...ICNP has led to a large database that validates nursing specific diagnoses, interventions and outcomes. It is cross-referenced with different nursing classification systems to compile common information across the continuum. A nurse in the medical unit is able to utilize a care plan that is formulated based on information compiled and translated into best evidenced based practice. “Information gathered is also useful in the educational setting expands nursing knowledge of interventions, outcomes and languages” (Rutherford, 2008). The nurse would choose a nursing diagnosis based on the assessment and collection of patient information. ICNP can be utilized incorporating other systems of classification such as Omaha System, NANDA, NIC, and HHCC (Hynn & Park, 2002). A nursing diagnosis is formulated and a recognized set of interventions would be initiated. With the added benefit of an electronic format at the bedside, the nurse is able to document at the bedside with more precision and timeliness, improving the accuracy of documentation. For example, a patient admitted with the diagnosis of COPD, the nurse could use the nursing diagnosis of impaired gas exchange. A care plan would be created with appropriate interventions and outcome criteria. Care would be more precise based on standardized interventions and outcomes derived from ICNP. A study in 2005 to assess the “expressiveness” of an ICNP based computerized nursing record system. The study discovered that bedside...
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...implications for nurses, nursing, national health policy, patient outcomes and population health associated with the collection of core criteria will also be discussed. Recommendations for additional core criteria will also be presented. Overview of Meaningful Use NANDA International (NANDA-I) was developed to identify and classify health problems within nursing, increase the visibility of nursing, organize nursing data and allow for accurate reimbursement for nursing care (Thede & Schwirian, 2015). NANDA-I states that it’s diagnoses are intended to communicate the professional judgements that nurses make every day to patients, other healthcare professional and the public (NANDA International, 2015). NANDA-I diagnoses relevant to the patient scenario given are 1) fluid volume deficit related to increased fluid loss and insufficient fluid intake 2) electrolyte imbalance related to increased fluid loss and insufficient fluid intake 3) knowledge deficit. The Center for Nursing Classification and Clinical Effectiveness, CNC (2015) defines the Nursing Intervention Classification (NIC) as a comprehensive, research-based, standardized classification of nursing interventions. “The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care” (CNC, 2015). NIC interventions relevant to the discussed scenario are fluid and electrolyte management. Activities or interventions include: 1) monitor...
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...MEDICAL MANAGEMENT: * Pain management * Fracture treatment * Realignment (aka reduction) immobilization to maintain alignment casting, splinting * Physical/occupational therapy- regaining/learning achievable mobility, ambulation and ADL capabilities * Treatment of skin integrity, complications * Maintenance/treatment of fluid volume + nutritional status MEDICAL MANAGEMENT: * Pain management * Fracture treatment * Realignment (aka reduction) immobilization to maintain alignment casting, splinting * Physical/occupational therapy- regaining/learning achievable mobility, ambulation and ADL capabilities * Treatment of skin integrity, complications * Maintenance/treatment of fluid volume + nutritional status COMPLLICATIONS * Infection * Shock – hypovolemic/hemorrhage * Pressure ulcers r/t possible decreased mobility/sensation * Compartment syndrome * Fat embolism syndrome * Muscle atrophy * Non-union (fracture doesn’t heal – no new callus formation) * Malunion (fracture heals in incorrect position, can = deformity + malfunction) * Re-fracture COMPLLICATIONS * Infection * Shock – hypovolemic/hemorrhage * Pressure ulcers r/t possible decreased mobility/sensation * Compartment syndrome * Fat embolism syndrome * Muscle atrophy * Non-union (fracture doesn’t heal – no new callus formation) * Malunion (fracture heals in incorrect position,...
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...The MRI will also show any prolapse in other pelvic organs, such as the bladder or vagina. (MayoClinic, 2017) Treatment of Rectal...
