Nursing Diagnoses for Planning Care

Nurses and healthcare consumers agree that nursing care is a key factor in achieving positive outcomes and enhancing client satisfaction. Nursing care is instrumental in all phases of acute care as well as in the maintenance of general wellbeing (prevention of illness, rehabilitation, and maximization of health), or where a return to health is not possible, the relief of pain and discomfort and a peaceful death. To this end, the nursing profession has identified a problem-solving process that “combines the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method”.

The original concept of nursing process was a three-step process of assessment, planning, and evaluation based on the scientific method of observing, measuring, gathering data, and analyzing the findings. After years of study, use, and refinement, the three-step process was expanded. The five steps—(1) assessment, (2) problem identification, (3) planning, (4) implementation (putting the plan into action), and (5) evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)—are central to nursing actions and the delivery of high-quality, individualized client care in any setting.

In 1991, the ANA Standards of Clinical Nursing Practice described the client care process and standards for professional performance, providing impetus and support for the use of nursing diagnosis in the practice setting. The work of NANDA International (formerly North American Nursing Diagnosis Association) has been ongoing for more than 25 years, beginning with efforts to identify client problems/needs for which nurses are accountable. NANDA continues to develop nursing diagnostic labels, which are now being complemented by the Iowa Intervention Project: Nursing Interventions Classification (NIC) and the Iowa Outcomes Project: Nursing Outcomes Classification (NOC). NIC directs our focus to the content and process of nursing care by identifying and standardizing the care activities nurses perform while NOC describes client outcomes that are responsive to nursing intervention and developing corresponding measurement scales.

Changes in the healthcare system continue to occur, requiring the profession of nursing to define itself in a way that will complement and facilitate the provision of appropriate, cost-effective evidenced-based care to all persons. Nurses need a common framework of communication and documentation so their contribution to healthcare is recognized as being essential and they are remunerated appropriately. At the very least, nursing requires a commonality of words describing practice so it can be captured and is visible in the healthcare databases.

The linkage of nursing diagnoses to specific nursing interventions and client outcomes has led to the development of a number of standardized nursing languages (Omaha System, Clinical Care Classification, Ozbolt Patient Care Data Set, Perioperative Minimum Data Set). The purpose of these languages is to help ensure continuity of appropriate highquality nursing care for the client regardless of setting. This is accomplished in part through enhanced communication, standardization of the process evaluating the care provided, and facilitation of documentation.

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Transmission of Hepatitis C

Hepatitis C is a disease with a significant global impact. According to the World Health Organization there are 170 million people infected with hepatitis C virus (HCV). There are considerable regional differences. In Europe and the United States chronic hepatitis C is the most common chronic liver disease. The majority of liver transplants performed in these regions are for chronic HCV. It is difficult to determine the number of new HCV infections, as most acute cases are not noticed clinically.

Parenteral exposure to the hepatitis C virus is the most efficient means of transmission. The majority of patients infected with HCV in Europe and the United States acquired the disease through intravenous drug use or blood transfusion, which has become rare since routine testing of the blood supply for HCV began. The following possible routes of infection have been identified in blood donors (in descending order of transmission risk):

• Injection drug use
• Blood transfusion
• Sex with an intravenous drug user
• Having been in jail more than three days
• Religious scarification
• Having been struck or cut with a bloody object
• Pierced ears or body parts
• Immunoglobulin injection

Very often in patients with newly diagnosed HCV infection no clear risk factor can be identified.

Factors that may increase the risk of HCV infection include greater numbers of sex partners, history of sexually transmitted diseases, and failure to use a condom. Whether underlying HIV infection increases the risk of heterosexual HCV transmission to an uninfected partner is unclear. The seroprevalence of HCV in MSM (men who have sex with men) ranges from about 4 to 8%, which is higher than the HCV prevalence reported for general European populations.

The risk of perinatal transmission of HCV in HCV RNA positive mothers is estimated to be 5% or less (Ohto 1994). Caesarean section has not been shown to reduce transmission. There is no evidence that breastfeeding is a risk factor.

