Nursing Diagnoses Organized According to Diagnostic Divisions

Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest

• Activity Intolerance
• Activity Intolerance, risk for
• Activity Planning, ineffective
• Disuse Syndrome, risk for
• Diversional Activity, deficient
• Fatigue
• Insomnia
• Lifestyle, sedentary
• Mobility, impaired bed
• Mobility, impaired wheelchair
• Sleep, readiness for enhanced
• Sleep Deprivation
• Sleep Pattern, disturbed
• Transfer Ability, impaired
• Walking, impaired

Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs

• Autonomic Dysreflexia
• Autonomic Dysreflexia, risk for
• Bleeding, risk for
• Cardiac Output, decreased
• Intracranial Adaptive Capacity, decreased
• Perfusion, ineffective peripheral tissue
• Perfusion, risk for decreased cardiac tissue
• Perfusion, risk for ineffective cerebral tissue
• Perfusion, risk for ineffective gastrointestinal
• Perfusion, risk for ineffective renal
• Shock, risk for

Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences

• Anxiety [specify level]
• Anxiety, death
• Behavior, risk-prone health
• Body Image, disturbed
• Conflict, decisional (specify)
• Coping, defensive
• Coping, ineffective
• Coping, readiness for enhanced
• Decision Making, readiness for enhanced
• Denial, ineffective
• Dignity, risk for compromised human
• Distress, moral
• Energy Field, disturbed
• Fear
• Grieving
• Grieving, complicated
• Grieving, risk for complicated
• Hope, readiness for enhanced
• Hopelessness
• Identity, disturbed personal
• Post-Trauma Syndrome
• Post-Trauma Syndrome, risk for
• Power, readiness for enhanced
• Powerlessness
• Powerlessness, risk for
• Rape-Trauma Syndrome
• Relationships, readiness for enhanced
• Religiosity, impaired
• Religiosity, risk for impaired
• Religiosity, readiness for enhanced
• Relocation Stress Syndrome
• Relocation Stress Syndrome, risk for
• Resilience, impaired individual
• Resilience, readiness for enhanced
• Resilience, risk for compromised
• Self-Concept, readiness for enhanced
• Self-Esteem, chronic low
• Self-Esteem, situational low
• Self-Esteem, risk for situational low
• Sorrow, chronic
• Spiritual Distress
• Spiritual Distress, risk for
• Spiritual Well-Being, readiness for enhanced

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ELECTROPHYSIOLOGY

Depolarization of the heart is the initiating event for cardiac contraction. The electric currents that spread through the heart are produced by three components: cardiac pacemaker cells, specialized conduction tissue, and the heart muscle itself.The ECG,however, records only the depolarization (stimulation) and repolarization (recovery) potentials generated by the atrial and ventricular myocardium.

The depolarization stimulus for the normal heartbeat originates in the sinoatrial (SA) node, or sinus node, a collection of pacemaker cells.These cells fire spontaneously; that is, they exhibit automaticity. The first phase of cardiac electrical activation is the spread of the depolarization wave through the right and left atria, followed by atrial contraction. Next, the impulse stimulates pacemaker and specialized conduction tissues in the atrioventricular (AV) nodal and His-bundle areas; together, these two regions constitute the AV junction. The bundle of His bifurcates into two main branches, the right and left bundles, which rapidly transmit depolarization wavefronts to the right and left ventricular myocardium by way of Purkinje fibers. The main left bundle bifurcates into two primary subdivisions, a left anterior fascicle and a left posterior fascicle. The depolarization wavefronts then spread through the ventricular wall, from endocardium to epicardium, triggering ventricular contraction.

Since the cardiac depolarization and repolarization waves have direction and magnitude, they can be represented by vectors. Vectorcardiograms that measure and display these instantaneous potentials are no longer used much in clinical practice.However, the general principles of vector analysis remain fundamental to understanding the genesis of normal and pathologic ECG waveforms.Vector analysis illustrates a central concept of electrocardiography—that the ECG records the complex spatial and temporal summation of electrical potentials from multiple myocardial fibers conducted to the surface of the body.This principle accounts for inherent limitations in both ECG sensitivity (activity from certain cardiac regions may be canceled out or may be too weak to be recorded) and specificity (the same vectorial sum can result from either a selective gain or a loss of forces in opposite directions).

