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Databases:

Nursing Reference Center Plus

GALE OneFile

Keywords: Nursing assessment

Nursing Diagnosis

Nursing Process

Cystic Fibrosis

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July 8th; 10:10am

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Name: Buu, Professional Writing Assistant

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Collecting objective and subjective data in order to identify a priority problem.

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The nursing diagnosis is an identified priority problem based off of the nurse's assessment findings, which can be addressed by nursing care. Some types of nursing diagnoses include actual nursing diagnoses and risk diagnoses. The actual nursing diagnosis is an already existing issue that can be identified by signs and symptoms. A risk nursing diagnosis is based on assessment findings that suggest the patient is at risk of such diagnosis.

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During planning, the nurse prioritizes the nursing diagnosis and develops short- and long-term goals. The goals must be achievable, measurable, appropriate, realistic, and have a timeframe (SMART). After setting a SMART goal, the nurse then identifies appropriate interventions to help achieve the set goals.

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The implementation step of the Nursing Process is when the nursing team initiates the interventions that were chosen to help the patient achieve their individualized short- and long-term goals.

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The evaluation step is intended to evaluate the patient and the patient's response to the implemented interventions.

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6kg weight loss

Normal sinus rhythm

Breath sounds

Respiratory rate

Pallor

Abdomen flat and nontender

Active bowel sounds x 4 quadrants

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Fatigue

0/10 pain

Decreased appetite

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Christopher Parrish is an 18-year-old male with history of multiple hospitalizations and cystic fibrosis. He reports fatigue and has lost 6kg since moving into a college dorm. He is awake and alert, his has a normal sinus rhythm of 80-85 bpm. Breath sounds are fine with respiratory rate 18b/m. Color is pale, bp 118/78, 0/10 pain with decreased appetite. His belly is flat and nontender. Bowel sounds are active. Christopher has an NG tube places in his right nares to maintain nutritional intake.

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Clustering data and identifying a priority diagnosis is important because it allows for the optimization of care and setting priority for planned care interventions. Laying out the foundation for care enables the nurse and other team members to best provide for the patient and their priority needs.

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The purpose of the nursing process is to use collected data to develop an individualized plan of care. In the nursing process, the first step allows the nurse to identify problems based on their assessment and then decide what the priority problem is. From there, the nurse makes a nursing diagnosis and can collaborate with the healthcare team to develop and implement a plan of care. After a plan is implemented, the nursing team will evaluate the patient to decide whether or not the plan is effective, and make changes where needed.

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Christopher Parrish's priority problem based on the assessment is malnutrition secondary to cystic fibrosis.

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The patient will achieve and maintain the appropriate daily caloric and nutritional intake during the next week.

The patient will gain 1lb in one week.

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Interventions include: Monitor the patient's dietary intake daily.

Monitor the patient's weight daily.

Educate the patient (and family) about appropriate dietary intake.

Collaborate with a nutritionist.

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Re-connect with the patient to evaluate signs and symptoms of malnutrition in one week. If patient is not meeting the set goals, re-evaluate plan of care.

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Secer, S., & Karaca, A. (2021). Evaluation of Nurses' Perceptions of Nursing Diagnoses and Their Opinions Regarding the Application of Nursing Process. Florence Nightingale Journal of Nursing, 29(2), 229+. http://dx.doi.org.lcc.idm.oclc.org/10.5152/FNJN.2021.20034

"Inadequacy of nursing process practice in general or at any stage will be negatively reflected in the care given."

"On the basis of these results, the awareness of nurses about the assessment stage should be increased. As it provides the basis for all stages of the nursing process, it is important to ensure complete and accurate assessment to provide correct and safe care because a problem at this stage will cause misinterpretation of all stages. A nurse who fails to obtain correct and sufficient data would make a wrong nursing diagnosis, and thus identify wrong nursing interventions and might follow an incorrect practice process."