Hemodialysis risk factors include blood transfusions, the duration of hemodialysis, the prevalence of HCV infection in the dialysis unit, and the type of dialysis. The risk is higher with in-hospital hemodialysis vs peritoneal dialysis.

Contaminated medical equipment, traditional medicine rites, tattooing, and body piercing are considered rare transmission routes.

There is some risk of HCV transmission for health care workers after unintentional needle-stick injury or exposure to other sharp objects.

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Simple music from John Lennon - Imagine (official video)

Imagine - John Lennon

Imagine - John Lennon, A song about humanism.

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Signs and Symptoms of Hydrocephalus

The signs and symptoms of hydrocephalus in infants and children vary depending on their age, the degree of hydrocephalus at presentation, the primary etiology, and the time over which the hydrocephalus develops. Ventriculomegaly can progress without obvious signs of increased intracranial pressure because of the plasticity of the infant brain and the ability of the cranium to expand.

In full-term infants, signs often include macrocephaly and progressively increasing occipital frontal head circumference, crossing percentile curves. Normal head circumference for a full-term infant is 33–36 cm at birth. A normal head circumference increases by approximately 2 cm/month during the first 3 months, by 1.5 cm/month during the 4th and 5th months, and by about 0.5 cm/month from months 6–12.

Signs and symptoms of hydrocephalus in children:

Premature infants

• Apnea
• Bradycardia
• Hypotonia
• Acidosis
• Seizures
• Rapid head growth
• Tense fontanel
• Splayed cranial sutures
• Vomiting
• Sunsetting eyes

Full-term infants

• Macrocephaly
• Rapid head growth
• Decreased feeding
• Increased drowsiness
• Tense fontanel
• Vomiting
• Distended scalp veins
• Splayed cranial sutures
• Poor head control
• Parinaud’s sign
• Sunsetting eyes
• Frontal bossing

Toddlers and older

• Headache
• Nausea
• Vomiting
• Irritability
• Lethargy
• Delayed development
• Decreased school performance
• Behavioral disturbance
• Papilledema
• Parinaud’s sign
• Sunsetting eyes
• Bradycardia
• Hypertension
• Irregular breathing patterns

 

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Nurse’s Ethical Duty in Wound Care

Performing an evaluation, assessment, or management of any type of wound is an ethical endeavor and may present ethical challenges at times. The specific concepts of paternalism, autonomy, beneficence, nonmaleficence, fidelity, role fidelity, veracity, therapeutic privilege, conflict of interest, confidentiality, and justice will be addressed.

The nurse might wonder why consideration of morals is of any importance when what he or she is doing is providing clinical services for some type of wound. The practice of wound care is fraught with areas in which the morals or society’s determination of right and good conduct of the health-care professional may be seriously tested. Understanding the concepts of morals, moral duty, and moral obligation are critical in providing wound care.

Specific obligations and duties for the privilege of professional access to patients, including the following:

• First, the patient’s interests are placed above the personal interest of the nurse. If this duty is overlooked or forgotten, the contract (standard of practice) among the health-care provider, the health-care organization, and the patient is broken. — Example: The health-care provider conducts a seminar and needs wound photographs to supplement the written and verbal components of the presentation. The provider takes photographs of the patient’s wounds solely for the purpose of using them in the seminar. The only reason for taking these photographs is for the convenience of the health-care provider, and therefore the activity is actually for the nurse’s personal interest and not for the patient’s best interest. The patient would need to grant the nurse informed consent to use the photographs to avoid any consideration that the photographs are for personal interest. The nurse would need to assure the patient that any refusals on the patient’s part would have no effect on the nurse-patient relationship or the patient’s treatment.
• The patient’s privacy is protected from another individual’s or society’s desire to know details of the patient’s treatment. It is the health-care provider’s responsibility to have a complete understanding of the legal rights of all involved. It is ultimately the responsibility of the nurse to know the legal rights of the patient, family, and health-care provider. However, in many areas of the world, the general public does not have any legal right to knowledge concerning the patient’s care, progress, or prognosis. The health-care provider must identify if the health-care organization has a policy or procedure concerning this challenge.
• Does the health-care provider have a duty to treat the patient who has a wound(s)?