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...------------------------------------------------- Clinical Preparation Worksheet- Information Necessary for Care ------------------------------------------------- ------------------------------------------------- Your Name _ Date of Care_3/17/2014_____ Pt. Initials__M.A.____________ ------------------------------------------------- Pt. age__51_______ Code Status _Full Code______________Braden /SKIN Score __K_____ ------------------------------------------------- Fall Risk- Fall risk with high injury probability __Level 2________________ ------------------------------------------------- ------------------------------------------------- Admitted from: Home/extended care facility? __Home___________________ ------------------------------------------------- ------------------------------------------------- Reason for admission - also called CC or Chief complaint: (This is in the pt.’s words. Ask them why they came to the hospital and record what they say as a direct quote.) ------------------------------------------------- Fell in the shower and became unconscious, tried to call girlfriend but couldn’t move left side ------------------------------------------------- ------------------------------------------------- Admitting Medical Diagnosis/Diagnoses: ------------------------------------------------- Stroke ------------------------------------------------- ------------------------------------------------- Medical and Surgery History:...
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...Discuss the general procedural considerations for radiographic examinations including: a) patient preparation for examination Many radiologic exams require specific patient preparation prior to the exam in order to ensure that the study is performed in the safest and most accurate manner possible. For example: ❖ MRI- With contrast: No solid foods 4 hours before your study. Clear fluids are allowed up to 2 hours before study. Without contrast: No foods or fluids up to 2 hours before study. Any use of medical or electronic devices should be informed before study. ❖ CT scan- Fluids and food may be restricted for several hours prior to the examination ❖ Mammogram- Do not use any powders, deodorant, perfume or lotions before the study. ❖ Ultrasound- Do not eat, drink, smoke or chew gum after midnight the night before morning appointment, or for at least 6 hours prior to afternoon appointment. b) Informed consent and who is responsible for obtaining the informed consent Informed consent is a legal protection of a patient's authorization or agreement to undergo a specific medical intervention. It is the responsibility of the attending licensed healthcare professionals- physicians and nurses- to obtain and witness the patient’s signature. The informed consent includes: • The patient’s diagnosis • The patient’s prognosis • The proposed treatment • The risks and benefits associated with the proposed treatment • Any alternative...
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...neurodegenerative disease that portrays progressive muscle paralysis, and eventually ends with death. As many as twenty thousand to thirty thousand people in the United States have amyotrophic lateral sclerosis, and an estimated five thousand people in the United States are diagnosed with the disease each year (Shiel, 2012). The etiology of the disease is unknown, but it plays a genetic factor. Less than ten percent has been shown to be inherited in families. ALS begins with the client with muscle weakness, stiffness, eventually to paralysis, then death caused by respiratory failure. Dysphagia occurs at onset in about one third of case, although generally it occurs in later stage of the disease (Noh, 2010). The nursing diagnosis is risk for aspiration related to impaired swallowing. Intervention for the diagnosis includes positioning the client in a 90 degree angle while in bed, a wheel chair or a chair. There is no known cure for the disease, but symptoms can be treated. Riluzole is administered to slow the progression of the disease. Pathophysiology Amyotrophic lateral sclerosis is a neurodegenerative disease that begins with rapid, progressive muscle weakness. It attacks the neurons that are responsible for moving voluntary muscles. Once the person is diagnosed with the disease, the person will inevitably face death during the later stages of the disease. Respiratory failure limits survival to 2-5 years after disease onset (Noh, 2010). The etiology of ALS is unknown...
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...MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT PATIENT PRIVACY GUIDELINES For MCCCD Health Care Integrated Educational System The Maricopa County Community College District has cooperative agreements with over 500 agencies for the clinical training of its students enrolled in all health-care fields and programs. To ensure that MCCCD students, faculty, and staff involved in those programs understand the patient privacy requirements of those clinical sites and of applicable law, including the Health Insurance Portability and Accountability Act of 1996, MCCCD offers this guidance for those persons to ensure compliance with those requirements. Note that the discussions, uses or disclosures discussed below encompass written, verbal, or electronic communications. |DO’S |DON’T’S | | | | |Do sign the MCCCD Faculty/Staff/Student Confidentiality Agreement before |Don’t discuss, use or disclose any patient information while in the | |any involvement in a clinical program. |clinical setting unless it is part of your clinical assignment. | |Do attend MCCCD training or in-classroom clinical instruction on |Don’t remove any record from the...
