Nursing Diagnosis 2014

i'm pam newton and i am a sim coordinatoractually here at mohave community college however the nursing students and i have beentalking for some time and i have been doing a presentation for them on a regular basisthat they keep asking me to do over and over again i did not realize how this might besomething of interest and beneficial to nursing students until i had them asking over andover again and what i'm talking about is a presentation on nursing process i have recentlybecome of aware of how much folks that are not medical or in the medical field i shouldsay or the nursing field that it is of interest to them as well because what it is nursingprocesses is a thought process a sort of trouble shooting thought process and it’s how nursesthink we came up with nursing process as a

way to put it down on paper and pencil quitesome time ago and well actually let me talk about the history of it just a little it'sactually been around since as long as nursing has been around, it’s a way we think andour care of patients so as long as nurses have been caring for patients it’s beenthere it has evolved over the years but the basics have never changed if you ever geta chance to read anything about florence nightingale she was not necessarily the founder of nursingbut she was the first to actually put it down where it could be read by others and she attemptedto help other folks understand how nurses thought and she was also communicating tonursing students this is how we think this is what we need to do and so-fourth ok sothat being said it’s been around for a very

long time we labeled it sometime ago as nursingprocess and trying to move it to a more solidified kind of thing over the years so that it’sin textbooks and things for nursing students the problem is, in doing that we took it outof our heads and tried to put it on paper and it became this i don't know somewhat morecomplicated thing not that it is it really isn't we are trying to teach a thought processso students are often when they come in and they have not been exposed to this thoughtprocess prior to being in a nursing program are often very confused and so once it's presentedin a very basic fashion and somewhat related to things that they already know it becomesclear and i hope, hopefully after you have seen this you have an understanding as welli thought of this by the way about 8 years

ago it’s a compilation of all the experiencesthat i've had as a nurse and also the experiences that i have had with students the studentsthat i have had over the last 8 years are the ones that have taught me how to teachthis that in itself is a long story but it’s a very fruitful process that's one of thereason i can do what i do today and i hope very clearly so i'm going to start and nursingprocess as nurses know and most nursing students, is assessment, nursing diagnosis, treatmentinterventions, goals, evaluations, and then labs/tests and medications the assessmenti have done and i have seen this done in other places this is not unique to me but it madesense to me and it seems to make sense to students to divide this into the normals andthe abnormals and this morning we are going

to be talking about congestive heart failureto begin with so what would be things that you expect to find abnormal and normal ina congestive heart failure patient now abnormal would be edema shortness of breath normalswould be skin except in the course of very advanced congestive heart failure patients,gi you’re not going to find many problems in their gi system or their gu system howeveryou might find that they have a dry cough and they might have crackles in their lungsso now we have this information down we can focus on the abnormal and leave the normalsaside because the abnormals are what we are going to address with our nursing processnurses and supporting body processes need to figure out what's wrong to begin with tothen be able to figure out what they need

to focus on and that's what a nursing diagnosisdoes the heading in this case and by the way nursing diagnosis are four parts heading,related to, as evidence by, and secondary to now i know that there are many nursinginstructors and nursing schools out there that don't include the secondary to and therelated to is done in various fashions however the way that i address this with studentsand i am trying to address to folks that do not have a medical background need to haveall four pieces and you will see why heading would be let's say decreased cardiac outputand that certainty happens in a congestive heart failure patient is not the diagnosisof decreased cardiac output so related to now has to be on a tissue level and the reasonthat i say that is because the thinking on

a tissue level in other words cells>tissues>organs>systemsfocusing on the tissue level for our related to helps clarify what we are trying to dowith this nursing diagnosis so on a tissue level what’s going on with the decreasedcardiac output well of course it is impaired or weakened and lets just put weak cardiacmuscle so we have decreased cardiac output, weak cardiac muscle, as evidence by, and i knowas evidence by there is other ways of stating that but basically what we are talking aboutis the signs and symptoms that are observed by in our case the nursing students so wewould let’s just say dry cough and then our secondary to is always the medical diagnosis and in this case it is congestiveheart failure or chf so that is all of the pieces and parts of the nursing diagnosisand why we approach which one the way we do

