Question

2. Nursing Diagnosis: Types of Nursing Diagnosis: (Ex: health promotion, risk, actual)-examples of each reach; Ex: What is Evaiuao 3. Care Plan Outcomes: examples 4. Nursing Interventions: examples: Direct care interventions 5. Care Plans: How do you prioritize Diagnosis'? 6. Nursing Intervention: Dependent, Independent, Collaborative, and Interdependent (Examples of each) 7. Assessments; Ex: MMSE (Cognitive) when to use? 8. Delegation: 5 rights of delegation-task, directions, person, supervision, circumstances

Answer 1

As per NANDA International, nursing diagnosis is defined as "Clinical judgement concerning a human response to health condition or life processes or a vulnerability for that response by an individual, family, group or community. "

Types of Nursing diagnosis are problem focussed, health problem bases or actual diagnosis, risk nursing diagnosis and syndrome nursing diagnosis. Examples are as follows

1. Actual Nursing diagnosis

Ineffective airway clearance related to excessive mucous secretions in airway as evidenced by abnormal breath sound, lowering of oxygen saturation and evidence of dyspnea.

2. Risk Nursing diagnosis

Risk for falls related to old age and decreased muscle coordination

3. Health promotion Nursing diagnosis

Readiness to enhance adherence to medications of hypertension

4. Syndrome nursing diagnosis

Chronic pain syndrome

Careplan outcomes:

Care plan outcome is described as measurable outcome that is expected to be achieved by the nurse which gives direction to the nurse towards implementation of Nursing implementation.

Example:

Patients will report reduced pain as evidenced by facial expression and vitals within normal limits.

Nursing intervention

Nursing interventions are implementation performed by the nurse to achieve the desired goal and expected outcome.

Example:

Assess for breath sound, shortness of breath, breathing rate and oxygen saturation valuea

Perform endotracheal suctioning maintaining strict aseptic techniques

Priorities in Nursing diagnosis

Prioritizing nursing diagnosis can be done on the basis of various theory. Commonly used theory as Maslow's Hierarchy which can give a guide to the priority in Nursing diagnosis

Example

Physiological needs -1. ineffective breathing pattern due to trauma to brain parenchyma as evidenced by tachypnea and lowered Oxygen saturation.

2. Acute pain related to Surgical incision to abdomen as evidenced by facial pain scale

Safety and security- risk for falls related to oldage

Nursing intervention is defined as any implementation performed by a nurse to relieve the patients complaint. Nursing intervention are of various types depending on the ability of the nurse to initiate an action or follow the doctors orders to care for the patient

Examples:

Dependent Nursing intervention- administer medication to the patient as per doctors prescription.

Independent nursing intervention- change the position of the patient every two hourly to prevent pressure injury.

Interdependent nursing intervention- formulate a diet plan in consultation with dietician to implement the dietary implementation but gain the optimum calories required.

Assessment-

Assessment is examination of the patient to verify with the patient complaint or response so as to formulate a nursing diagnosis. There are various types of assessment methods. One of them is MMSE mini mental status examination is mainly used to measure cognitive impairment which is commonly found in conditions such as dementia, Alzheimer or memory related disease.