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...resting, he started to cough at the same time with difficulty in breathing. Then his relatives send him in the hospital, then the nurse immediately gives him oxygen. To ensure the condition of the patient, there are a lot of diagnostic exam done to the patient, as the result, the patient had lung cancer. He was hospitalized for few months but then the patient died because of complication. PATHOPYSIOLOGY: Inhalation of carcinogen Tracheobronchial airways Carcinogen binds to and damages the cell’s DNA Developing malignant cell DNA becomes unstable Pulmonary epithelium change Invasive carcinoma Lung cancer DIAGNOSTING EXAM: * MRI * Bronchoscopy * Chest X-ray * Magnetic Resonance * Imaging * Lymph node biopsy * Pulmonary function test INTERVENTION: PHARMACOLOGIC INTERVENTIONS * Expectorants and antimicrobial agents to relieve dyspnea and infection. * Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to achieve pain control. * Chemotherapy using cisplatin in combination with a variety of other agents and immunotherapy treatments may be indicated....
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...Associate Degree Nursing Program NURS 122 Concept Care Map Evaluation Rubric: Maternal-Newborn |Value/categories |0 |1 |2 | |Assessment with Pathophysiology | < 90% data filled |> 90% data filled in |Complete with | | |incorrectly |correctly |Pathophysiology | |Lab work/rationale or reason for| | | | |labs | | | | | |0 |1 |2 | | |95% lab work and reasons | | |documented |documented |documented | |Step 3 - Care Map |0 |1 |2 | |Problem category Physiological |2 appropriate problems with|3 appropriate problems with|4 or more appropriate | |and psychological related to |Reason for admit and key |Reason for admit and key |problems with Reason for | |stages of postpartum |assessments |assessments |admit and assessments | | ...
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...closest to the body of the uterus, and squamous cells, which cover the exocervix or ectocervix, the part next to the vagina. The cancer cells that form from the exocervix is called squamous cell carcinomas and the cancer cells that form from the endocervix is called adenocarcinomas. Cervical cancer develops slowly over time and does not occur overnight. Initially, cells in the cervix go through changes known as precancerous changes or dysplasia. Once these abnormal cells become cancerous and begin to grow, the cancer will start to spread and becomes invasive if left untreated (American Cancer Society, 2016). This research will focus on understanding cervical cancer, prevalence of the disease, diagnostic tests, treatment modalities, nursing care, possible complications of the disease and the disease outcome. Description of the Condition Cervical cancer has been known to affect women worldwide and is labeled as the third most common cancer in women. Globally, the yearly statistical incidence of newly diagnosed cervical cancer reported by the World Health organization was about 530, 000 and 275000 cancer deaths. The large percentage of cervical cancer death occurs in developing and undeveloped countries (Mcgraw, & Ferrante, 2016). As far as the United States registry in the year 2013, the Centers for Disease Control and Prevention (2016) reported an incidence of 11,955 and 4,217 cases of death. Regionally, the cervical cancer incidence rate in Washington State is 6.7 while...
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...Traumatic Brain Injury WUT2 Task Western Governors University A. Investigated Disease Process The disease process I will be reviewing is traumatic brain injuries. A traumatic brain injury occurs when sudden trauma occurs to an individual’s brain. Traumatic brain injuries are considered closed or penetrating. Traumatic brain injuries are categorized as mild, moderate or severe based on the amount of damage that occurs to the brain. (ninds.nih.gov, 2015) A1. Pathophysiology To understand traumatic brain injuries, we must first discuss the numerous causes of brain injury. When injury occurs to the brain, the patient encounters the primary injury that is directly related and occurs at the time of the injury. Secondary injury occurs as a result of the primary injury but often leads to a more significant sequela based on the type of initial trauma. Non penetrating injuries to the cranium that lead to traumatic brain injuries are not always related to direct blows of the cranium. Rapid acceleration and deceleration injuries along with compression injuries may lead to traumatic brain injuries. This type of injuries can lead to injuries to the brain tissue that could include compression, stretching and shearing injuries to the brain tissue. These type of injuries are classified as “diffuse axonal injuries”. Diffuse axonal injuries are one of the most common and extensive types of traumatic brain injuries. These injuries often lead to death or severe irreversible...
