What is Nursing Diagnosis

What is Nursing Diagnosis - And Why Should I Care?
One of the most frequent questions we get goes something like this….”My patient has Congestive Heart Failure. What is the highest priority/most likely nursing diagnosis?”
There is no right answer, because it’s the wrong question! Assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. A medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

There is no right answer, because it’s the wrong question! Assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. A medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

WHAT IS A NURSING DIAGNOSIS?
Maybe the easiest thing is to start with what a nursing diagnosis is NOT.

A nursing diagnosis is NOT:
    > Merely a label that you make up that “sounds like” it explains what you are seeing in your patient.
    > Another way of explaining the medical diagnosis, or of renaming a medical condition.
    > Something that “goes with a particular medical diagnosis”.

Nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515). 

In other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment. The medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing diagnosis.

WHY SHOULD YOU CARE?
Because an accurate nursing diagnosis based on a thorough assessment results in more effective and safer patient care. Period.

Let’s take a look at an example:

A man is admitted through the Emergency Department with a medical diagnosis of Viral Pneumonia with the following profile:

    > Age 78;
    > Dyspneic and demonstrating very shallow breathing;
    > Pulse oximeter is showing 90% on 4L of O2;
    > History of COPD.

What is the primary nursing diagnosis? 

Did you think of impaired gas exchange? Seems obvious, doesn’t it, considering the data and medical diagnosis? However, the question the nurse should ask is this: “What is causing the low SpO2?”

After completing a thorough assessment, the nurse discusses her findings with the patient, including the very shallow breathing. She learns the patient is breathing shallowly because he’s in pain. He’s suffering from posthepatic neuralgia as a result of a very painful course of shingles. In this example, the assessment-based, primary nursing diagnosis is chronic pain.

Consider these two scenarios:
Nursing Diagnosis Linked to the Medical Diagnosis
A care plan is developed to address the nursing diagnosis of impaired gas exchange, based on the medical diagnosis of Viral Pneumonia. The posthepatic neuralgia as a cause for shallow breathing is not identified and overlooked in treatment.

OR

Nursing Diagnosis Linked to Nursing Assessment and Critical Thinking
A care plan is developed to address the nursing diagnosis of chronic pain, with treatment designed to resolve this as the primary cause of the shallow breathing, and to prevent recurrence.
Which scenario provides the best patient care and outcome? What do you think the relationship is – or is not – between medical diagnosis and nursing diagnosis?

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Nursing Care Plan For Myocardial Infarction (MI)

Myocardial infarction (MI or AMI for acute myocardial infarction) is the rapid development of myocardial necrosis (die of heart cells) caused by a critical imbalance between oxygen supply and demand of the myocardium.

This is serious medical condition that sometimes called as a heart attack or a coronary thrombosis. The medical team should be take quickly action to give treatment and Nursing Care to prevent complication or die.

With myocardial infarction, reduce blood flow in one of the coronary arteries leads to myocardial ischemia, injury and necrosis. From the ECG result, with a Q-wave MI it's mean that the tissue damage extends through all myocardial layers. Non-Q-wave MI, ussually only the innermost layer is damage.

Possible causes of Myocardial infarction (MI) are : Coronary artery occlusion, Coronary spasm and Coronary stenosis. There are some risk factors to develop of Myocardial infarction such as :

• Aging


• Decrease serum HDL levels


• Diabetes Mellitus


• Drug use, specifically use of amphetamines or cocaine


• Elevated serum Triglyceride, LDL and Cholesterol levels


• Excessive intake of saturated fats, carbohydrates, or salt


• Family history of CAD


• Hypertension


• Obesity


• Post menopausal women


• Sedentary lifestyle


• Smoking


• Stress

Nursing Care Plan For Myocardial Infarction (MI):

Assessment findings on the patient with myocardial infarction are : Dyspnea, Diaphoresis, Arrhythmias, Tachicardia, Anxiety, Pallor, Hypotension, Nausea and vomiting, Elevated temperature. The specific complain from the patient is crushing substernal chest pain (may radiate to the jaw, back and arms) that unrelieved by rest or nitroglycerin (NGT) tablet.

Diagnostic evaluation patient with myocardial infarction:

• ECG show deep, wide @ wave ; elevated or depressed ST segment; and T wave inversion or cardiac arrythmias.


• Blood chemistry test result show increased creatine kinase (CK), lactate dehydrogenase (LD), lipid, and troponin T levels; increased WBC count; positive CK_MB fraction; and flipped LD1.

Nursing diagnoses for patient myocardial infarction (MI) are:

1. Chest discomfort (pain) due to an inbalance Oxygen (O2) demand supply


2. Potential Arrhythmias related to decrease cardiac output


3. Respiratory difficulties (dyspnoea) due to decrease CO


4. Anxiety & fear of death related to his condition


5. Activity intolerance related to limitations imposed


6. Potential for complications of thrombolytic therapy


7. Discharge medications, follow up & Health teachings

Planing and goals of nursing care plan;

• The patient won't develop preventable complication


• The patient will understand the necessary treatment and lifestyle changes.