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Reference Ranges—Hematology and Coagulation

Reference Ranges—Hematology and Coagulation

LABORATORY TEST NORMAL ADULT REFERENCE RANGE CLINICAL SIGNIFICANCE Conventional Units SI Units Bleeding Time 3-10 minutes 3-10 minutes ▪ Prolonged in thrombocytopenia, defective platelet function, and aspirin therapy D-dimer <250 mg/mL <250 mg/mL ▪ Increased in disseminated intravascular coagulation, malignancy, and arterial and venous thrombosis Erythrocyte Count Males 4,600,000-6,200,000/mm3 4.6-6.2 × 1012/L ▪ Increased in severe diarrhea and dehydration, polycythemia, acute poisoning, and pulmonary fibrosis ▪ Decreased in all anemias in leukemia and after hemorrhage, when blood volume has been restored Females 4,200,000- 5,400,000/mm3 4.2-5.4 × 1012/L Erythrocyte Indices Mean corpuscular volume (MCV) 84-96 µ3 84-96 Fl ▪ Increased in macrocytic anemia; decreased in microcytic anemia Mean corpuscular hemoglobin (MCH) 28-34 µµg/ cell 28-34 pg ▪ Increased in macrocytic anemia; decreased in microcytic anemia Mean corpuscular hemoglobin concentration (MCHC) 32%-36% Concentration fraction: 0.32-0.36 ▪ Decreased in severe hypochromic anemia Erythrocyte Sedimentation Rate (ESR)-Westergren Method ▪ Increased in tissue destruction, whether inflammatory or degenerative; during menstruation and pregnancy; and in acute febrile diseases Males younger than age 50 <15 mm/hour <15 mm/hour Males older than age 50 <20 mm/hour <20 mm/hour Females younger than 50 <20 mm/hour <20 mm/hour Females older than age 50 <30 mm/hour <30 mm/hour Fibrinogen 200-400 mg/ dL 2-4 g/dL ▪ Increased in pregnancy, cancer, inflammation, and nephrosis ▪ Decreased in severe liver disease and abruptio placentae Fibrin Split (Degradation) Products < mg/L < mg/L ▪ Increased in disseminated intravascular coagulation, myocardial infarction, and pulmonary embolism Fibrinolysis (Whole Blood Clot Lysis Time) No lysis in 24 hours - ▪ Increased activity associated with massive hemorrhage, extensive surgery, transfusion reactions, and liver disease Hematocrit Males 42%-52% Volume fraction: 0.42-0.52 ▪ Decreased in severe anemia, anemia of pregnancy, and acute massive blood loss ▪ Increased in erythrocytosis of any cause, and in dehydration or hemoconcentration associated with shok Females 37%-47% Volume fraction: 0.37-0.47 Hemoglobin Males 13-18 g/ dL 2.02-2.79 mmol/L ▪ Decreased in various anemias, pregnancy, severe or prolonged hemorrhage, and with excessive fluid intake ▪ Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation due to heart failure, and normally in people living at high altitudes Females 12-16 g/dL 1.86-2.48 mmol/L International Normalized Ratio (INR) 1.0 - ▪ INR used to standardize the prothrombin time and anticoagulation therapy 2-3 for therapy in atrial fibrillation, deep vein thrombosis, and pulmonary embolism 2.5-3.5 for therapy in prosthetic heart valves Leukocyte Count Total 5,000-10,000/mm3 5-10 × 109/L ▪ Total is elevated in acute infectious diseases, predominantly in the neutrophilic fraction with bacterial diseases, and in the lymphocytic and monocytic fractions in viral diseases ▪ Elevated in acute leukemia, following menstruation, and following surgery or trauma ▪ Eosinophils elevated in collagen disease, allergy, and intestinal parasitosis ▪ Depressed in aplastic anemia, agranulocytosis, and by toxic chemotherapeutic agents used in treating malignancy Basophils 0%-0.5% Number fraction: 0.6-0.7 Eosinophils 1%-4% Number fraction: 0.01-0.04 Lymphocytes 20%-30% Number fraction: 0.00-0.05 Monocytes 2%-6% Number fraction: 0.2-0.3 Neutrophils 60%-70% Number fraction: 0.02-0.06 Partial Thromboplastin Time (Activated) 20-35 seconds - ▪ Prolonged in deficiency of fibrinogen, factors II, V, VIII, IX, X, XI, and XII, and in heparin therapy Platelet Count 140,000-400,000/mm3 0.140-0.4 × 1012/L ▪ Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperatively; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy ▪ Decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy Prothrombin Time 9.5-12 seconds - ▪ Prolonged by deficiency of factors I, II, V, VII, and X, for malabsorption, severe liver disease, and coumarin anticoagulant therapy Reticulocytes 0.5%-1.5% of red cells Number fraction: 0.005-0.015 ▪ Increased with any condition stimulating increase in bone marrow activity (infection, blood loss ‘pacute and chronically following iron therapy in iron deficiency anemia’, and polycythemia vera) ▪ Decreased with any condition depressing bone marrow activity, acute leukemia, and late stage of severe anemias *Laboratory values may vary according to the techniques used in different laboratories.