now interventions or treatments for folksthat aren't sure of the word intervention interventions is what we do what does thenurse do the nurse has figured out this is what the abnormals are this is what the nursingdiagnosis is so the focus is going to be on decreased cardiac output so then what interventionsare we going to take so we are going to educate this patient and it is going to be about dietexercise if they are in the hospital they may be on an iv so we will administer theiv administer the medications we may do an inspirameter with them that's some basic stuff that's the interventionsthat we would do with this patient and of course there are many more now with goals,we are going to do this with them where do we want them to go where do we want them toend up because it is no good if we have no

idea where we are going we cannot take thepatient there so we are going to do two long-term and short-term and i know nursing studentsout there i know that your instructors ask for many more than two but i am just goingto demonstrate two or illustrate two for you long-term would be could easily be a goalthat would be accomplished long after the patient has left the hospital for instanceit could be something that they are going to accomplish in home care or in cardiac rehabor whatever that is fine and short-term can be as short as in the next half-hour so long-termlet’s say they’re going to patient will oh and that's the other thing before i goany farther you must make them measurable and have to be specific there is no otherway to do it you cannot do it any other way

and i will tell you why in two seconds patientwill walk 50 ft. on 05/01/14 of 8 am okay that is a very specific goal extremely specificand the reason you want it so specific is so that you can easily say met or unmet orunable if you ever have a problem in writing your evaluation the problem is in the goaldo not write the evaluation over and over and struggle and struggle if you have a problemyou immediately go back to goal, if the goal is not specific enough that's why you’rehaving a problem with the evaluation it’s not a problem of the evaluation there is onlythree evaluations met, unmet or unable don't worry about those partially unmet or partiallywhatevers those are too gray for beginning students beginning students must have threechoices met unmet or unable to make it clear

and concrete what am i doing with this patientso that is a good long term goal and the reason i say long term by the way is because todayis the 18th of april so this is may 1st i'm anticipating this patient would be dischargedwhen they are walking this 50 ft. so this would for me be an unable short term goalsince this patient is in the hospital with me today would be patient will and by theway i do not like the words demonstrate and all those very non-specific verbs it needsto be will walk lift whatever it is but make it an action verb there are tons of actionverbs on the internet look it up there is tons of them so patient will do inspirameteronce and reach 1500 on 04/18/14 at 8 am that is something that you can easily say met unmetand forget the unable i am going to walk into

this patients room in an hour at 8 o'clockhand them their inspirameter and ask them to do the best they can and if they reach1500 it’s a met now this is where it gets confusing for nursing students because ifthat patient were to do 1600 or 1800 they are actually doing better but it is stillunmet my goal was 1500 the fact that they are doing better is great don't get me wrongbut it did not meet your goal your goal was not specific enough to that particular patientand they did better than you anticipated that's fabulous we want the patient to do betterbut your goal is that they reach 1500 so that's how you write goals specifically and measurablenumbers are best 800 ml of urine if you’re going to try and describe the color of theurine you’re going to have a problem it

is not as measurable it is easy to say urinewas yellow to you was amber to someone else and what is amber to somebody else is actuallyorange and it is not measurable a patient walking from the bed to the bathroom soundslike measurable but think about a hospital room that is semi-private is this patientin the bed closest to the bathroom or is this patient in the bed farthest from the bathroomand yet you have that goal walking from the bathroom to the bed we don't know how farthat patient is actually walking you need to make it measurable how many feet is itto the bathroom in older hospitals was great they used to have the floor tiles on the floorthat were 12x12 and all you had to do was count the number of tiles but i know thisis not the case in newer hospitals now however

it is easy enough to estimate and that's okayyou can do that but it still gives a better idea than saying the patient will walk fromthe bed to the bathroom okay so now for chf patient the congestive heart failure patientwhat labs and tests would we anticipate now this where the nursing students get all i'mnot going to order these tests i'm not going to be necessarily involved i’m not evennecessarily going to draw the blood for these tests why do i have to have this in my nursingprocess my thought process well the thing is, is that you have to anticipate what needsto be done and you also have to know how to read those results because very often you’rethe person that's standing there calling the physician and you need to speak knowledgeablyone and you need to anticipate what they or

