Nursing process. Nursing Diagnosis. -Judgment or conclusion about the risk for-or actual-need/problem of the pt. (NANDA format ). Nursing Diagnosis: Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures by:
-Judgment or conclusion about the risk for-or actual-need/problem of the pt. (NANDA format).
Nursing Diagnosis: Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures by:
Risk for altered sexuality pattern
Sexual Dysfunction, Altered Sexuality Patterns
Opportunity to enhance sleep
Risk for sleep pattern disturbance
Sleeps Pattern Disturbance
Opportunity to enhance comfort level
Risk for pain, Risk for Aspiration
Pain, Chronic Pain and Dysreflexia.
Opportunity to enhance cognition
Risk for altered thought processes
Risk for dysfunctional grieving, High risk for Loneliness.
Risk for Altered Parent/Infant/Child Attachment
Spiritual disturbance (distress of the human spirit).
Risk for spiritual distress
Potential for enhanced spiritual Well- Being
*Nursing Diagnosis: ALTERED THOUGHT PROCESSES
*Definition:A state in which an individual experiences a disruption in cognitive operations and activities
Use CONSENSUAL VALIDATION &SEEKING CLARIFICATION technique when communication reflects alteration in thinking. (Ex: “Is it that you mean? “or“ I don’t understand what you mean by that. Would you please explain?”) These techniques reveal to pt. how he is being perceived by others, while responsibility for not understanding is accepted by nurse.
Give positive reinforcement, as pt. is able to differentiate b/w reality- &nonreality-based thinking. Positive reinforcement enhances self-esteem & encourages repetition of desirable behaviors.
Use touch cautiously, particularly if thoughts reveal ideas of persecution. Ptswho are suspicious may perceive touch as threatening and may respond with aggression.
1.Pt’s thinking processesreflect accurate interpretation of environment.
2.Pt is able to recognize negative or irrational thoughts and intervene to stop their progression.
*Nursing Diagnosis: ALTERED NUTRITION, LESS THAN BODY REQUIREMENTS
*Definition: The state in which an individual experiences an intake of nutrients insufficient to meet metabolic needs
**Inability to ingest food due to:
Keep strict documentation of intake, output, &calorie count. This is necessary to make accurate nutritional assessment &maintain pt’ssafety.
Ensure that ptreceives small, frequent feedings, including a bedtime snack, rather than three larger meals. Large amounts of food may be objectionable, or even intolerable, to pt.
Stay with ptduring mealsto assist as needed and to offer support and encouragement.
1.Patient has shown a slow, progressive weight gain during hospitalization.
2.Vital signs, blood pressure, and laboratory serum studies are within normal limits.
3.Patient is able to verbalize importance of adequate nutrition and fluid intake.
*Nursing diagnosis: SLEEP PATTERN DISTURBANCE
Performing relaxation exercises to soft music (or other technique) may be helpful before sleep.
1.Patient is sleeping 6 to 8 hours per night without medication.
2.Patient is dealing to fall asleep within 30 minutes of retiring.
3.Patient isdealing with fears and feelings rather than escaping from them through-excessive sleep.