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Nursing Care Plan 3 – Nursing Diagnosis: Acute Pain related to psychological distress as evidenced by patient verbalizing pain, moaning and crying, narrowed focus and altered passage of time, and pallor. Desired Outcome : Within 4 hours of nursing interventions, the patient will demonstrate a reduction in crying and pain verbalization.

Intervention	Rationale
Assess to what extent cultural, environmental, intrapersonal, and intrapsychic factors may be contributing to pain.	These influences alter the patient’s expression of the pain experienced. This assessment can be used to evaluate each patient’s unique response.
Respond immediately to reports of pain.	If the patient is experiencing an altered passage of time due to pain, fear about delayed pain relief can exacerbate the pain experience. Prompt responses to reports of pain reduce anxiety and promote trust.
Promote periods of rest for the patient.	Fatigue can contribute to pain. A quiet, darkened room with minimal noise and interruptions can promote rest and reduce pain.
Use relaxation and breathing exercises and/or music therapy.	These techniques help produce a sense of tranquility for the patient. The goal is to reduce pain related to tension or stress,

What are common nursing diagnosis?

What is the most common nursing diagnosis? According to NANDA, some of the most common nursing diagnoses include pain, risk of infection, constipation, and body temperature imbalance.

What are the 5 types of nursing diagnosis?

Types and Components of Nursing Diagnoses Problem-Focused Nursing Diagnoses 1 A problem-focused nursing diagnosis “describes human responses to health conditions/life processes that exist in an individual, family, or community. It is supported by defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences” (NANDA-I, 2009).

1. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
2. Label The label should be in clear, concise terms that convey the meaning of the diagnosis.
3. Defining Characteristics For problem-focused nursing diagnoses, defining characteristics are signs and symptoms that, when seen together, represent the nursing diagnosis.

If a diagnosis has been researched, defining characteristics can be separated into major and minor designations. Table 3.1 represents major and minor defining characteristics for the researched diagnosis, Defensive Coping (Norris & Kunes-Connell, 1987).

Major. For researched diagnoses, at least one must be present under the 80% to 100% grouping. Minor. These characteristics provide supporting evidence but may not be present.

Most defining characteristics listed under a nursing diagnosis are not separated into major and minor. Related Factors In problem-focused nursing diagnoses, related factors are contributing factors that have influenced the change in health status. Such factors can be grouped into four categories:

Pathophysiologic, Biologic, or Psychological. Examples include compromised oxygen transport and compromised circulation. Inadequate circulation can cause Impaired Skin Integrity.

Table 3.1 FREQUENCY SCORES FOR DEFINING CHARACTERISTICS OF DEFENSIVE COPING

Defining Characteristics Frequency Scores (%) Major (80%-100%) Denial of obvious problems/weaknesses 88 Projection of blame/responsibility 87 Rationalizes failures 86 Hypersensitive to slight criticism 84 Minor (50%-79%) Grandiosity 79 Superior attitude toward others 76 Difficulty in establishing/maintaining relationships 74 Hostile laughter or ridicule of others 71 Difficulty in testing perceptions against reality 62 Lack of follow-through or participation in treatment or therapy 56 Norris, J., & Kunes-Connell, M. (1987). Self-esteem disturbance: A clinical validation study. In A. McLane (Ed.), Classification of nursing diagnoses: Proceedings of the seventh NANDA national conference, St. Louis, MO: CV Mosby.

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Treatment-Related. Examples include medications, therapies, surgery, and diagnostic study. Specifically, medications can cause nausea. Radiation can cause fatigue. Scheduled surgery can cause Anxiety, Situational. Examples include environmental, home, community, institution, personal, life experiences, and roles. Specifically, a flood in a community can contribute to Risk for Infection ; divorce can cause Grieving ; obesity can contribute to Activity Intolerance, Maturational. Examples include age-related influences, such as in children and the elderly. Specifically, the elderly are at risk for Social Isolation ; infants are at Risk for Injury ; and adolescents are at Risk for Infection,

Risk and High-Risk Nursing Diagnoses NANDA-I defines a risk nursing diagnosis as “human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability” (NANDA-I, 2009).

The concept of “at risk” is useful clinically. Nurses routinely prevent problems in people experiencing similar situations such as surgery or childbirth who are not at high risk. For example, all postoperative individuals are at risk for infection. All women postdelivery are at risk for hemorrhage. Thus, there are expected or predictive diagnoses for all individuals who have undergone surgery while on chemotherapy or with a fractured hip.

All persons admitted to the hospital are at Risk for Infection related to increased microorganisms in the environment, risk of person-to-person transmission, and invasive tests and therapies. Refer to Box 3.1 for an illustration of this standard diagnosis and how it is individualized to become a high-risk diagnosis.

