Nursing Diagnosis - Essay Example

Nursing diagnoses Nursing diagnoses The nursing process is defined as a system that organizes and delivers nursing care to individuals. The process involves five critical steps. These are the assessment, diagnosis, planning, implementation, and evaluation (G.King, p. 10-12). Each step is very critical as they are of significant importance to the process of coming up with an effective nursing care plan. Assessment involves a systematic collection of data as it involves capturing the patient’s necessary information, medical records, and reasons for their admission, laboratory values, current medications and their current health status. This step should be done exhaustively ensuring that all information about the patient is collected and critically analyzed before proceeding to the next step. Doing this will reduce the chances of coming up with a nursing care plan that overlooked critical information about the patient that is undesired. The next step will be to conduct a diagnosis that will entail coming up with clinical judgments about the problems the patient may be facing. It will cater for both the actual and potential problems that are likely to arise based on the assessment that will have been done in the previous step. The diagnoses will also be as per the guidelines but across by the North American Nursing Diagnoses Association (NANDA) (G.King, p. 34-36).The nursing diagnostic will consist of three parts that include the health problem, contributing factors and other defining characteristics. These defining characteristics are important to consider because they reflect the behavior that the nursing intervention is targeting. Thus, they will also help in evaluating the outcome of the nursing interventions that I will propose; thereby the success of the nursing care plan can be determined. From the nursing process described above if a patient, for example, is suffering from acute pain there may be different factors that related to this. It may be because of illness, an injury, myocardial infarction or it may even be a chronic disorder. Pain may additionally be because of emotional, cultural, psychological or spiritual distress. Because of this complexity related to factors associated with pain, a precise assessment of the patient needs to be done before diagnosing the patient. Related factors such as obstetrical pain and pain due to trauma also needs be considered. The defining characteristics includes acts such as patient guarding the body part causing pain, distraction behavior like moaning and acts of restlessness. In addition, there are facial expressions by the patients showing discomfort and verbal communication from the patient about the illness need be considered (G.King, p. 29-32). Thus, the assessment of such a situation entails the nurse assessing the pain characteristic that will be in terms of sharpness of the pain, location of the pain and duration of the pain. The nurse would then have to monitor and check vital signs associated with the pain including the temperature, heart rate, blood pressure, restlessness and the ability of the patient to focus. The nurse also needs to understand what pain mean to the patient and understand the patient’s expectation regarding pain relief. Once the patient’s condition has been accessed, the next step would be to come up with nursing interventions. Since our case involves patient suffering from acute pain, the best plan would first to relieve the patient of the pain and the best way would be to stop or prevent it. Intervening early enough would decrease the amount of analgesic, which would otherwise have been required. The nursing intervention also needs to eliminate any additional stressors that may act as sources of discomfort. These stressors may be due to the environment stimuli, intra-psychic or intrapersonal factors that would either decrease the patient’s ability to tolerate the pain or exaggerate their experience of the pain. The nurse can choose to provide adequate rest periods to facilitate relaxation and comfort. The nurse may also choose to use either pharmacological or non-pharmacological methods to relieve the pain. Pharmacological methods may involve using local anesthetic agents, non-steroidal anti-inflammatory drugs (NSAIDs) which may be administered orally, or through use of opiates. The non-pharmacological methods may require the use of cognitive behavioral strategies such as distraction techniques and relaxation exercises (G.King, p. 23). The nurses can the access the pain level every four hours to evaluate the progress of the nursing intervention. If the patient were experiencing a case of ineffective breathing pattern, the first step would be to do an assessment that enables the nurse to determine the cause of the condition. Ineffective breathing pattern may occur due to heart failure, hypoxia, infection, diaphragmatic paralysis, neuromuscular impairment or airway obstruction. The nurse needs access these factors as well us pay close attention to the patient’s defining characteristics that may include, cyanosis, nasal flaring, coughing, tachypnea, and dyspnea. Carrying out this assessment would involve assessing the patient’s respiratory rate, checking and monitoring the patients breathing pattern. In addition examining the nasal muscles associated with breathing, controlling the paradoxical motion for diaphragmatic muscle fatigue and noting the position assumed the patients for natural breathing (G.King, p.58). Having done this, the nurse would now have adequate details to formulate and administer the appropriate nursing interventions. Depending on the scenario the nurse may opt to position the patient in such a manner that would aid them achieve an optimal breathing pattern. The nurse can also encourage the patient to take deep breaths using demonstrations. Criteria of likely outcomes should be SMART with S, which stands for specific, and focus to the client. In this, the patient needs to perform deep breathing at least twice a day. M stands for measurable which entails quantifying the desired response impartially. A stands for Attainable or perceivable – setting goals that are attainable is vital in treating the borderline personality disorder to ensure the patients is able to recover from the condition steadily. R stands for Realistic therefore, as a nurse, it will be vital and realistic to have all things in place so as to help in addressing the patients situation in this case proper workforce and equipments need to be utilized. T stands for Time bound or time limited. A nurse needs to have standard whether the progress is being realistic to assist in setting the desired priorities. To evaluate the nursing intervention techniques applied the nurse note the rate and depth of the patient’s respiration and their breathing pattern every 4 hours to see if the patients breathing pattern has been maintained (G.King, p. 19-22). If the patient is not willing to participate in social events or shows a sense of discomfort in the presence of other people, then it is clear the patient may be suffering from the impaired social interaction syndrome. The nurse would have to conduct an assessment to determine the cause and factors leading to this behavior. The assessment would involve reviewing the family’s patterns related to the social interaction within themselves and other people. Furthermore, this is because social interaction is learned to a much extend around family; thus it acts as the primary origin of its development. The nurse can also ask the patient to write down the factors or behaviors that discomfort them thus this may suggest action to be taken. The nurse can also choose to employ positive self-talk techniques such as telling one “It is possible to enjoy social activities." To evaluate the effectiveness of these procedures, the nurse can assess the patient social behavior weekly to note if there are positive changes. Reference King, Gemma. (2015) Staff Attitudes towards People with Borderline Personality Disorder. Mental Health Practice 17.5 (2014): 30-34. Academic Search Complete. Read More