recommend to them what needs to be done soon a chf patient we would probably do a, a physician would probably order a cbc, a cmp,a bnp, and an echo now those folks that are not in the medical field or in the nursingfield i know these acronyms are just drive people crazy, but a cbc is a complete bloodcount and all that is, is your red blood cells, your white blood cells, all that kind of stuffit just tells the physician and the nurse the number of cells that you have that's itjust counting them that's why it’s called the complete blood count and a cmp is a comprehensivemetabolic panel sounds fancy all that does is tell the physician and the nurse whereyou’re at for salts and things like calcium and all that, that's all your salts and yourelectrolytes you have heard that word before

all that means is we count, we know whereyour blood level is at, at that particular moment because all of those salts work togetherto keep you alive and then bnp is specific, well relatively specific to congestive heartfailure folks, it is a i’m not going to get complicated but it’s a chemical thatis produced its actually specifically by blood vessel in our bodies that comes off our heartthat in congestive heart failure folks tends to stretch and when it stretches it throwsoff this chemical the higher the level the greater the stretch that's all there is toit so we need to know where that stretch level is in congestive heart failure folks the morethat blood vessel is being stretched then the more fluid they have in their body themore their heart is tiring to work and it’s

not capable and so on and so on then we knowwhere they fall as far as being a mild chf or a mild congestive heart failure patientor a moderate or a sever severe of course is treated all together differently than amild so we need to know where that stretch is and then an echo this sounds awful youknow whatever all it is, is an ultrasound of your heart that's all it is they are takinga look at the structures and most importantly they want to know where and this is anotherone ef or ejection refract is how efficiently your heart is working how much blood is itactually pushing out now the problem with an echo is that it is just it’s more ofan estimate than it is an exact and so sometimes the doctor may say depending on the resultshere that a muga is needed following an echo

and a muga is a more exact measurement ofthe ejection fracture and they use a radio isotope and they measure it with x-ray that'sall it is specialized x-ray basically alright so there are some other tests they may ormay not order but those are kind of the basics and then medications what do we commonly givecongestive heart failure patients well we give them diuretics now diuretics are thosemedications that help the body get rid of fluid the heart when it's not working welltends to well the body tends to accumulate fluid because the heart is not working aswell the pumps not working so the body is going park that fluid until it’s becauseits accumulating and it cannot function with all of that so it parks it i always talk aboutit being parked in a garage if you don't need

something you put it in your garage becauseyou might need it later you never know so if you can’t get rid of it right now wellyou put it in your garage well the problem is your garage only has so much room and aftera while it keeps accumulating and accumulating and there is no room to put it in the garagethen you’re in trouble because there is no place to put it and that's exactly whathappens to congestive heart failure patients at any case we give them diuretics now there'sproblems with a side effect of these diuretics and that is another whole different lecturebut it does have to do with the electrolytes and so that's why the cmp is so importantalso we tend to give them ace inhibitors and beta blockers which are two medications thatlower your blood pressure and basically help

your heart work and then especially beta blockershelp your heart work more efficiently but in any case and then aspirin and that's kindof the basics there are some others and they are generally depending on the physician dependingon the patient and where the patient is at in this disease process mild congestive failurefolks of course are in one regimen and severe can be on another and the amounts of thesedrugs are tied directly into that as well but i don't want to get that specific becausewhat i'm tiring to do is give you an overview of how nurses think so let’s start at thisend and let’s talk about copd or congestive not congestive i did it didn't i chronic pulmonarynope chronic obstructive pulmonary disease i am so used to saying copd i’ve been sayingit for so many years but what it is and that

