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Nursing Diagnosis & Collaborative Problems, S&S, Cause/@risk,…
Nursing Diagnosis & Collaborative Problems
Clinical Diagnosis
Diagnosis: hypothesizing as to the cause of the S&S
Differential Diagnosis: ruling out possible causes & coming up with a final diagnosis as to what's the cause
Assessment: gathering objective & subjective data
Types of Diagnosis:
Nursing Diagnosis- What's the human response to health problem? How does the illness impact on their quality of life?
Resp. Diagnosis- Ineffective airway clearance, impaired gas exchange, ineffective breathing patterns, knowledge deficit, activity intolerance, anxiety, ineffective self-health management
Medical Diagnosis- What's the biophysical response to health problems? What's the impact of the disease on cellular structure & function?
Resp. Diagnosis- Asthma, chronic bronchitis, emphysema, TB
Collaborative Problems- Are there physiological complications of a medical diagnosis/procedure that a nurse can't prevent independently
Resp. Diagnosis- risk for complications of hypoxia/ atelectasis/pneumothorax
Nursing Diagnosis
clinical judgement about individual, family or community responses to actual or potential health problems/life processes.
2 domains added to Gordons Functional Health Pattern Framework: comfort + growth & development
Ineffective Airway Clearance
inability to clear secretions or obstructions from the resp. tract to maintain a clear airway.
Characteristics: absence of cough, adventitious breath sounds, alteration in resp. pattern + resp. rate, cyanosis, difficulty verbalizing, diminished breath sounds, dyspnoea, excessive sputum, orthopnoea, restlessness, wide-eyed look
Associated Cond.: Airway spasm, allergic airway, asthma, chronic obstructive pulmonary disease, exudate in alveoli, hyperplasia of bronchial walls, infection, neuromuscular impairment, presence of artificial airway
Related factors: excessive mucus, exposure to smoke, foreign body in airway, retained secretions, 2nd hand smoke, smoking
Impaired Gas Exchange
Associated Cond.: alveolar-capillary membrane changes, ventilation-perfusion imbalance
Characteristics: abnormal ABG/ pH/ breathing pattern/ skin colour, confusion, decrease in CO2 level, diaphoresis, dyspnoea, headache, hypercapnia, hypoxemia, hypoxia, irritability, nasal flaring, restlessness, tachycardia, visual disturbance
Excess or deficit in oxygenation and/or CO2 elimination at the alveolar capillary membrane
Ineffective Breathing Patterns
Characteristics: abnoraml breathing pattern, altered chest excursion, bradypnoea, decrease in expiratory volume/ inspiratory pressure/ vital capacity, nasal flaring, orthopnoea, tachnypoea, pursed lip breathing
Related factors: anxiety, body position, fatigue, hyperventilation, obesity, pain, resp. muscle fatigue
Inspiration and/or expiration that doesn't provide adequate ventilation
Associated Cond.: bon/ chest wall deformity, hyperventilation syndrome, musculoskeletal impairment, spinal cord injury
Diagnostic Categories
Health Protection: potential problems that the pt. is @ risk of developing in the future
Health Promotion: readiness of the pt. to self-manage, maintain or promote health
Health Restoration: actual pt. problems that the pt. is currently experiencing
expressions of wanting to manage illness effectively, choices of daily activities are appropriate for meeting goals
abnormal breath sounds, increased resp. rate, cyanosis, dyspnoea, ineffective cough
N/A
Collaborative Problem
Nurse works autonomously & implements nurse prescribes interventions
Nurse works collaboratively & implements physician prescribes interventions
physiological complication of medical diagnosis nurse can't prevent
Risk for complication of atelectasis, Risk for complications of hypoxaemia/hypoxia/hypercapnia, Risk for complications for cor pulmonale
S&S
Cause/@risk
Label
Category
Health Restoration
Ineffective Airway Clearance
airway spasm, excess mucus production. neuromuscular dysfunction
Health Protection
Risk for Activity Intolerance
resp. problems, deconditioned status
Health Promotion
Readiness for Enhanced Self-Health Management
N/A