NURS 105 Chapters 17-20

September 10, 2009

Chapter 17 – Nursing Diagnosis
Medical diagnosis/nursing diagnosis p 248
↑ must be doctor

Italicized example 248: teach, monitor, assess pain

Identify problem, set goal for intervention, go about it (implement).

NANDA International Nursing Diagnoses p 250-251

↑ Diagnosis Label – Part 1 of Diagnosis…*Copy Part 1 word-for-word*
Diagnostic reasoning p 252
4 types of Diagnosis p 253:
1) Actual – happening now
2) Risk – high risk: Example – risk for developing infection
3) Health promotion
4) Wellness

Part 2 of Diagnosis – not in text

Comes from client – glean from data collected

High Risk For = HRF

Part 1 Related To Part 2

High Risk for Infection R/T 1) Recent back surgery
2) Recent history of steroid use

HRF Impaired skin integrity R/T Immobile, difficulty turning,

urinary incontinence
↑
Etiology

Etiology also known as “Part 2”, “Related to section”

Part 1 Related to Part 2

Diagnostic statement Bridge Etiology

Cannot use medical diagnosis! p 254

If no data to support diagnosis, Part 1 is incorrect.
 September 17, 2009
Chapter 17 – Chapter 18

Pain R/T inflammation of ankle

↑ ↑ ↑
Part 1 Related to NO medical diagnosis!

Sources of diagnostic errors p 257

BOX 17-4 S OURCES OF DIAGNOSTIC E RRORS

Collecting
Lack of knowledge or skill
Inaccurate data
Missing data
Disorganization

Interpreting
Inaccurate interpretation of cues
Failure to consider conflicting cues
Using an insufficient number of cues
Using unreliable or invalid cues
Failure to consider cultural influences or developmental stages

Clustering
Insufficient cluster of cues
Premature or early closure
Incorrect clustering

Labeling
Wrong diagnostic label selected
Evidence exists that another diagnosis is more likely
Condition is a collaborative problem
Failure to validate nursing diagnosis with client
Failure to seek guidance

Errors in the Diagnostic Statement

Look at #2, #7, #10, and #11 p 258
#2 – Identify a Nanda-I diagnostic statement rather than the symptom.
#7 – Identify the client problem rather than the nursing intervention.
#10 – Avoid legally inadvisable statements.
Do NOT pass judgments! Objectively describe – won’t get sued for slander!
#11 – Identify the problem and etiology to avoid a circular statement.
Example:
Constipation R/T inability to pass stool

(Both sides say same thing.)

Chapter 18 – Planning Nursing Care

Priorities p 263
Pain
Ineffective airway clearance
Impaired gas exchange
HRF Impaired skin integrity
HRF Constipation
*Maslow p 71-72*
Basic physiological 1st
Physical/psychological 2nd
Love/belonging 3rd
Prioritize
Self-esteem – won’t quite reach full
potential
Self-actualization – highest you can
achieve in personal & professional life

Goals – also known as “Expected Client Outcome (ECO)” p 264

Example: Constipation R/T immobility (secondary to?)administration of narcotics

Next step: ECO: (don’t make harder than it is) Time frame
Patient will have a BM by end of clinical. *Every goal must have a time frame*

Example: Pain R/T inflammation of ankle tissue

ECO: Pain relief within 2 hours of analgesic administration. ( or 1 hr, 30 min, etc)
-With pain, must include measurement to see if relieved (look for clues).
*Add: AEB: (as evidenced by)…have to know what evidence will be
How did you diagnose pain?
(Subjective) 1) Patient reports absence of pain (or pain reduced to 2/10, 3/10, etc - fraction)
2) Absence of facial grimacing, grunting
3) Coughing without clutching chest

Short-term/long-term goal p 265

Short-term goal – objective behavior or response client expected to achieve in a short time
(usually < 1 week)
Long-term goal – objective behavior or response client expected to achieve over a longer period
(usually several days, weeks, or months)

Guidelines for writing goals p 267

Must be client-centered – what will client be able to do?
Must be observable, measureable
Can’t say “pain is reduced”
Can say “pain is reduced to 2/10”
Must be time-limited
Must be realistic
 September 24, 2009
Care plan in class:
Fluid volume deficit

Still no urine until not dehydrated?

Monitor, assess, check – all mean same thing

*Every nursing intervention needs to have some:

 Assessing – anything that gathers data: VS, pulse oximetry, auscultating breath sounds, skin
turgor, palpation/percussion/auscultation, looking at skin, monitoring I/O
 Doing – changing dressing, administering medicine assisting with turning
 Teaching

Under “Do:” – look at order and copy what it reads.

Chapter 20 - Evaluation
Need to evaluate every intervention one-by-one
Example: What you did here, you do there

Teach:
Can they state?
Did they learn?
Taught_____, how did they respond?
 October 1, 2009
Chapter 19 – Implementing Nursing Care

p 283
Resources
Anticipating
Implementational skills
 Cognitive
 Interpersonal
 Psychomotor

p 285 (Bold terms)

Activities of daily living (ADLs) – activities usually performed in the course of a normal day, including
ambulation, eating, dressing, bathing, brushing teeth, and grooming
Instrumental activities of daily living (IADLs) – skills such as shopping, preparing meals, writing checks,
and taking medications
Lifesaving measure – a physical care technique that you use when a client’s physiological or
psychological state is threatened
Counseling – a direct care method that helps the client use a problem-solving process to recognize and
manage stress and to facilitate interpersonal relationships; the change results in the development of
new attitudes and feelings
Teaching – focus of change is intellectual growth or the acquisition of new knowledge or psychomotor
skills

p 286
Adverse reaction – a harmful or unintended effect of a medication, diagnostic test, or therapeutic
intervention

p 287
Indirect care measures – actions that support the effectiveness of direct care interventions

(Best covered on the board.)

