and symptoms

Medication Administration and Safety

• Legal and ethical considerations
• A privilege, not a right which includes accountability

Patient Charts

• Chart or electronic medical record
• Primary source of information
• Communication link
• Legal document
• Content:
  • Summary sheet/info
  • Consent forms
  • Medical order sheet
  • History & physical examination
  • Progress notes
  • Nurses’ notes
  • Laboratory tests record
  • Graphic record
  • Flow sheets
  • Consultation reports
  • Medication administration record/medication profile
  • Patient education record
• “If you didn’t chart it, it didn’t happen”
• “If not documented, it is not done”

Nursing Process and Patient-Centered Care

• Foundation for nursing practice
• Problem-solving approach
• On-going cyclic process that responds to changing requirements of the patient
• Steps:
  • Assessment
  • Nursing Diagnosis
  • Planning
  • Implementation
  • Evaluation

Assessment

• Admission until discharge
• Problem-identifying
• Collecting data
• Sources:
  • Primary source
  • Secondary source
  • Tertiary source

Nursing Diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. It provides a basis for nursing interventions and has four levels: actual, risk/high-risk, health promotion, and syndrome.