SPARKS AND TAYLORS NURSING DIAGNOSIS REFERENCE MANUAL PDF
Home > Books > Sparks and Taylor's Nursing Diagnosis Reference Manual. Sparks and Taylor's Nursing Diagnosis Reference Manual View PDF. Sparks and Taylor's Nursing Diagnosis Pocket Guide (1) - Ebook download as PDF File .pdf), Text File .txt) or read book online. to another. or others are directly concerned. and nursing interventions. and references. your care plan can help. Sparks and Taylor's Nursing Diagnosis Reference Manual 9th edition provides clearly written, authoritative care plan guidelines for all NANDA.
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This clearly written, easy-to-use reference manual contains the evidence-based information that nursing students and practicing nurses need to diagnose and. Read Sparks & Taylor's Nursing Diagnosis Reference Manual PDF Ebook by Linda Phelps DNP sppn.infohed by LWW, ePUB/PDF. Ralph, Sheila Sparks and Cynthia M. Taylor. Sparks and Taylor's Nursing Diagnosis Reference Manual. Philadelphia: Wolters Kluwer/Lippincott Williams.
They also provide the same information; therefore, neither is more correct than the other.
Choose the method or a variation of it that works well for you and is appropriate for your patient population. Follow this routine whenever you assess a patient, and try not to deviate from it.
You may want to plan your physical examination around the patients chief complaint or concern. To do this, begin by examining the body system or region that corresponds to the chief complaint. This allows you to identify priority problems promptly and reassures the patient that youre paying attention to his chief complaint.
Record your examination results thoroughly, accurately, and clearly. Although some examiners dont like to use a printed form to record physical assessment findings, preferring to work with a blank paper, others believe that standardized data collection forms can make recording physical examination results easier. These forms simplify comprehensive data collection and documentation by providing a concise format for outlining and recording pertinent information.
They also remind you to include all essential assessment data. When documenting, describe exactly what youve inspected, pal- pated, percussed, or auscultated. Dont use general terms such as normal, abnormal, good, or poor. Instead, be specific. Include posi- tive and negative findings. Try to document as soon as possible after completing your assessment. Remember that abbreviations aid con- ciseness.
A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable Herdman, , p. The nursing diagnosis must be supported by clinical infor- mation obtained during patient assessment. Each nursing diagnosis describes a patient problem that a nurse can professionally and legally manage. Becoming familiar with nurs- ing diagnoses will enable you to better understand how nursing prac- tice is distinct from medical practice.
Although the identification of problems commonly overlaps in nursing and medicine, the approach to treatment clearly differs. Medicine focuses on curing disease; nurs- ing focuses on holistic care that includes care and comfort. Nurses can independently diagnose and treat the patients response to illness, certain health problems and risk for health problems, readiness to improve health behaviors, and the need to learn new health information.
Nurses comfort, counsel, and care for patients and their families until theyre physically, emotionally, and spiritually ready to provide self-care. The nursing diagnosis expresses your professional judgment of the patients clinical status, responses to treatment, and nursing care needs.
You perform this step so that you can develop your care plan. In effect, the nursing diagnosis defines the practice of nursing. In addition to identifying the patients needs in coping with the effects of illness, consider what assistance the patient requires to grow and develop to the fullest extent possible. Your nursing diagnosis describes the cluster of signs and symptoms indicating an actual or potential health problem that you can identifyand that your care can resolve.
Nursing diagnoses that indicate potential health problems can be identified by the words risk for that appear in the diagnostic label. There are also nursing diagnoses that focus on prevention of health problems and enhanced wellness. Creating your nursing diagnosis is a logical extension of collecting assessment data. In your patient assessment, you asked each history question, performed each physical examination technique, and con- sidered each laboratory test result because it provided evidence of how the patient could be helped by your care or because the data could affect nursing care.
To develop the nursing diagnosis, use the assessment data youve collected to develop a problem list.
Less formal in structure than a fully developed nursing diagnosis, this list describes the patients problems or needs.
Its easy to generate such a list if you use a con- ceptual model or an accepted set of criterion norms. Examples of such norms include normal physical and psychological development and the assessment parameters based on the NNN Taxonomy of Nursing Practice see Appendix A.
You can identify the patients problems and needs with simple phrases, such as poor circulation, high fever, or poor hydration. Next, prioritize the problems on the list and then develop the work- ing nursing diagnosis. Some nurses are confused about how to document a nursing diag- nosis because they think the language is too complex.
By remember- ing the following basic guidelines, however, you can ensure that your diagnostic statement is correct: Use proper terminology that reflects the patients nursing needs. Make your statement concise so its easily understood by other healthcare team members.
Use the most precise words possible. Use a problem-and-cause format, stating the problem and its related cause. NANDA-I diagnostic headings, when combined with suspected eti- ology, provide a clear picture of the patients needs. The category can reflect an actual or potential problem.
Consider this sample diagnosis: Heading: Disturbed Sleep Pattern Etiology: select the appropriate Related To phrase from the choices in the care plan Signs and symptoms: I dont get enough sleep. My husband wakes me several times during the night to assist him. You note dark circle under her eyes and some jitteriness.
Do not state a direct cause-and-effect relationship which may be hard to prove. Remember to state only the patients problems and the probable origin. Omit references to possible solutions. Your solutions will derive from your nursing diagnosis, but they arent part of it. Errors can also occur when nurses take shortcuts in the nursing process, either by omitting or hurrying through assessment or by basing the diagnosis on inaccurate assessment data.