The high-risk concept is very useful for persons who have additional risk factors that make them more vulnerable for the problem to occur. In the hospital or other health care facilities, individuals should be assessed if they are at high risk for falls, infection, or delayed transition. High-risk individuals need additional preventive measures.

Dec 6, 2019 | Posted by in NURSING | Comments Off on Types and Components of Nursing Diagnoses

How do you describe pain in nursing?

Definition of Terms – Pain:

” Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1989)”Pain is an unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual or potential tissue damage” (IASP 2020)

Pain assessment : is a multidimensional observational assessment of a patients’ experience of pain. Pain measurement tools : are instruments designed to measure pain.

What is a nursing diagnosis for swelling?

Edema is swelling caused by fluid build-up in the tissues, It can occur in any part of the body but is most noticeable in the arms, hands, legs, and feet. Edema is a common finding and may go away on its own or may be a symptom of an underlying health condition, an allergic reaction, or an adverse effect of a medication. There are different types of edema but the most common ones include:

• Cerebral Edema: This is a serious and life-threatening type of edema characterized by fluid buildup in the brain.
• Pulmonary Edema : This is another serious type of edema that occurs when fluid accumulates in the lungs. This causes shortness of breath and respiratory distress.
• Lymphedema : This condition typically occurs in the arms and legs and is associated with problems in the lymph nodes.
• Peripheral Edema : Edema in the extremities is usually a clinical manifestation of health conditions associated with the circulatory system, kidneys, or lymph nodes.
• Pedal Edema : This condition occurs when fluid is pooled in the lower legs and feet and is common among pregnant women.

A detailed physical assessment and medical history are essential to determine the cause of edema. Diagnostic tests that help uncover potential causes include ultrasounds, x-rays, MRIs, blood tests, and urinalysis.

What is a nursing diagnosis for stress?

Diagnoses Related to Stress and Coping – Nursing diagnoses related to stress and coping are Stress Overload and Ineffective Coping, See Table 3.6 to compare the definitions and defining characteristics for these nursing diagnoses. Table 3.6 Stress and Coping Nursing Diagnoses

Nursing Diagnosis	Definition	Selected Defining Characteristics
Stress Overload	Excessive amounts and types of demands that require action.	Excessive stress Impaired decision-making Impaired functioning Increase in anger Increased impatience
Ineffective Coping	A pattern of invalid appraisal of stressors, with cognitive and/or behavioral efforts, that fails to manage demands related to well-being.	Alteration in concentration Alteration in sleep pattern Change in communication pattern Fatigue Inability to ask for help Inability to deal with a situation Ineffective coping strategies Insufficient social support Substance misuse

What is an example of a diagnosis?

Example Sentences – The unusual combination of symptoms made accurate diagnosis difficult. She is an expert in the diagnosis and treatment of eye diseases. The diagnosis was a mild concussion. His doctor made an initial diagnosis of pneumonia. The committee published its diagnosis of the problems affecting urban schools. Jodi Helmer, Fortune Well, 18 June 2023 Green also pointed out that even when a genetic condition can’t be treated, a diagnosis may still be useful. — Aria Bendix, NBC News, 17 June 2023 These laws have created new obstacles for pregnant patients facing life-threatening complications like severe fetal anomalies, cancer diagnoses and ectopic pregnancies – when a fertilized egg implants outside the uterus. — Elizabeth Lanphier, The Conversation, 16 June 2023 He was diagnosed in February and revealed the diagnosis on social media in March. — CBS News, 16 June 2023 Snell described the moment of his diagnosis as life-changing. — Cydney Henderson, USA TODAY, 16 June 2023 Malin announced his diagnosis with a screenshot of the Rolling Stone story onto his Instagram account Wednesday morning. — Jonah Valdez, Los Angeles Times, 14 June 2023 Bayer starred as a woman who chases her dreams of being a home-shopping channel host by accidentally lying about her past leukemia diagnosis returning. — James Grebey, Vulture, 9 June 2023 Antonio Smith was transferred from the Red Eagle Community Work Center to the Kilby Infirmary after his diagnosis, — Amy Yurkanin | [email protected], al, 6 June 2023 See More These examples are programmatically compiled from various online sources to illustrate current usage of the word ‘diagnosis.’ Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

What are the 4 categories of 21 nursing problems?

Abdellah’s Typology of 21 Nursing Problems – The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care.