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...Pathology and Disease Profile Report 1.Primary Major Dx: Paranoid Schizophrenia 2. Definition/Process/Manifestation (Signs and Symptoms): Schizophrenia is a devastating brain disease that affects a person’s thinking, language, emotions, social behavior, and ability to perceive reality accurately. It is described as a psychotic disorder. The term “psychotic” refers to delusions, any prominent hallucinations, disorganized speech, or disorganized catatonic behavior. The lifetime prevalence of schizophrenia is 1% world-wide with no differences related to race , social status, culture, or environment. The most typical age for onset of schizophrenia is during the late teens and early twenties, although cases of onset at age 5 or 6 have been reported. Earlier onset usually happens in males 18-25 y/o, with later onset in females 25-35y/o. These later onset individuals have less evidence of structural brain abnormalities, and have better outcomes. Schizophrenia most likely occurs as result of a combination of inherited genetic factors and extreme non-genetic factors e.g. (virus infection, birth injuries, nutritional factors)., which can affect the genes governing the brain or injure the brain directly. Schizophrenia is not a single disease but a syndrome that involves neurobiochemical and neuroanatomical abnormalities with strong genetic links. It does have a high heritability rate of about 80%. Substance a buse disorders along with nicotine dependence is very common...
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...Running head: Executive Management Project Code 100 Chamberlain College of Nursing EX630: Executive Practicum Professor Valda Upenieks 6/16/2012 The Master of Science Nursing student with the collaboration of my nurse executive mentor Mrs. Darville created a project that is valuable for the facility and a rewarding experience for me as a graduate student. My personal practicum experience took place at St Elizabeth’s Hospital, which is a small 90 bed community hospital located in Gonzales, La. St Elizabeth’s Hospital is a part of the Franciscan Missionaries of Our Lady Health System which was organized in 1984 to unite with three existing hospitals in Louisiana which were already a part of the system extending the healthcare of Jesus Christ to those most in need. The facility serves the people of Ascension Parish and surrounding areas (St Elizabeth, 2010). St Elizabeth’s Hospital has hundreds of outpatient and inpatient services that include: Cancer Center, Cardiopulmonary, Laboratory, MRI Center, Telemetry, Intensive Care, Weight Loss Surgery, Surgery, Ambulatory Surgery Center, Emergency Department, After Hours, Community Clinic and Physician Tower. St Elizabeth’s Hospital is a very small hospital compared to most but it is outstanding in all it does, they have been recognized for contributions to community, large business of the year, best place to work, performance excellence, capstone quality award, just to name a few (St Elizabeth Hospital...
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...Family Nursing Diagnosis Susan Kenney, RN NUR/405 June 9, 2014 Beth Edwards, MSN, FNP-BC Family assessment, roles and structure The family I have been working with consists of three sisters who live in a house owned by the eldest of the three, C.H. C.H. is a 64 year old Caucasian female who was born with cerebral palsy and mental retardation. She has never been able to walk, and her mentation never progressed past the age of an approximately 4 year old child. She lived at home with her parents and two sisters and one brother until the age of 11 when she was institutionalized in a facility notorious for the mistreatment and neglect of its residents. The facility has long since closed, and in 1991, C.H. was placed with our organization, Community Vision Inc. (CVI). Her parents were both deceased by that time, and her sister D.H.C. assumed legal guardianship, with sister N.W. helping with her needs. CVI is a non-profit organization that assists disabled individuals to live as independently as possible, and enables them to purchase and live in their own homes if possible. We provide caregivers and in collaboration with social services and interdisciplinary personnel facilitate the supported individual to live to their maximum potential. Each person has their own individual service plan with health, safety, and vocational goals, and staffing is provided as required to meet the individual’s needs. Assessment of C.H. and her living situation The home the sisters...
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