Nursing Diagnoses
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Nursing Diagnoses
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when ...
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Nursing Process
The nursing process is a modified scientific method that is a fundamental part of nursing practices in many countries around the world. Nursing practice was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later. The nursing process uses clinical judgement to strike a balance of epistemology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970s. Evidence Based Practice (EBP) Evidence based practice is a process that is used in the healthcare field to used as a problem-solving approach to make clinical decisions. This is collected by reviewing, analyzing, and forming the best sources for the patient-care. EBP assist with the nursing process by providing ...
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Pain
Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Pain motivates organisms to withdraw from damaging situations, to protect a damaged body part while it heals, and to avoid similar experiences in the future. Congenital insensitivity to pain may result in reduced life expectancy. Most pain resolves once the noxious stimulus is removed and the body has healed, but it may persist despite removal of the stimulus and apparent healing of the body. Sometimes pain arises in the absence of any detectable stimulus, damage or disease. Pain is the most common reason for physician consultation in most developed countries. It is a major symptom in many medical conditions, and can interfere with a person's quality of life and general fun ...
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Nursing Outcomes Classification
The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered. With the development of advanced nursing practice and the need to demonstrate effectiveness in patient care, academics and advanced practitioners have started researching and identifying nursing-sensitive outcome. These are defined as defined as an individual's, family or community state, behaviour or perception that is measured along a continuum in response to nursing intervention. Nursing sensitive outcomes have been identifying in rheumatology nursing, paediatric ...
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Nursing Interventions Classification
The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan. The NIC provides a four level hierarchy whose first two levels consists of a list of 433 different interventions, each with a definition in general terms, and then the ground-level list of a variable number of specific activities a nurse could perform to complete the intervention. The second two levels form a taxonomy in which each intervention is grouped into 27 classes, and each class is grouped into six domains. An intent of this structure is to make it easier for a nurse to select an intervention for the situation, and to use a computer to describe the intervention in terms of standardized labels for classes and domains. Another intent is in each case to make it easy to use a Nursing Minimum Data Set (NMDS). The terminology is an American Nur ...
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Nursing Care Plan
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". Nurses practice in many specialties with varying levels of certification and responsibility. Nurses comprise the largest component of most healthcare environments. There are shortages of qualified nurses in many countries. Nurses develop a plan of care, working collaboratively with physicians, therapists, patients, patients' families, and other team members that focuses on treating illness to improve quality of life. In the United Kingdom and the United States, clinical nurse specialists and nurse practitioners diagnose health problems and prescribe medications and other therapies, depending on regulations that vary by state. Nurses may help coordinate care performed by other provide ...
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Nursing Process
The nursing process is a modified scientific method that is a fundamental part of nursing practices in many countries around the world. Nursing practice was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later. The nursing process uses clinical judgement to strike a balance of epistemology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970s. Evidence Based Practice (EBP) Evidence based practice is a process that is used in the healthcare field to used as a problem-solving approach to make clinical decisions. This is collected by reviewing, analyzing, and forming the best sources for the patient-care. EBP assist with the nursing process by providing ...
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Nursing
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". Nurses practice in many specialties with varying levels of certification and responsibility. Nurses comprise the largest component of most healthcare environments. There are shortages of qualified nurses in many countries. Nurses develop a plan of care, working collaboratively with physicians, therapists, patients, patients' families, and other team members that focuses on treating illness to improve quality of life. In the United Kingdom and the United States, clinical nurse specialists and nurse practitioners diagnose health problems and prescribe medications and other therapies, depending on regulations that vary by state. Nurses may help coordinate care performed by other provide ...
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Clinical Formulation
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and is deemed to be a core component of that profession. Mental health nurses, social workers, and some psychiatrists may also use formulations. Types of formulation Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy, psychodynamic therapy, and applied behavior analysis. The structure and content of a clini ...
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Clinical Care Classification System
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings. Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions. The use of the CCC has expanded into other settings, and it is claimed to be appropriate for multidisciplinary documentation. The CCC, capturing the essence of patient ...
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Readiness For Enhanced Spiritual Well-being
The nursing diagnosis readiness for enhanced spiritual well-being is defined as an "ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others, art, music, literature, nature, or a power greater than oneself." (Anonymous, 2002, p. 68) and was approved by NANDA in 2002. Defining characteristics A person with this diagnosis may: * Having an enhanced desire for hope; * Feel that there is meaning and purpose to their life; * Have a sense of peace or serenity; * Surrender love; * Be forgiving towards themself, and request forgiveness of others; * Have a satisfying philosophy of life; * Experience joy, courage, or heightened coping; * Pray or meditate; * Connect with others; * Provide service to others; * Experience connections with nature; * Experience connections with or a desire to create art, music, or literature, particularly of a religious or spiritual nature; * Experience a connection with a power greater than onese ...
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Constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day. Constipation has many causes. Common causes include slow movement of stool within the colon, irritable bowel syndrome, and pelvic floor disorders. Underlying associated diseases include hypothyroidism, diabetes, Parkinson's disease, celiac disease, non-celiac gluten sensitivity, Vitamin B12 deficiency, vitamin B12 deficiency, colon cancer, diverticulitis, and inflammatory bowel disease. Medications associated with constipation in ...
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Nursing Assessment
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances. ...
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