Nursing Intervention for myocardial infarction (MI):

1. Monitor ECG result to detect ischemia, injury new or extended infarction, arrhythmia, and conduction defects


2. Monitor, record vital signs and hemodynamic variables to monitor response to the therapy and detects complication


3. Administer oxygen as prescribe to improve oxygen supply to the heart


4. Obtain an ECG reading during acute pain to detect myocardial ischemia, injury or infarction


5. Maintain the patient's prescribed diet to reduce fluid retention and cholesterol levels


6. Provided postoperative care if necessary to avoid postoperative complications and help the patient achieve a full recovery


7. Allay the patient's anxiety because the anxiety increase oxygen demands.

Nursing Evaluation for myocardial infarction (MI):

• The patient explains how and when to take medicine and state reportable adverse reaction


• The patient describes appropriate lifestyle changes to reduce the risk of future cardiac event


• The patient experiences no complication after heart attack (myocardial infarction)

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Nursing Care Plan For Discharge Patient

When the doctor decided that the patient already in the good condition, The nurses have to prepare what they must do or see what is the patient needs after discharge from hospital.

Nursing care pan for the discharge patient do not important for the patient only, but to the family also the nurses should explain what they can do related to patient's needs.

Plan and Outcome data :

• The patient or family's discharge planning will begin on day of admission including preparation for the education and or equipment.



• On the day of discharge, patient / family will receive verbal and written instructions concerning: Medications, Diet, Activity, Treatments, Follow up appointments, Signs and symptoms to observe for (when to contact the doctor), Care of incisions, wounds, etc.



• Other data may can help.

Nursing Care Plan For Discharge Patient

Nursing Interventions :

1. Assess needs of patient/family beginning on the day of admission and continue assessment during hospitalization.



2. Anticipated needs/services:
   
   • Respiratory equipment,
   
   
   • Hospital bed,
   
   
   • Wheel chair, Walker,
   
   
   • Home health nurse,
   
   
   • Home PT/OT/ST
   
   



3. Involve the patient/family in the discharge process.



4. Discuss with physician the discharge plan and obtain orders if needed.



5. Contact appropraite personnel with orders.



6. Provide written and verbal instructions at the patient/family's level of understanding.



7. Verbally explain instructions to patient/family prior to discharge and provide patient/family with a written copy.



8. Ascertain that patient has follow-up care arranged at discharge.


9. Provide verbal and written information on what signs and symptoms to observe and when to contact the physician.



10. Assess if any community resources should be utilized (i.e.: Home Health Nurse), and contact appropriate personnel.



11. Document all discharge teaching on Discharge Instruction Sheet and Nursing notes.



12. Other: ...

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10 Worst Medical Treatment Dangers 2013

   Advances in health technology are often a double-edged sword. They provide new ways to improve patient care but also create new opportunities for harm if design flaws aren't identified and fixed, equipment isn't properly maintained, or safety and usage protocols aren't followed. To help minimize the chance of adverse events, ECRI Institute of Plymouth Meeting, Pennsylvania, an independent nonprofit organization that studies improvement to patient care, has named the Top Ten Health Technology Hazards for 2013.
   The hazards were chosen on the basis of potential for injury or death, frequency of occurrence, how many patients are affected, notoriety in the media, and measures hospitals can take to lessen these risks.

Alarm Hazards
   Alarms on infusion pumps, ventilators, and other devices are designed to inform medical staff of a problem that needs prompt attention. But the sheer number of alarms in a hospital can overwhelm staff, leading to complacency and delayed response. Caregivers often turn down the volume of alarms.
   "If too many alarms are sounding, then all alarms start to lose their meaning," said Rob Schluth, Senior Project Officer of ECRI's Health Devices Group. "Focus on reducing audible alarms for events that don't require action on the part of the staff. Perhaps a visual indicator is sufficient for some conditions.
   "Facilities can fix problems that cause alarms to sound in the first place," he said. "For example, reinforcing skin prep techniques and replacing electrodes on a regular basis can prevent ECG leads from coming off and thus prevent leads-off alarm conditions from developing."

Medication Administration Errors Using Infusion Pumps
   Infusion devices are the subject of more adverse incident reports to the US Food and Drug Administration than any other medical technology, according to the Association for the Advancement of Medical Instrumentation. From 2005 through 2009, more than 700 deaths associated with infusion devices were reported.
   Data-entry mistakes such as mistyping information or entering it into the wrong field can be dangerous. Errors are caused by illegible orders or drugs that are improperly prepared or given to the wrong patient.
   "It's essential to build in time and resources for clinical and technical staff to determine which data flows will meet clinical needs, and then develop and refine workflows, policies, and procedures around using the integrated system," said Erin Sparnon, Senior Project Officer in ECRI's Health Devices Group

Radiation Burns From Diagnostic Radiology Procedures
   Inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Image quality typically improves as the dose increases. As a result, there is a tendency to use higher doses that are associated with greater risk to the patient. Acute reactions such as radiation burns and hair loss are relatively rare but still occur too frequently, the ECRI report states.
   Radiation-induced burns occur because the radiation beam may stay on the same area of skin for too long, said Jason Launders, Director of Operations of ECRI's Health Devices Group. "Alternative projections can reduce the incidence of burns," he said. "It is difficult to track the dose to a specific area of skin. Fluoroscopy systems keep track of the exposure time and alarm after a pre-set time. The alarms are usually ignored