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Ethical Core Concepts of Nursing Practice

Professional nurses occupy the frontlines of the health care arena. So, it is no surprise that they are the part of the health care team patients trust most with their health and welfare. Along with this privilege, nurses carry equal duties of responsibility and accountability to follow ethical principles and standards of care integral to the profession. Greater efforts must be made from within the profession to apply evidence-based research data to daily practice systematically and deliberately, thereby increasing patient safety, improving outcomes, and reducing risk and adverse events. Transformation of the professional culture within the health care system itself would give nurses at the bedside the incentive to join in these efforts as full partners with leaders in health care. Additional measures might include protocol implementation, preceptor performance review, peer review, continuing education, patient satisfaction surveys, and the implementation of risk management techniques. However, in certain instances, either despite or in the absence of such internal mechanisms, claims are made for an alleged injury or alleged malpractice liability. Although the vast majority of claims may be without merit, many professional nurses will have to deal with the unfamiliar legal system. A system of ethical principles and standards of care will be beneficial in such situations. Therefore, it is preferable for the nursing profession to incorporate certain ethical and legal principles and protocols into practice to make sure that the patient receives only safe and appropriate care.

 

Clinical ethics literature identifies four principles and values that are integral to the professional nurse's practice: the nurse's ethical duty to respect the patient's autonomy and to act with beneficence, nonmaleficence, and justice.

 

RESPECT FOR THE INDIVIDUAL AND HIS AUTONOMY

• Respect for the individual's autonomy incorporates principles of freedom of choice, self-determination, and privacy.
• The professional nurse's duty is to view and treat each individual as an autonomous, self-determining person with the freedom to act in accordance with self-chosen, informed goals, as long as the action does not interfere or infringe on the autonomous action of another.
• See the National League of Nursing Statement on Patients' Rights (see Box 2-1).
• The Joint Commission has established National Patient Safety Goals based on such settings as ambulatory care, assisted living, and the facility. See www.jointcommission.org/patientsafety/nationalpatientsafetygoals for more information.

BENEFICENCE

The principle of beneficence affirms the inherent professional aspiration and duty to help promote the well-being of others and, often, is the primary motivating factor for those who choose a career in the health care profession. Health care professionals aspire to help people achieve a better life through an improved state of health.

 

NONMALEFICENCE

• The principle of nonmaleficence complements beneficence and obligates the professional nurse not to harm the patient directly or with intent.
• In the health care profession, this principle is actualized only with the complementary principle of beneficence because it is common for the nurse to cause pain or expose the patient to risk of harm when such actions are justified by the benefits of the procedures or treatments.
• It is best to seek to promote a balance of potential riskinduced harms with benefits, with the basic guideline being to strive to maximize expected benefits and minimize possible harms. Therefore, nonmaleficence should be balanced with beneficence.

 

JUSTICE

• Justice, or fairness, relates to the distribution of services and resources.
• As the health care dollar becomes increasingly more scarce, justice seeks to allocate resources fairly and treat patients equally.
• Dilemmas arise when resources are scarce and insufficient to meet the needs of everyone. How do we decide fairly who gets what in such situations?
• One might consider whether it is just or fair for many people not to have funding or access to the most basic preventive care, whereas others have insurance coverage for expensive and long-term hospitalizations.
• Along with respect for people and their autonomy, the complex principle of justice is a culturally comfortable principle in countries such as the United States. Nonetheless, the application of justice is complex and often challenging.

 

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Preventing Patient Falls

Falls are a major cause of injury and death among elderly people. In fact, the older the person, the more likely he is to die of a fall or its complications. 

Factors that contribute to falls among elderly patients include lengthy convalescent periods, a greater risk of incomplete recovery, medications, increasing physical disability, and impaired vision or hearing.

If you're helping a fallen patient, send an assistant to collect the assessment or resuscitation equipment you need.

Preventing 

Assess your patient's risk of falling at least once each shift (or at least every 3 months if the patient is in a long-term care facility). Your facility may require more frequent assessments. Note any changes in his condition -such as decreased mental status- that increase his chances of falling. If you decide that he's at risk, take steps to reduce the danger.

Correct potential dangers in the patient's room. Position the call light so that he can reach it. Provide adequate nighttime lighting.