It is important to remember that this information concerns the ethical decision making only and is not to be construed as presenting a legal argument for or against treatment. Failure to treat may have potential legal consequences.

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Overview of Respiratory Function

The major function of lungs and pulmonary circulation as the pulmonary system is to deliver oxygen (O₂) to cells and remove carbon dioxide (CO₂) from the cells (gas exchange). The adequacy of oxygenation and ventilation is measured by partial pressure of arterial oxygen (PaO₂) and partial pressure of arterial carbon dioxide (PaCO₂). The pulmonary system also functions as a blood reservoir for the left ventricle when it is needed to boost cardiac output; as a protector for the systemic circulation by filtering debris/particles; as a fluid regulator so water can be kept away from alveoli; and as a provider of metabolic functions such as surfactant production and endocrine functions.

Terminology in Respiratory

• Alveolus—air sac where gas exchange takes place
• Apex—top portion of the upper lobes of lungs
• Base—bottom portion of lower lobes of lungs, located just above the diaphragm
• Bronchoconstriction—constriction of smooth muscle surrounding bronchioles
• Bronchus—large airways; lung divides into right and left bronchi
• Carina—location of division of the right and left main stem bronchi
• Cilia—hairlike projections on the tracheobronchial epithelium, which aid in the movement of secretions and removal of debris
• Compliance—ability of the lungs to distend and change in volume relative to an applied change in pressure (eg, emphysema—lungs very compliant; fibrosis—lungs noncompliant or stiff)
• Dead space—ventilation that does not participate in gas exchange; also known as wasted ventilation when there is adequate ventilation but no perfusion, as in pulmonary embolus or pulmonary vascular bed occlusion. Normal dead space is 150 mL.
• Diaphragm—primary muscle used for respiration; located just below the lung bases, it separates the chest and abdominal cavities
• Diffusion (of gas)—movement of gas from area of higher to lower concentration
• Dyspnea—subjective sensation of breathlessness associated with discomfort, often caused by a dissociation between motor command and mechanical response of the respiratory system as in:
  • Respiratory muscle abnormalities (hyperinflation and airflow limitation from chronic obstructive pulmonary disease [COPD]).
  • Abnormal ventilatory impedance (narrowing airways and respiratory impedance from COPD or asthma).
  • Abnormal breathing patterns (severe exercise, pulmonary congestion or edema, recurrent pulmonary emboli).
  • Arterial blood gas (ABG) abnormalities (hypoxemia, hypercarbia).
• Hemoptysis—coughing up of blood
• Hypoxemia—PaO₂ less than normal, which may or may not cause symptoms (Normal PaO₂ is 80 to 100 mm Hg on room air.)
• Hypoxia—insufficient oxygenation at the cellular level due to an imbalance in oxygen delivery and oxygen consumption (Usually causes symptoms reflecting decreased oxygen reaching the brain and heart.)
• Mediastinum—compartment between lungs containing lymph and vascular tissue that separates left from right lung
• Orthopnea—shortness of breath when in reclining position
• Paroxysmal nocturnal dyspnea—sudden shortness of breath associated with sleeping in recumbent position
• Perfusion—blood flow, carrying oxygen and CO₂ that passes by alveoli
• Pleura—serous membrane enclosing the lung; comprised of visceral pleura, covering all lung surfaces, and parietal pleura, covering chest wall and mediastinal structures, between which exists a potential space
• Pulmonary circulation—network of vessels that supply oxygenated blood to and remove CO₂-laden blood from the lungs
• Respiration—inhalation and exhalation; at the cellular level, a process involving uptake of oxygen and removal of CO₂ and other products of oxidation
• Shunt—adequate perfusion without ventilation, with deoxygenated blood conducted into the systemic circulation, as in pulmonary edema, atelectasis, pneumonia, COPD
• Surfactant—fluid secreted by alveolar cells that reduces surface tension of pulmonary fluids and aids in elasticity of pulmonary tissue
• Ventilation—movement of air (gases) in and out of the lungs
• Ventilation-perfusion (V/Q) imbalance or mismatch—imbalance of ventilation and perfusion; a cause for hypoxemia. V/Q mismatch can be due to:
  • Blood perfusing an area of the lung where ventilation is reduced or absent.
  • Ventilation of parts of lung that are not perfused.

