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Nursing Diagnoses VS Medical Diagnoses

What are nursing diagnoses and how do they differ from medical diagnoses? How do nursing diagnoses fit in the nursing process and why are they so critical to safe, effective nursing care?
nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes. medical diagnosis, on the other hand, is the identification of a disease based on its signs and symptoms.
The professional practice of nursing is the diagnosing and treatment of these basic human responses. Nurses need a common language to describe the human responses of individuals, families, and communities to health threats. NANDA strives to classify in a scientific manner these basic human responses.
Nursing diagnoses are based on assessment data and are classified under the concepts of ingestion, digestion, absorption, metabolism, urinary/gastrointestinal elimination, sleep/rest, activity/exercises, energy balance, sexuality, post trauma responses, comfort, and growth and development.
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Diagnosis – Second Step in the Nursing Process

Definition 

  • Is the 2nd step of the nursing process.
  • the process of reasoning or the clinical act of identifying problems


Purpose 

  • 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.


Nursing Diagnosis 

  • 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

Student Resources: Nursing Diagnoses

Image Courtesy: http://allnurses.com
Three Activities in Diagnosing: 

  1. Data Analysis
  2. Problem Identification
  3. Formulation of Nursing Diagnosis


Characteristics of Nursing Diagnosis 

  1. It states a clear and concise health problem.
  2. It is derived from existing evidences about the client.
  3. It is potentially amenable to nursing therapy.
  4. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE) 

  1. Problem statement/diagnostic label/definition = P
  2. Etiology/related factors/causes = E
  3. Defining characteristics/signs and symptoms = S
  •   *Therefore may be written as 2-Part or a 3-Part statement.

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Documenting and Reporting

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

Image: http://magazine.nursing.jhu.edu

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Purpose of Charting: 

To make record of—

  1. The significant observation of the patient’s condition both mental and physical.
  2. The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
  3. The incident which might have some bearing on the patient’s condition.

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Communication in Nursing

Communication 

  1. Is the means to establish a helping-healing relationship. All behavior communication influences behavior.
  2. Communication is essential to the nurse-patient relationship for the following reasons:
  3. Is the vehicle for establishing a therapeutic relationship.
  4. 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 

  1. Sender – is the person who encodes and delivers the message
  2. Messages – is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
  3. Receiver – is the person who receives the decodes the message.
  4. Feedback – is the message returned by the receiver. It indicates whether the meaning of the sender’s message was understood.

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Communication

Definition

  • 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

Referent

  • Or stimulus motivates a person to communicate with another. It may be an object, emotion, idea or act.

Sender

  • Also called the encoder, is the person who initiates the interpersonal communication or message

Message

  • The information that is sent or expressed by the sender.

Channels

  • It means, conveying messages such as through visual, auditory and tactile senses.

Receiver

  • Also called the decoder, is the person to whom the message is sent

Feedback

  • Helps to reveal whether the meaning of the message is received
 


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Changing a Central Line Catheter Dressing

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:

  • place folded 2×2 over insertion site to include sutures to prevent the tape/ elastoplast from sticking to the line and sutures.
  • paint around the edges of the gauze with skin prep and allow to dry.
  • cut elastoplast to fit over insertion site and sutures.
  • apply elastoplast and secure edges with tape.

b. Occlusive Dressing- (Tegaderm):

  • do not use 2×2
  • skin prep is optional
  • apply occlusive dressing according to manufacturer’s guidelines.
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.

Changing and flushing a central line access cap

  • 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

Source:

http://www.rnpedia.com/home/notes/fundamentals-of-nursing-notes/changing-a-central-line-catheter-dressing

Caring

Definition

  • 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

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Bowel Elimination

The Large Intestine 

  • Primary organ of bowel elimination
  • Extends from the ileocecal valve to the anus
Functions 
  • 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 

  1. Age
  2. Diet
  3. Position
  4. Pregnancy
  5. Fluid Intake
  6. Activity
  7. Psychological
  8. Personal Habits
  9. Pain
  10. Medications
  11. Surgery/Anesthesia

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Blood Transfusion Therapy

Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).Blood components include:

  1. 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.
  2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
  3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
  4. Granulocytes ( basophils, eosinophils, and neutrophils )
  5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
  6. 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.
  7. Albumin, a plasma protein.
  8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
  9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
  10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
  11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

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