Nursing Dx

Definition:Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.RELATED FACTORSUnconscious conflict about essential [beliefs]/goals and values of lifeSituational/maturational...

Definition: Risk of hypersenitivity to natural latex rubber productsRISK FACTORSHistory of reactions to latex Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plantsHistory of allergies and asthmaProfessions with daily exposure to latex Multiple surgical procedures, especially from infancy NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions...

Over time, the nursing process expanded to five steps and has gained widespread acceptance as the basis for providing effective nursing care. Nursing process is now included in the conceptual framework of all nursing curricula, is accepted in the legal definition of nursing in the Nurse Practice Acts of most states, and is included in the ANA Standards of Clinical Nursing Practice.The five steps of the nursing process consist...

Definition: A hypersensitive reaction to natural latex rubber productsRELATED FACTORSHypersensitivity to natural latex rubber proteinDEFINING CHARACTERISTICSSubjectiveLife-threatening reactions occurring <1 hour after exposure to latex proteins: Tightness in chest; [feeling breathless]Gastrointestinal characteristics: Abdominal pain; nausea Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal ...

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airwayRELATED FACTORSEnvironmentalSmoking; secondhand smoke; smoke inhalationObstructed airwayRetained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial...

Definition: At risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activitiesRISK FACTORSHistory of previous intolerancePresence of circulatory/respiratory problems, [dysrhythmias]Deconditioned status; [aging]Inexperience with the activity[Diagnosis of progressive disease...

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activitiesRELATED FACTORSGeneralized weaknessSedentary lifestyleBedrest/immobilityImbalance between oxygen supply and demand, [anemia][Cognitive deficits/emotional status; secondary to underlying disease process/depression][Pain, vertigo, dysrhythmias, extreme stress]DEFINING CHARACTERISTICSSubjectiveVerbal report of...

Concept mapping is an exciting alternative format for illustrating a written plan of care. A mapped care plan will look very different from traditional plans of care, which are usually completed on linear forms.To begin mapping a client plan of care, you must begin with the central topic—the client. Now you are thinking like a nurse. Create...

Have you ever asked yourself whether you are more right-brained or left-brained? Those who naturally use their left brains are more linear in their thinking. Right-brain thinkers see more in pictures and illustrations. It is best for nurses to use the whole brain (right and left) when thinking about providing the broad scope of nursing care to clients.No More Columns!Traditional nursing care plans are linear—that is, they are...

The plan of care may be recorded on a single page or in a multiple-page format, with one page for each nursing diagnosis or client diagnostic statement. The format for documenting the plan of care is determined by agency policy. As a practicing professional, you might use a computer with a plan-of-care database, preprinted standardized care plan forms, or clinical pathways. Whichever form you use, the plan of care enables visualization...

The nurse’s initial responsibility is to observe, collect, and record data without drawing conclusions or making judgments/assumptions. Self-awareness is a crucial factor in this interaction, because perceptions, judgments, and assumptions can easily color the assessment findings. Validation is an ongoing process that occurs during the data-collection phase and upon its completion, when the data are reviewed and compared. The...

 Data gathered during the interview and physical examination, and from other records/sources are organized and recorded in a concise, systematic way and clustered into similar categories. Various formats have been used to accomplish this, including a review of body systems. This approach has been utilized by both medicine and nursing for many years but was initially developed to aid the physician in making medical diagnoses....

The InterviewInformation in the client database is obtained primarily from the client (who is the most important source) and then from family members/significant others (secondary sources), as appropriate, through conversation and by observation during a structured interview. Clearly, the interview involves more than simply exchanging and...

The Nursing: Scope & Standard of Practice addresses the assessment process. The standard stipulates that the data-collection process is systematic and ongoing. The nurse collects client health data from the client, significant others, and healthcare providers when appropriate. The priority of the data-collection activities is determined by the client’s immediate condition or needs. Pertinent data are collected using appropriate...

We will look at the process and progress of describing the work of nursing. At first glance, it seems a simple task. However, over many years, the profession has struggled with it. The struggle, in part, is a result of changes in healthcare delivery and financing, the expansion of nursing’s role, and the dawning of the computer age. Gordon reminds us that classification system development parallels knowledge development in a discipline. Astheory...