- Is the 2nd step of the nursing process.
- the process of reasoning or the clinical act of identifying problems
- To identify health care needs and prepare a Nursing Diagnosis.
- To diagnose in nursing
- It means to analyze assessment information and derive meaning from this analysis.
- Is a statement of a client’s potential or actual health problem resulting from analysis of data.
- Is a statement of client’s potential or actual alterations/changes in his health status.
- A statement that describes a client’s actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes.
- Is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
- It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health problems that can be resolves/prevented by collaborative and independent nursing interventions.
- Analysis – separation into components or the breaking down of the whole into its parts.
- Synthesis – the putting together of parts into whole
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Three Activities in Diagnosing:
- Data Analysis
- Problem Identification
- Formulation of Nursing Diagnosis
Characteristics of Nursing Diagnosis
- It states a clear and concise health problem.
- It is derived from existing evidences about the client.
- It is potentially amenable to nursing therapy.
- It is the basis for planning and carrying out nursing care.
Components of A nursing diagnosis (PES or PE)
- Problem statement/diagnostic label/definition = P
- Etiology/related factors/causes = E
- Defining characteristics/signs and symptoms = S
- *Therefore may be written as 2-Part or a 3-Part statement.
Guidelines for Good Documentation and Reporting
1. Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells
2. Accuracy – information must be accurate so that health team members have confidence in it
3. Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand
4. Currentness – ongoing decisions about care must be based on currently reported information.
At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status
5. Organization – the nurse communicate in a logical format or order
6. Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed
Purpose of Charting:
To make record of—
- The significant observation of the patient’s condition both mental and physical.
- The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
- The incident which might have some bearing on the patient’s condition.
- Is the means to establish a helping-healing relationship. All behavior communication influences behavior.
- Communication is essential to the nurse-patient relationship for the following reasons:
- Is the vehicle for establishing a therapeutic relationship.
- It the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.
Basic Elements of the Communication Process
- Sender – is the person who encodes and delivers the message
- Messages – is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
- Receiver – is the person who receives the decodes the message.
- Feedback – is the message returned by the receiver. It indicates whether the meaning of the sender’s message was understood.
- It is the process of exchanging information or feelings between two or more people. It is a basic component of human relationship, including nursing.
The Communication process
- Or stimulus motivates a person to communicate with another. It may be an object, emotion, idea or act.
- Also called the encoder, is the person who initiates the interpersonal communication or message
- The information that is sent or expressed by the sender.
- It means, conveying messages such as through visual, auditory and tactile senses.
- Also called the decoder, is the person to whom the message is sent
- Helps to reveal whether the meaning of the message is received
Sample Central Line Dressing Checklist
|Critical Performance Elements||YES||NO|
|1. Gather all necessary equipment: roll of tape, label, and central line line dressing kit.|
|2. Wash hands. Explain procedure to the patient and/or significant others. Check for providone-iodine or tape allergy.|
|3. Organize supplies and equipment at bedside to decrease the amount of time that site is open to air.|
|4. *** Open central line kit. Don mask. (Don gown if soiling is likely).|
|5. Place patient in supine position with head turned away from catheter insertion site to decrease potential for contamination by patient’s secretions. Place a mask over the patient’s mouth and nose or sterile drape over ventilated or trached patient.|
|6. *** Don a pair of clean gloves.|
|7. Remove present dressing carefully to minimize trauma and prevent accidental dislodgment of catheter. Discard soiled dressing in proper trash receptacle.|
|8. Visually inspect the skin and catheter site for signs of infection, leakage, or other mechanical problems.|
|9. *** Remove soiled gloves and don sterile gloves.|
|10. *** Working in a circular motion from insertion site outward to edge of dressing border cleanse skin, insertion site, and distal portion of catheter with :a. Providone-iodine scrub swabsticks x 3 – to remove bacteria and fungi.
b. Alcohol swabsticks x 3 – to remove the betadine scrub.
c. Betadine solution swabsticks x 3 to cover a 3″ x 6″ area from site to periphery- to provide protective barrier against pathogens. Blot excess or pooled solution. Allow to dry.
*** For patients with IODINE ALLERGY- If 4% chlorhexidine is used, remove it with alcohol swabs after a two to five minute dwell time.
|11. If a tubing change is necessary:a. Instruct the patient to perform Valsalva maneuver or hold his/her breath (or immediately after a ventilator delivers a breath).
b. Quickly disconnect and reconnect the IV tubing ensuring secure junction.
|12. *** Dressing- may use elastoplast or occlusive dressing as follows:a. Elastoplast:
b. Occlusive Dressing- (Tegaderm):
|13. *** Loop and secure IV tubing to dressing and arm or chest.|
|14. *** Label dressing with time, date of dressing change and insertion, and initials.|
|15. Discard supplies used. Wash hands.|
|17. *** Document the dressing change, the condition of the insertion site on nursing note and flow sheet. Document any problems encountered in nursing progress notes on.|
|NOTE: If 2×2 gauze used after initial insertion under occlusive (Tegaderm) dressing, dressing must be changed in 24 hours.|
*** Must perform these critical elements for successful completion.
- Check client’s chart and care plan to determine time of last access cap change.
- Identify client
- Explain procedure to client and provide privacy
- Gather equipment
- Wash your hand and don gloves
- Repeat procedure with the remaining access caps
- Remove gloves and wash hands
- Central to all helping professions, and enables persons to create meaning in their lives.
- Means that people, relationships, and things matter
Nursing Theories of Caring
Culture Care Diversity and Universality Theory (Leininger)
- Based on transcultural nursing model
- Transcultural nursing: a learned branch of nursing that focuses on the comparative study & analysis of cultures as they apply to nursing and health-illness practices, beliefs, and values
- Goal of Transcultural Nursing: to provide care that is congruent with cultural values, beliefs, and practices
- Cultures exhibit both diversity and universality
- Diversity – perceiving, knowing, and practicing care in different ways
- Universality – commonalities of care
- Fundamental Theory Aspects – culture, care, cultural care, world view, folk health or well-being systems
- Primary organ of bowel elimination
- Extends from the ileocecal valve to the anus
- Completion of absorption of H2O, Nutrients (chyme from sm. intest. – 1-1.5 L)
- Manufacture of some vitamins
- Formation of feces
- Expulsion of feces from the body
The Small and Large Intestines
Process of Peristalsis
- Peristalsis is under control of nervous system
- Contractions occur every 3 to 12 minutes
- Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
- One-third to one-half of food waste is excreted in stool within 24 hours
Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.
Factors that influence Bowel Elimination
- Fluid Intake
- Personal Habits
- Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
- Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
- Platelets, either HLA (human leukocyte antigen) matched or unmatched.
- Granulocytes ( basophils, eosinophils, and neutrophils )
- Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
- Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation.
- Albumin, a plasma protein.
- Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
- Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
- Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
- Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.