makes it sound like this terrible whateverall it is, is an umbrella term for three disease processes that you have all probably heardof one time or another these processes are asthma chronic bronchitis and emphysema allpretty commonly known and who hasn't had been in elementary one time or another and hada fellow classmate that has asthma we all know what asthma looks like right we saw whenwe went out on the playground with that kid and they were running around and they mighthave gotten a little blue or short of breath and what did they do reach in their pocketpull out their inhaler do a couple puffs and the next thing you know they are running aroundagain there is no problem we know what asthma looks like and isn't it on the televisionbeing the medications being advertised on

a constant basis so we know medications aswell don't we because their bronchodilators and they are if they are in the hospital theymight be corticosteroid and they may be on that type of inhaler not so much those kidsin elementary as elderly folks are a lot of times on the low level inhaler corticosteroidsinhalers they also and of course if they are in the hospital they may be on iv corticosteroidsbut these are two of the common some of the others have to do with an allergy processlike leukotriene inhibitor and some other things that might ease their breathing but these are kind of the basic ones and thenlabs and tests so you know they are going to have the good old cbc and the reason forthe cbc remember is the complete blood count you want to know where their white blood cellsare as well as their red blood cells but the

white blood cells let us know whether or notthere is an infection process going on these folks as you can well imagine if they havecompromised breathing or compromised lungs then they may be prone to things like pneumoniaor whatever and of course infections so if we do a cbc then we know where the white bloodcells are and if they are high there very likely might be an infection the other possibilitytoo is the red blood cells if they are not where they need to be, let’s say they arelow, there may be something else going on and that could be a trigger for the shortnessof breath because if you don't have enough red blood cells to carry the oxygen you’regoing to be short of breath okay so cbc that's important and more than likely going to doa cmp just to make sure that everything is

where it needs to be and then something likea pulmonary function test would be very commonly ordered and then as you can imagine i don'tneed to explain its a test to see where the actuate function of the lungs is if it’snot where it needs to be then something needs to be corrected there also allergy testingthings like that and from here on out its more specific to the patient but as you canimagine the allergy testing may help the patient and the medical personnel figure out whatthe triggers may be particularly for those asthmatic folks okay so we got that, and thenwe are going to skip evaluation for now and we are going to go over to goals and as youcan imagine some of the goals that would be specific to the patient with let’s say asthmawould be again it could be the patient walking

if they are not moving around patient willwalk then of course the specific time and date and then the same thing with the inspramotoerthe patient will use the inspramoter and specific time and date okay so again all you have todo is remember here it must be specific to the patient and it must be measurable specificand measurable so remember those numbers dates and times and then you won’t go around treatmentsand interventions for someone with asthma actually i hate to say similar to a congestiveheart failure patient is of course diet exercise and educating them in diet and exercise administeringthe iv and meds and so forth as ordered and use of the inspramotoer but we could alsoinclude here education them on those possibly allergy triggers that we identified with theallergy testing very often for the little

folks its pets or pet dander and it couldbe an environmental thing there is a lot it can be food too so those are things thereis a ton of education to be done there especially since asthmatic folks you can’t see yourlungs working so we as nurses we can think this through and we have an understandingof what the disease process is but they don't so that's where that education comes in forthem to help them understand their body processes and why it’s going wrong they can’t seeit so they don't understand it so we can help them understand and then understand how weare thinking this through nursing diagnosis for someone with asthma our heading wouldbe ineffective airway for one that would actually be very specific so ineffective airway therelated to would be inflammation in the brochonicals

again i am saying asthma that's not goingto work for esphmsa folks inflammation in the bronchioles certainly that is tissue andthat is a tissue level than as evidence by certainly they have a dry cough but you couldalso say shortness of breath and that kind of thing that's our as evidence by and thenof course our secondary too is asthma does that sound like that little kid on the playgroundit does doesn't it so what would we find in these folks remember that little kid on theplayground with the dry cough you know they started coughing and they stopped runningand they sat down because they were not able to get that breath in because they were shortof breath and then let’s say they might have gotten a little blue which is calledcyanosis might have gotten just a little blue