Patient Data Errors in EHRs and Health IT
   Mistakes that cause one patient's data to end up in another patient's record aren't new.
   "Getting the right patient's data into the right record doesn't just happen automatically," said Rob Schluth. "It requires well-designed systems, careful implementations, and attention to workflow processes. For example, a physiologic monitor may be set up to transmit data to a patient's electronic health record. But what happens when the monitor is connected to a different patient? Or if that patient is moved to a different monitor? Correctly associating and disassociating a device with the patient's record are key steps in the process."

Devices and IT Systems That Don't Interface
   Interfaces between medical devices don't always function as intended and can allow dangerous conditions to exist. For example, ECRI found that one monitoring system didn't communicate audible or visual alarms from an interfaced ventilator to warn caregivers of a critical patient circuit disconnection.
   "Interoperability provides a pathway for good things to be shared across devices and systems," said Rob Schluth. "Patient data and test results can be transmitted without lengthy delays or the need for repeated data entry. Bad things can also travel along those pathways. A fault in one system could affect other connected systems. A pathway could be incomplete, meaning that some vital information isn't transmitted.

Air Embolism Hazards
   Intravascular air embolism is a potentially lethal complication of certain medical and surgical procedures. While relatively rare, fatal incidents do occur. The Pennsylvania Patient Safety Authority found 59 confirmed or suspected air embolism adverse events from 2004 through 2011, including 7 cases of permanent harm and 6 deaths. The largest percentage of reported events is associated with the use of central venous access devices.
   "It's hard to say whether incidents are because of complacency, because specific individuals didn't understand the risks in a particular situation, or because of an unusual combination of factors," said Rob Schluth. "These incidents illustrate that even well-known hazards warrant attention to remind caregivers of the risks, as well as steps to take to minimize them."
   ECRI recommends instituting a time-out procedure for activities that present a high embolism risk, reinforcing the appropriate procedures to follow for removing air from solution delivery systems, and requiring clinicians to trace any line to its source before connecting the line to a patient's IV access device

Using Technology for Adults on Children
   Technology designed for adult patients often needs to be used on children, in some cases because no alternatives exist. Pediatric-specific devices are slow to reach the market because of the small numbers of patients available to study, the devices' high-risk nature, and high development costs.
   Children can be placed at risk when "adult" technologies need to be used in their care. Examples include the use of inappropriate dose settings during radiology procedures, a lack of child-appropriate selection options in medication administration and computerized provider order-entry systems, and the absence of pediatric emergency supplies in care areas where children may be seen.

Dirty Endoscopes and Surgical Instruments
   Cross-contamination hazards that occur when flexible endoscopes aren't properly reprocessed have been on ECRI's top 10 hazards list for years. ECRI wants facilities to address the reprocessing function more broadly in their patient safety efforts. Numerous reported incidents involved "dirty" instruments being processed for use in surgery and other medical procedures. The contamination was often not detected until after the item had been used on a patient.
   "It's important that reprocessing staff be taught proper protocols," said Rob Schluth. "It is helpful to explain why each step is needed, describing exactly what can happen if a step is skipped. Frontline workers need to be aware of the hazards.
   "Look at the root causes for any failure. Is the issue that the staff doesn't know the correct procedure, or are other factors contributing to the problem?" he asked. "For example, is sufficient time allotted to perform the procedure correctly, or does staff feel pressured to take short cuts? Are the necessary supplies available? Are the instructions unclear or out of date? Is reprocessing too difficult because the device wasn't adequately precleaned in the procedure room?"

Texting While Performing Surgical Procedures
   Interruptions from pagers and other devices have long been part of medicine, but smartphones and other mobile devices now make it easier for clinicians to be interrupted for non-work-related reasons -- and to make their own interruptions.
   Half of the respondents to a 2010 survey of perfusionists acknowledged texting during heart-lung bypass procedures, with 15% further admitting that they accessed the Internet and 3% reporting that they visited social networking sites during procedures. Additional distractions occur more frequently than people think, exposing patients to danger.
   "These devices can be used for any number of clinically useful purposes," said Rob Schluth. "But they can divert the caregiver's attention away from the patient or the task at hand. Receiving personal text messages or using the devices to check social media during patient care are questionable behaviors. Even the act of focusing on the device rather than observing the patient, or listening to information being exchanged, can affect the quality of care."

Surgical Fires
   There are an estimated 600 surgical fires per year. Although that's only a miniscule percentage of the millions of operations performed, these almost entirely preventable events still occur too frequently. The hazard remains on ECRI's top 10 list because of the potential devastating consequences, including disfigurement and death.
   "A quick assessment of the potential fire risks before the start of a procedure can help staff guard against bringing together the elements of the fire triangle -- oxidizers, ignition sources, and fuel," said Rob Schluth.

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