Primary Nursing Diagnoses Paper

• Presents with shortness of breath, difficulty in breathing, anxiety, confusion, cyanosis, tachycardia, arrhythmia, tachypnea, and hypoxemia

A 22 year old female has been brought to the emergency room after fainting at home with complaints of flu-like symptoms for the last eight days (GCU, 2010). She has reported vomiting several times a day and having difficulty keeping food or liquids down. She states she has been “taking more than recommended dose of antacids to help with nausea symptoms”. She has become dehydrated, so an IV has been placed and fluids have been started. She also has had an arterial blood gas (ABG) drawn that has shown acid-base deficits. This paper will discuss how a focused history, physical exam, nursing diagnosis and the nursing process of care is important in helping this patient get better. It will also discuss the differences between a complete assessment and a focused assessment.

A 54 year old black female presents with dyspnea and chest discomfort on exertion, postural lightheadedness, palpitations and a functional limitation of less than one flight of stairs. She denies fever or chills. Further questioning reveals she has been experiencing worsening shortness of breath for one week. Past medical history includes hypertension, Epstein Barr virus and osteoporosis. Surgical history included hysterectomy. She is a 1 ppd smoker and admits to drinking 3-5 alcoholic drinks per week for 10 years. Medications include candesartan, multivitamin, and calcium

Throughout my clinical rotation, the only concern for this patient was pain management and discomfort from the chest tube site. The patient was given Ketorolac for a pain of 4/10 using the numeric pain sale. The patient was also at risk for pneumonia and pressure ulcers from immobility and not coughing/deep breathing. Nursing interventions were getting the patient up to the chair and using the incentive spirometer ten-times per hour. Another concern was SOB and fatigue with activities.

The patient did have black soot around his nose and mouth. Thats when first responders started manual ventilation's via BVM and 02 at 15 LPM. At this time Medic 1 assumed patient care. Medic 1 assigned first responders to obtaining vitals signs that are stated in the vital section of the report. It was at this time that Medic 1 applied a OPA after first measuring on what size to use. First responders also applied fast patches to the patients right upper chest and left midaxillary line At this time Medic 1 assigned first responders to start chest compressions a 15:2 ratio. Medic 1 at this time started a IO in the patients plateau region of the right leg. The Plateau region is inferior and lateral to the knee cap. At this time Normal Saline bolus was started with a 60 drop per ML set. Medic 1 found the patient to be in a sinus rhythm At this time miscommunication with Medic 1 and first responders happen with chest comparisons started. We then secured the patient on the cot via 4 straps and transported a code red patient to the nearest hospital. While enroute to hospital radio report was given with chief compliant and treatments listed in the appropriate category of the report. Vitals was continued to be taken every 5

The patient reports being sick with the flu for the past 8 days. She has been vomiting several times a day and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated. After fainting at home she was taken to the hospital. An arterial blood gas sample was drawn and then an IV was placed to help rehydrate her.

My two nursing diagnoses would be social isolation related to cultural difference as evidence by patient speaking Spanish as a first language. The rational for that would be that the no one can speak Spanish fluently and is a different culture from me. We would need to get an interpreter to help interpret for us between the patient and the healthcare team. They would need to book a service for someone to either come into the office or have them interpret over the internet like skype. I would evaluate it by seeing if the communication between the patient and the health care team is able to translate all the word and that the patient understands everything that is going on. My second one would be impaired verbal communication related to sensory

At today’s visit, she is awake, alert, oriented. She was evaluate by hospice and was appropriate for admission but she refused admission and states that she wanted to continue with palliative care for the next 2 weeks. I am here to follow up for her disabling dyspnea. She is noticeable dyspneic on my arrival. She states that she continues to have chronic dyspnea/shortness of breath and that she does not want oxygen but is willing to try medication. She complains of a new onset cough, intermittent, clear secretion. She does not feel it is associated to her Lisinopril. She complains of GERD. She states that she would like to try morphine for her shortness of breath and if it is not effective then she will elect hospice

A CRNA has much responsibility in the hospital setting and also the outpatient setting depending on the area. Most CRNA 's have Anesthesiologist working above one. A CRNA that works in a hospital setting has many areas to specialize in, such as cardiology, orthopedics, epidurals, general surgery, pediatrics/neonatal. This role differs from other nursing roles in many ways. A CRNA meets with the patients and gives the patient medication to sleep. The CRNA will monitor the patient’s hemodynamic measures during the procedure and titrate medication based on patient’s response to surgery. A Nurse Anesthetist must further one’s education to a masters or now a doctorate degree. An RN that is pursuing this degree needs to have at least one year of Intensive care unit experience, or Emergency room at a level one trauma center. Acute care is important because patients in this setting can change dramatically very quick. The nurse has to know how to deal with a patient that is critical. The reason that one needs this experience is because a nurse working in the icu works under stressful conditions with critical patients. administering anesthetics is critical because one has to monitor the patient, and anything could change in a heartbeat. A nurse that has acute care experience has learned Advanced cardiac life support, ECG monitoring, hemodynamic values, and have worked with an acute care multi disciplinary team to treat the patient.

Nurses are diagnosticians. A nursing diagnosis is defined as “a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community” (Herdman, T. H., Kamitsuru, S., & North American Nursing Diagnosis Association, 2014, p. 25). Nursing diagnoses are different than medical diagnoses because they help to identify the problems that patients are facing as a result of the disease. The problems identified are within the nurse’s scope of practice. The accuracy of diagnosis of human response is crucial because all the nursing actions will flow from that specific diagnosis ( Black, B. P., and Chitty, K. K., 2014). Margaret Lunney states that the accuracy of the nursing diagnosis is professional behavior in which the nurse is fully accountable for it (Lunney, 2001). Professional behavior and accountability were acknowledged when considered the diagnoses for my case study, S.M.

Nursing diagnosis is identified after data collection and analysis. The North American Nursing Diagnosis Association (NANDA) identifies one nursing diagnosis related to infection; risk of infection is an increased risk for being invaded by pathogenic organisms. The risk factors that increase a client’s susceptibility to infections are as follows:

Possible nursing diagnosis: Altered nutrition less than body requirements related to oral intake Associated With Decreased lack of appetite. Imbalance nutrition less than body requirements related to knowledge deficit. Insufficient muscle strength and weakness related to Decreased oral intake. Within the care plan you may be included if it is a symptom that should make us ask whether there is more below because it may be that a new medication that we have offered the greatest decrease your appetite or have a more severe disease, is a sign Alarm makes us investigate further. patients older than 80 years have appetite disturbances associated in the first instance, to physiological factors. The elderly usually eat less because their physical needs

The primary nursing diagnosis for this patient was impaired tissue perfusion (cerebral) related to increased intracranial pressure secondary to subdural and subarachnoid hemorrhage. S.C. was unconscious upon his arrival to the emergency department. He was intubated in the field as a result of depressed breathing. He had a craniotomy and ventriculostomy placed to relieve and monitor intracranial pressure and redirect CSF. His pupillary reflex was diminished with uneven +sluggishly reactive pupils that became unreactive by day three of his time in the ICU. He had a gag reflex and cough reflex that remained throughout his time in the ICU, and he had an absent corneal reflex.

Ineffective coping R/T Inability to meet basic needs (as evidenced by dry mucous membranes, insomnia, lack of appetite.)

A consecutive series of patients who had undergone anatomically successful MH closure and were followed for at least 6 months postoperatively were enrolled in this study.