1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, sleep
3. To promote safety by preventing accidents, injuries, or other trauma and preventing the spread of infection,
4. To maintain good body mechanics and prevent and correct the deformity.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition for all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiologic responses of the body to disease conditions—pathologic, physiologic, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings, and reactions.
13. To identify and accept interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and nonverbal communication.
15. To promote the development of productive interpersonal relationships.
16. To facilitate progress toward achievement and personal spiritual goals.
17. To create or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical and emotional.
20. To use community resources as an aid in resolving problems that arise from an illness.
21. To understand the role of social problems as influencing factors in the cause of illness.

Moreover, patients’ needs are further divided into four categories: basic to all patients, sustenance care needs, remedial care needs, and restorative care needs,

Is abdominal pain a nursing diagnosis?

Nursing Process – Nurses conduct thorough histories and physical assessments to assist with the diagnosis of abdominal pain. This can include diet, medical and surgical histories, and detailed pain assessments. Nurses prepare patients for diagnostic tests and review results to collaborate with the healthcare team.

What is an example of a diagnosis in a nursing care plan?

2. Identify and list nursing diagnoses. – After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems) that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses.

Is depression a nursing diagnosis?

What is Major Depression? – Major depression (or major depressive disorder) is classified under mood disorders which are characterized by disturbances in the regulation of mood, behavior, and affect that go beyond the normal fluctuations that most people experience.

Persistently low or depressed mood Anhedonia or decreased interest in pleasurable activities Feelings of guilt or worthlessness Lack of energy Poor concentration Appetite changes Psychomotor retardation or agitation Sleep disturbances Suicidal thoughts

The DSM-5 also classifies depressive disorders as:

Disruptive mood dysregulation disorder Major depressive disorder Persistent depressive disorder (dysthymia) Premenstrual dysphoric disorder Depressive disorder due to another medical condition

Furthermore, depressive disorders may be further categorized by specifiers:

Peripartum onset Seasonal pattern Melancholic features Mood-congruent or mood-incongruent psychotic features Anxious distress Catatonia

Major depressive disorder is a highly prevalent psychiatric disorder. It has a lifetime prevalence of about 5% to 17%, with the average being 12%. The prevalence rate is almost double in women than in men (Bains & Abdijadid, 2022). Non-Hispanic Asian adults were least likely to experience mild, moderate, or severe symptoms of depression compared with Hispanic, non-Hispanic white, and non-Hispanic black adults (Halverson & Bienenfeld, 2023).

According to the CDC, from 2016 to 2019, 2.7 million children aged 3 to 17 years were diagnosed with depression. The incidence of depression was 0.9% in preschool-aged children, 1.9% in school-aged children, and 4.7% in adolescents according to a study. In another study, more than 22% of female high school students and more than 11% of male high school students reported one current or lifetime episode of unipolar depression (Halverson & Bienenfeld, 2023).

Although rates of depression in women and men are highest in those aged 25 to 44 years, the incidence of clinically significant depressive symptoms increases with advanced age, especially when associated with medical illness or institutionalization (Halverson & Bienenfeld, 2023).

Major depressive disorder is a clinical diagnosis; it is mainly diagnosed by the clinical history given by the client and mental status examination. The clinical interview must include medical history, family history, social history, and substance abuse history along with symptomatology. A complete physical examination, including a neurological examination, should also be performed (Bains & Abdijadid, 2022).

You can learn more about major depression in our study guide here,

Why is a nursing diagnosis important?

A nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.

What is the priority of nursing diagnosis?

Setting Priorities – Because some diagnoses have a higher priority than others, they are more important. Nursing diagnoses are ranked in order of importance. Survival needs or imminent life-threatening problems take the highest priority.For example, the needs for air, water, and food are survival needs.

1. Nursing diagnostic categories that reflect these high-priority needs include Ineffective Airway Clearance and Deficient Fluid Volume.
2. Safety needs are the next priority, with nursing diagnostic categories such as Risk for Injury or Risk for Suffocation.
3. At a lower level of priority are the social and psychological needs for love, self-esteem, companionship, and fulfillment; some possible nursing diagnostic categories are Ineffective Role Performance, Anxiety, and Social Isolation.

The reason for the client’s admission to your facility is the most important concern; however, it may not be a priority nursing concern at any given moment. The client may have a number of nursing diagnoses that are unrelated to the primary care problem.

Attempts to treat them may be unsuccessful because the client has more urgent, immediate needs. These other problems can be deferred until a later time. In addition, materials and human resources availability, as well as time limitations, affect the order of priority. Equipment, supplies, and staff must be available.

Keep in mind that you cannot treat every nursing diagnosis that a client may have. The client also determines the priority of health concerns. For example, a smoker may be fully aware of the health risks of smoking, but may choose to continue. In this case, plans to help the client quit smoking will fail, even though the need for oxygen is a requirement for survival, and thus, is a high priority.