Nursing Process and NANDA Diagnoses

Risk for Infection

Patients undergoing surgery, those with immune system issues, or those with open wounds are at risk for infection. Being in a hospital environment also increases this risk. Post-surgical patients are also likely to experience pain.

NANDA Diagnoses

Nursing diagnoses are approved and regularly updated. Nurses can utilize a list of NANDA diagnoses separated by systems, such as cardiac, respiratory, safety, neurological, genitourinary, and intestinal. Examples include:

• Constipation (GI system)
• Bladder infection (GU system)
• Cognitive changes (Neurological system)

Pain and anxiety are the most commonly used nursing diagnoses in hospitalized patients. Addressing pain can sometimes be a priority, depending on its severity. However, issues such as ineffective breathing or hemorrhaging take precedence.

The NANDA list covers areas such as elimination, intestinal, gastrointestinal infection, activity, rest, sleep, and energy. Nursing students should familiarize themselves with this list for clinical care plans, where they identify two diagnoses based on patient assessment.

Prioritization and Planning

Prioritizing the issues that we've assessed is critical. Hemorrhage and breathing issues are top priorities, followed by pain or elimination needs. The planning stage involves identifying goals and desired outcomes.

For example, if a patient reports pain as an 8 out of 10, the diagnosis is acute pain related to the surgery, as evidenced by the patient's statement. The intervention would be administering pain medication, with the goal of decreasing the patient's pain within 30 minutes.

This process is analogous to everyday situations. For instance, assessing an empty cupboard leads to a diagnosis of lack of food. The plan involves going to the market (intervention), with the outcome of having full cupboards by a specific time.

The nursing process aims to standardize care, ensuring every patient receives consistent quality. This involves defining and documenting each step.

Implementation and Interventions

Implementation involves carrying out interventions. Non-pharmacological interventions for pain include:

• Ice
• Heat
• Counter pressure
• Massage

For breathing difficulties, non-pharmacological interventions include sitting the patient up in bed. Oxygen is a medication that requires an order unless there's a standing order because excessive oxygen can be harmful.

During tests, it's important to stay focused on learned material and avoid overthinking hypothetical scenarios. Every test question typically has one answer choice that is completely unrelated to the problem.

Evaluation

Evaluation involves assessing whether the goals and interventions were effective. For example, if a patient's pain decreases from 8 to 2 out of 10 after morphine administration, the intervention was successful.

Similarly, if a patient's difficulty breathing improves with the head of the bed elevated and oxygen administered, as evidenced by an increase in pulse oximetry from 90% to 98%, the interventions were effective.

Assessment: Data Collection

Assessment involves collecting, validating, organizing, and recording data. In electronic health records, normal findings are noted, while abnormal findings, such as crackling lungs, are documented in detail.

Abnormal findings require intervention, while normal findings require continued monitoring. However, most hospitalized patients will have at least some pain due to surgery or other conditions.

Diagnosis: Identifying the Problem

A diagnosis is a statement of the problem identified by the nurse. It's an issue that can be prevented or treated independently. A health problem requires nursing intervention to prevent and treat the disease, framed in terms of the patient's physical, emotional, interpersonal, social, or spiritual response.

It is crucial that the nursing diagnosis is not a restatement of the medical diagnosis. For example, instead of saying "pneumonia" as the nursing diagnosis, one should say "ineffective breathing pattern" or a "perfusion problem."

The medical diagnosis relates to a system (e.g., respiratory for pneumonia), while the nursing diagnosis is based on the symptoms found during assessment. NANDA is a clinical judgment about the patient's experiences and responses to health problems.

Assessment is vital before diagnosis, reporting to a physician, administering medication, or any other intervention. Accurate assessment becomes more efficient with experience.

Neurological exams are not necessary for healthy patients; instead, a quick assessment of cognitive and neurological normalcy suffices. Diagnostic reasoning involves tailoring assessments based on the patient's condition. For example, a normal assessment is geared towards a normal assessment for a patient in labor, while in the ICU a complete neurological evaluation may be undertaken for a comatose patient.

The assessment should change based on the patient's diagnosis and overall health. Conclusions about the client's health status are verified through health history and subjective data. It is important to verify problems with the patient by communicating with them and not making assumptions.

Data Analysis and Interpretation

Analyzing and interpreting data involves identifying significant data, clustering cues into related categories, and identifying data gaps and inconsistencies. This helps in drawing conclusions about the patient's health status and identifying the etiology of the problem. Prioritizing the problems includes checking the NANDA list to choose the right diagnosis and remembering that ABC (Airway, Breathing, Circulation) always takes priority.