Place the patient's personal belongings and aids (purse, wallet, books, tissues, urinal, commode, cane or walker) within easy reach.

Instruct him to rise slowly from a supine position to avoid possible dizziness and loss of balance.

Keep the bed in its lowest position so the patient can easily reach the floor when he gets out of bed. This also reduces the distance to the floor in case he falls. Lock the bed's wheels. If side rails are to be raised, observe the patient frequently.

Advise the patient to wear nonskid footwear.

Respond promptly to the patient's call light to help limit the number of times he gets out of bed without help.

Check the patient at least every 2 hours. Check a high-risk patient every 30 minutes.

Alert other caregivers to the patient's risk of falling and to the interventions you've implemented.

Consider other precautions, such as placing two high-risk patients in the same room and having someone with them at all times.

Encourage the patient to perform active range-of-motion (ROM) exercises to improve flexibility and coordination.

 

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Common Signs of a Sleep Disorder

Look over this list of common signs of a sleep disorders, and talk to your doctor if you have any of them:

• It takes you more than 30 minutes to fall asleep at night.
• You awaken frequently in the night and then have trouble falling back to sleep again.
• You awaken too early in the morning.
• You frequently don’t feel well rested despite spending 7–8 hours or more asleep at night.
• You feel sleepy during the day and fall asleep within 5 minutes if you have an opportunity to nap, or you fall asleep at inappropriate times during the day.
• Your bed partner claims you snore loudly, snort, gasp, or make choking sounds while you sleep, or your partner notices your breathing stops for short periods.
• You have creeping, tingling, or crawling feelings in your legs that are relieved by moving or massaging them, especially in the evening and when you try to fall asleep.
• You have vivid, dreamlike experiences while falling asleep or dozing.
• You have episodes of sudden muscle weakness when you are angry, fearful, or when you laugh.
• You feel as though you cannot move when you first wake up.
• Your bed partner notes that your legs or arms jerk often during sleep.
• You regularly need to use stimulants to stay awake during the day.

Also keep in mind that, although children can show some of these same signs of a sleep disorder, they often do not show signs of excessive daytime sleepiness. Instead, they may seem overactive and have difficulty focusing and concentrating. They also may not do their best in school.

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Which Pediatrician Should We Choose?

They’re skilled listeners, and can pick up the cues of what’s said between the lines to know what’s really worrying a parent. Children feel at ease around a good pediatrician, so exams are more thorough and enjoyable. If you’ve found your dream pediatrician, your children will look forward to their visits. You’ll be relying on the pediatrician’s office, too: How well is it run? How good is the staff? If their office is poorly run, even great pediatricians won’t be able to keep parents happy.

Pediatricians come in all shapes and personalities. Which one to choose often comes down to personal preference and comfort.

Old versus Young
The stereotype is that older doctors have more years of valuable experience, and younger doctors are more up-to-date on the latest research and techniques. There’s some truth in this. Whether you end up favoring youth versus experience, you’ll want to work with doctors who keep up on their reading and maintain a healthy curiosity about children’s health. Any doctor, young or old, who feels they already know all they need to know is someone you should avoid. If your gut feeling is that you’d prefer a doctor with some grey hairs, go with that; if you think your children would prefer a younger physician, go that route. Either way can be fine, as long as you are confident and comfortable with your pediatrician’s skills and experience. 

I’m sometimes asked if I have children, or if a pediatrician needs to have children to be competent. Although I’ve certainly learned a tremendous amount from my own three kids, I think pediatricians who keep their minds open and really watch children will be able to learn what they need to know, even if they don’t have children of their own.

Man versus Woman
Most general pediatricians coming out of training are now women, so it’s going to get more difficult to find a male pediatrician in the future. If you’ve got your own comfort zone about who seems more competent, go with your gut. Most younger children don’t care whether their doctor is a man or woman, but many teenagers do. Though you may have to change doctors in ten years, don’t get too concerned about matching the genders of your baby and your pediatrician.

Personality Types
Some doctors are quiet and thoughtful; some are kind of kooky. Some are quite direct, and don’t beat around the bush; some are much more “gentle” in the way they communicate. Some doctors become more emotionally attached to their families and might act more “friendly”; others prefer to maintain a profession detachment. These and many other aspects of a pediatrician’s personality may fit better or worse with what you’re looking for. Meet a variety of doctors until you find one that “clicks” for you.

Availability
An otherwise excellent pediatrician with commitments to teaching, research, or other matters may not be regularly available. This may matter more to you if your children are younger or have special health needs that require more frequent visits to a doctor who knows them well.

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