around the lips so some cyanosis and someanxiety anybody that cant breath is going to be anxious it’s a given okay so dry coughshort of breath cyanosis and anxious now the normals for these folks very often again islike the congestive heart failure they don't tend to have too many problems with theirskin now i of course if they are the allergic folks they may and i realize that but veryoften they don't they don't probably unless they are having some sort of food allergytheir gi track is fine and you wouldn't anticipate anything with their gu either now this iscrucial because you can see what we just did we went backwards we started down here andwent this way with this nursing process and that is the way nurses think we teach it goingthis way going from assessment all the way

down to medications but we think it this waywe start at medications and we go this way the interesting thing about that's thinkingdefectively that is the most common way for all of us to think we start thinking deductivelyat age two and either life or our parents reinforced that deductive thinking you knowit’s the old if i touch this hot thing i will get burned that's deductive thinkinginductive is teaching it this way and it’s the more familiar way for folks to think sowhen they come in and generally it starts at the college level we try to teach theminductively and there is nothing wrong with that its presenting the information and theydo need to put it together the problem is it’s just not as easy for folks so thinkingdeductively until you can get the information

down then you can think inductively thereis nothing wrong with that and that's how you think defectively with this process youstart with the medications go to labs and tests then you write out your goals then youdo your treatments then you think nursing diagnosis and thinking deductively you goup from the bottom so you go asmaha dry cough inflammation ineffective air way and i justrealized i forgot to do that when i was doing this lecture but i know it backwards and forwardsnow as a student you want to do it backwards you want to think medical diagnosis firstremember when you know that kid on the playground you know what they look like you know whattheir symptoms were you know that to be asthma okay so if that is asthma then you can writethat down easily and then you can think of

those symptoms associated with that comeseasily you saw that kid on the playground and then your now learning as you’re inthe nursing program and hopefully before because its pathopsyhology what’s happening on atissue level what is happening on that tissue level and at inflammation and then and believeme there are many other answers here that are absolutely correct but what's happeningon a tissue level and there-for you can come up with the nursing diagnosis the least knownto you, the least familiar it is the most unfamiliar for a nursing student to be ableto come up with a nursing diagnosis they have not heard nursing diagnosis prior to beingin the nursing program so you’re going from the known to the unknown you are using yourdeductive reasoning because you know that

best and it comes easiest so then moving thisway you can then come up with your abnormals you probably came up with one or two hereanyway so now you can list these and then think about the normals that you would findin that patient now one of the problems with this and students ask me to do this presentationall the time but then when i end it i always tell them one of the problems with this isnow you know how to do this it’s not that hard it’s just not that hard and the thingis, is you can do this with very minimal information so the next time you go to clinical and yourclinical instructor was there before you and figured out your patient assignment and thenwhen you got there they gave you the name of the patient that you were to care for thatday and you went to the chart or the nurse

in charge of that patient and you collectedthe list of medications and you got the diagnosis and then won’t you know here comes the clinicalinstructor and says listen there’s a really cool surgery going on, and your one of thefew students that i can find real quick here i am going to send you down there and youmay be a beginning student and that’s okay i am going to show you how to gown and doeverything and you’re just going to stand in the corner and watch the surgery becausei think you will get a lot out of it and so you do you go down there and you do get alot out of it you stand in the corner and you watch this procedure or do get involvedin whatever this is and it’s so cool and then you realize what time it is and you gorunning back up to the floor and you say to

your clinical instructor i was there the wholetime, and now clinical is over and i never went in and even introduced myself to my patientdo i really have to do that care plan and you know that instructor is going to say yesyou have to do the care plan because she is trying to teach you nursing process she istrying to teach you how nurses think so she wants you to do that care plan and all youhave is the medications and the diagnosis the medical diagnosis but now that you knowthis you can do it because all you have to do is put down the medications and then thinkit out and look it up what labs and tests do they need to have done or most likely tohave done what goals would you have for that patient what treatments and interventionswould you do most commonly do with a patient

with that diagnosis you can do the nursingdiagnosis by starting with the medical diagnosis and using your powers of deduction to go backwardsand make up your nursing diagnosis and then what are the symptoms you would most likelyfind with that patient and what would you most likely find normal you now have yourcare plan and that’s the problem you now know how to do it, so you can’t say i can’tdo it.