Risk for fall is a high priority diagnosis because of the potential consequences. However, this diagnosis will most likely be replaced by another diagnosis as their status improves. It is therefore crucial to regularly reassess the patient, and update the care chart accordingly.

Types of Nursing Diagnoses

Types include actual, potential, possible, and wellness diagnoses:

• Actual: Representing existing problems.
• Potential: Representing risks for potential problems from arising
• Wellness: Readiness to learn or improved conditions.

The choice depends on the presence of signs and symptoms along with risk factors. An algorithm exists to inform the selection of the appropriate diagnosis.

Components of a Nursing Diagnosis

A typical diagnosis includes:

• Diagnostic Label: Refers to the standardized name describing the nursing diagnosis.
• Related To: Refers to the underlying cause or contributing factor to the problem.
• As Evidenced By: Refers to the signs and symptoms observed.

For example: Acute pain related to surgical incision as evidenced by a pain score of 8/10.

Students were told not to worry should they struggle with this, as with experience it will become more clear.

Nursing diagnoses facilitate communication among healthcare professionals regarding patient goals. However, educators may be imperfect, but the aim is to successfully get a nursing degree.

Writing Quality Diagnoses

• Do not rely solely on the NANDA label.
• Include both the problem and the etiology.
• Ensure the etiology does not restate the problem.
• Avoid using medical diagnoses and treatments as etiological factors; instead, use "secondary to."
• Write clearly, concisely, descriptively, and specifically.
• State the problem as a patient response.
• Use nonjudgmental language and avoid legally questionable language.
• Ensure the diagnosis is logically consistent with the assessment findings.

Prioritization of Care

• First Level Priority: Emergent, life-threatening conditions (loss of life or limb).
• Second Level Priority: Not a direct threat to life but may cause destructive physical or emotional changes.
• Third Level Priority: Support health but not urgent.

Anaphylaxis questions always require consideration based on emergent, life-threatening issues.

Tachycardia (elevated pulse) is not to be ignored because it is an early sign of hemorrhage. Late signs includes blood pressure levels of 60/40, requiring swift action since in that state the patient may be in dire condition.

Collaborative Problems

Nursing diagnoses relate to outcomes and interventions. The problem suggests the desired outcome, and the etiology suggests the interventions.

Planning: Creating a Care Plan

Planning involves selecting standardized care plans, creating individualized care plans, or identifying outcomes and goals.

A written patient care plan is important because it:

• Serves as a central source of information.
• Ensures care is completed.
• Provides continuity of care.
• Promotes efficient use of nursing efforts.
• Provides a guide for assessing and charting.
• Meets requirements of accrediting agencies.

Types of care plans include preprinted standardized plans, computerized plans, and individualized plans, balancing standardized medicine with individualized care based on patient factors.

Goals are changes in the client's health status that are hoped to be achieved. Nursing-sensitive outcomes can be influenced by nursing interventions.

• Short-term goals: Achieved within a few hours.
• Long-term goals: Achieved over a longer period, such as during hospitalization.

Interventions: Implementing the Plan

Nursing interventions are classified as part of NANDA and linked to diagnoses and outcomes. A typical nursing intervention consists of the label (diagnosis), the definition (written-out diagnosis), and a list of specific activities.

Example:

• Diagnosis: Ineffective breathing pattern related to alveolar capillary membrane changes as evidenced by use of accessory muscles, decreased \text{O}_2 saturations, dyspnea, and a respiratory rate of 22.
• Outcome(s): Respiratory rate will remain between 18 and 20, oxygen saturation will be equal to or greater than 95%, absence of accessory muscle usage, patient verbalizes ease of breathing.
• Interventions: Monitoring respiratory rate and depth every two hours, assessing lung sounds, monitoring oxygen saturation, administering supplemental oxygen, reducing anxiety through calm communication and reduced stimuli, and positioning to encourage better breathing.

Evaluation: Assessing Progress

The final step in the nursing process assesses the client's progress toward goals. Priorities and interventions change as the patient progresses toward discharge.

The trend of labs and the general condition of the patient should improve, indicating that the interventions are working. The effectiveness of care plans, quality of care, and adherence to standards are all evaluated.

Review the outcomes, judge their achievement, record them. Additionally, assess the collaborative problems such as follow-up procedures and doctor's appointments.

Simplified, videos can be a very effective method of learning the concepts presented in this chapter.