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Biologic and Genetic Principles on Nursing

The impact of genetics on nursing is significant. The American Nurses Association (ANA) officially recognized genetics as a nursing specialty. This effort was spearheaded by the International Society of Nurses in Genetics (ISONG), which also initiated credentialing for the Advanced Practice Nurse in Genetics and the Genetics Clinical Nurse. ANA and ISONG have collaborated in the establishment of a scope and standards of practice for nurses in genetics practice. Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics were finalized in 2006. They reflect the minimal genetic and genomic competencies for every nurse regardless of academic preparation, practice setting, role, or specialty.

Cell as The Basic Unit of Biology

• Cytoplasm—contains functional structures important to cellular functioning, including mitochondria, which contain extranuclear deoxyribonucleic acid (DNA) important to mitochondrial functioning.
• Nucleus—contains 46 chromosomes in each somatic (body) cell, or 23 chromosomes in each germ cell (egg or sperm).

Chromosomes

Each somatic cell with a nucleus has 22 pairs of autosomes (the same in both sexes) and 1 pair of sex chromosomes. Females have two X sex chromosomes; males have one Y sex chromosome and one X sex chromosome. Normally, at conception, each individual receives one copy of each chromosome from the maternal egg cell (1 genome) and one copy of each chromosome from the paternal sperm cell (1 genome), for a total of 46 chromosomes (2 genomes). Karyotype is the term used to define the chromosomal complement of an individual, for example, 46, XY, as is determined by laboratory chromosome analysis. Each chromosome contains 800 to 3,000 genes.

 

Genes

Gene is the basic unit of inherited information. Each copy of the human genome in the nucleus has about 30,000 genes. Cells also have some nonnuclear genes located within the mitochondria within the cytoplasm. Alternate forms of a gene are termed alleles. For each gene, an individual receives one allele from each parent, and thus has two alleles for each gene on the autosomes and also on the X chromosomes in females. Males have only one X chromosome and, therefore, have only one allele for all genes on the X chromosome; they are hemizygous for all X-linked genes. At any autosomal locus, or gene site, an individual can have two identical alleles (homozygous) for that locus or can have two different alleles (heterozygous) at a particular locus. Genotype refers to the constitution of the genetic material of an individual; for practical purposes it is commonly used to address a specific gene pair. For example, the gene for sickle cell disease, the gene for cystic fibrosis, or the gene for familial polyposis. Phenotype refers to the physical or biochemical characteristics an individual manifests regarding expression of the presence of a particular feature, or set of features, associated with a particular gene. Each gene is composed of a unique sequence of DNA bases.

 

DNA: Nuclear and Mitochondrial

• Human DNA is a double-stranded helical structure comprised of four different bases, the sequence of which codes for the assembly of amino acids to make a protein—for example, an enzyme. These proteins are important for the following reasons:
  • For body characteristics such as eye color.
  • For biochemical processes such as the gene for the enzyme that digests phenylalanine.
  • For body structure such as a collagen gene important to bone formation.
  • For cellular functioning such as genes associated with the cell cycle.
• The four DNA bases are adenine, guanine, cytosine, and thymine-A, G, C, and T.
• A change, or mutation, in the coding sequence, such as a duplicated or deleted region, or even a change in only one base, can alter the production or functioning of the gene or gene product, thus affecting cellular processes, growth, and development.
• DNA analysis can be done on almost any body tissue (blood, muscle, skin) using molecular techniques (not visible under a microscope) for mutation analysis of a specific gene with a known sequence or for DNA linkage of genetic markers associated with a particular gene.

Normal Cell Division

Mitosis occurs in all somatic cells, which, under normal circumstances, results in the formation of cells identical to the original cell with the same 46 chromosomes.

Meiosis, or reduction division, occurs in the germ cell line, resulting in gametes (egg and sperm cells) with only 23 chromosomes, one representative of each chromosome pair.

During the process of meiosis, parental homologous chromosomes (from the same pair) pair and undergo exchanges of genetic material, resulting in recombinations of alleles on a chromosome and thus variation in individuals from generation to generation.

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