Chapter 20
One thing to evaluate – Interventions
Also evaluate at end
 Goal whether/not met
 If not, may not mean you did something wrong
 Then evaluate whether it was appropriate diagnosis or not
Honestly assess whether/not goal met & whether/not diagnosis appropriate, then answer why not?
Evaluate…
 Intervention
 Goal
 Entire care plan

Care plan in class:

Impaired gas exchange

ECO – restates diagnosis

Mandatory assessments – must be met

 ABBREVIATIONS

a – before M – minim
a.c. – before meals min - minute
ADL – activities of daily living mg – milligram
aq. – water no. – number
A.M. – morning noc – night
amb. – ambulatory NPO – nothing by mouth
amt – amount O2 – oxygen
Ax – axillary OB – obstetrics
b.i.d. – 2 times per day OR – operating room
BM – bowel movement o.d. – right eye
BMR – basal metabolic rate o.s. – left eye
BP – blood pressure o.u. – both eyes
BRP – bathroom privileges oz – ounce
C (w/ line over) – with P – pulse
Ca – cancer peds – pediatrics
C – centigrade per – by or through
cc – cubic centimeters p.o. – by mouth
caps – capsules p (w/ line over) – after
c/o – complains of p.c. – after meals
DC – discontinue p.r.n. – as needed
dr – dram post-op – postoperative
elix – elixir pre-op – preoperative
exam – examination pt – patient
ECG (EKG) – electrocardiogram PT – physical therapy
EEG – electroencephalogram q.d. – every day
F – Fahrenheit q.h. – every hour
Fe – iron q.o.d. – every other day
GI – gastrointestinal R – respirations
gm – gram RBC – red blood cell
gr – grain RLQ – right lower quadrant
gtt – drop RUQ – right upper quadrant
GU – genitourinary Rx – take thou, treatment, therapy
h, hr – hour sol – solution
Hgb – hemoglobin sp gr – specific gravity
H2O - water SS – soapsuds
h.s. – bedtime s (w/ line over) – without
I&O – intake & output stat – immediately
IM – intramuscular syr - syrup
IV – intravenous s.c. , s.q. - subcutaneous
Kg – kilogram tab – tablets
lab. – laboratory t.i.d. – 3 times per day
lb. – pound tinc., tr – tincture
liq - liquid TPR – temperature, pulse, respirations
LLQ – left lower quadrant Via – by way of
LUQ – left upper quadrant WBC – white blood cell
wt. – weight -cele – combining form meaning tumor
VS – vital signs Chondr(i)(o) – pertaining to cartilage
CSF – cerebro spinal fluid circum – around
CVA – cerebro vascular accident contra – against
D & C – dilation & curettage cyst(i)(o) – pertaining to bladder
Px – prognosis cyt(o) – combining form for cell
Sx – symptom -derm – combining form meaning skin
CBC – complete blood count e, ex – out, away
Hct – hematocrit ecto – on outer side
BUN – blood urine nitrogen enter(o) – pertaining to intestines
FBS – fasting blood sugar fasci – pertaining to band or bundle fibrous
GTT – glucose tolerance test tissue
UA – urinalysis gastr – pertaining to stomach or abdomen
PBI – protein bound iodine hem(at) – pertaining to blood
EMG – electromyogram hepat(o) – pertaining to liver
LP – lumbar puncture hist(o) – pertaining to tissue
IVP – intravenous pyelogram hyper – over, above
abd. – abdomen hypo – under, below
ant – anterior hystro – pertaining to uterus
AP – anteroposterior ile(o) – pertaining to ileum
CC – current complaint inter – between
CNS – central nervous system intro – into, within
Dx – diagnosis mamm(o) – pertaining to breast
HEENT – head, eyes, ears, nose, throat my(o) – pertaining to muscle
Hx – history nephr(o) – pertaining to kidney
L – left neuro – pertaining to nerves
Lat – lateral oss, osteo – pertaining to bone
Post – posterior para – beside, beyond
PERRLA – pupils equal round react to light and per – through, excessive
accommodation plegia – meaning paralysis
R/O – rule out pleur(o) – pertaining to pleural
WNL – within normal limits Pneumo – pertaining to lungs, air
ID – intradermal pre – before, in front of
ab – away from pro – before, in half of
ad – to, toward, near to pur, pyo – related to pus
aden(o) – pertaining to the gland re – back, again, contrary
adip(o) – pertaining to fat ren – pertaining to kidney
alve – trough, channel, carie retro – backward, located behind
angio – pertaining to a vessel, usually blood supra – above, upon
ante – before, forward sym, syn – together, with
anti – against, opposed to trans – across, through
arterio – pertaining to joint
Articul – to join
bi – twice, double
-blast – pertaining to early embryonic or
developmental stage
cardio – pertaining to heart
caud – pertaining to tail