Keep in mind that a nursing diagnosis is a statement of a health problem that a nurse is licensed to treata problem for which youll assume responsibility for therapeutic decisions and accounta- bility for the outcomes. A nursing diagnosis is not a: diagnostic test schedule for cardiac angiography piece of equipment set up intermittent suction apparatus problem with equipment the patient has trouble using a commode nurses problem with a patient Mr.
Jones is a difficult patient; hes rude and wont take his medication. At first, these distinctions may not be clear. The following examples should help clarify what a nursing diagnosis is: Dont state a need instead of a problem.
Incorrect: Fluid replacement related to fever Correct: Deficient fluid volume related to fever Dont reverse the two parts of the statement. Incorrect: Lack of understanding related to noncompliance with diabetic diet Correct: Noncompliance with diabetic diet related to lack of understanding Dont identify an untreatable condition instead of the problem it indicates which can be treated.
Incorrect: Skin integrity impairment related to improper posi- tioning Correct: Impaired skin integrity related to immobility Dont identify as unhealthful a response that would be appropri- ate, allowed for, or culturally acceptable.
Incorrect: Anger related to terminal illness Correct: Ineffective therapeutic regimen management related to anger over terminal illness Dont make a tautological statement one in which both parts of the statement say the same thing. Incorrect: Pain related to alteration in comfort Correct: Acute pain related to postoperative abdominal disten- tion and anxiety Dont identify a nursing problem instead of a patient problem. Incorrect: Difficulty suctioning related to thick secretions Correct: Ineffective airway clearance related to thick tracheal secretions During this phase of the nursing process, you identify expected out- comes for the patient.
Expected outcomes are measurable, patient- focused goals that are derived from the patients nursing diagnoses. These goals may be short- or long-term. Short-term goals include those of immediate concern that can be achieved quickly.
Long-term goals take more time to achieve and usually involve prevention, patient teaching, and rehabilitation. In many cases, you can identify expected outcomes by converting the nursing diagnosis into a positive statement.
For instance, for the nursing diagnosis impaired physical mobility related to a fracture of the right hip, the expected outcome might be The patient will ambulate independently before discharge.
When writing the care plan, state expected outcomes in terms of the patients behaviorfor example, the patient correctly demonstrates turning, coughing, and deep breathing.
Also iden- tify a target time or date by which the expected outcomes should be accomplished.
كتاب SPARKS AND TAYLOR’S Nursing Diagnosis Pocket Guide
The expected outcomes will serve as the basis for evaluating your nursing interventions. Keep in mind that each expected outcome must be stated in measurable terms. If possible, consult with the patient and his family when establishing expected outcomes. Outcome statements should be tailored to your practice setting. For example, in the intensive care unit you may focus on maintain- ing hemodynamic stability, whereas on a rehabilitation unit you would focus on maximizing the patients independence and prevent- ing complications.
When writing expected outcomes in your care plan, always start with a specific action verb that focuses on the patients behavior. By telling your reader how the patient should look, walk, eat, drink, turn, cough, speak, or stand, for example, you give a clear picture of how to evaluate progress.
You need to choose which ones are needed for this patient. You will have to specify which person the goals refer to when family, friends, or others are directly concerned. It contains outcomes organized into 29 classes and seven domains. Each outcome has a definition, a list of measurable indica- tors, and references. The outcomes are research-based, and studies are ongoing to evaluate their reliability, validity, and sensitivity. Planning The nursing care plan refers to a written plan of action designed to help you deliver quality patient care.
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It includes relevant nursing diagnoses, expected outcomes, and nursing interventions. Keep in mind that the care plan usually forms a permanent part of the patients health record and will be used by other members of the nursing team.
The care plan may be integrated into an interdiscipli- nary plan for the patient. In this instance, clear guidelines should outline the role of each member of the healthcare team in providing care. A written care plan gives direction by showing colleagues the goals you have set for the patient and giving clear instructions for helping achieve them. If the patient is discharged from your healthcare facility to another, your care plan can help ease this transition.
For example, if one expected outcome statement reads The patient will transfer to chair with assistance, the appropriate nursing interventions include plac- ing the wheelchair facing the foot of the bed and assisting the patient to stand and pivot to the chair. If another expected outcome statement reads The patient will express feelings related to recent injury, appropriate interventions might include spending time with the patient each shift, conveying an open and nonjudgmental attitude, and asking open-ended questions.
Because all of your activities are based on assessment data, Determine is listed first. The interven- tion types will appear in the following order: Determine, Perform, Inform, Attend, and Manage. To provide comprehensive care, con- sider each of the intervention types carefully in your selection.
Reviewing the second part of the nursing diagnosis statement the part describing etiologic factors may help guide your choice of nursing interventions. For example, for the nursing diagnosis Impaired individual resistance related to poor impulse control, you would determine the best nursing interventions for learning techniques to manage behavior.
Try to think creatively during this step in the nursing process. Its an opportunity to describe exactly what you and your patient would like to have happen and to estab- lish the criteria against which youll judge further nursing actions. The planning phase culminates when you write the care plan and document the nursing diagnoses, expected outcomes, and nursing interventions. Write your care plan in concise, specific terms so that other healthcare team members can follow it.
Keep in mind that because the patients problems and needs will change, youll have to review your care plan frequently and modify it when necessary. Implementation During this phase, you put your care plan into action.
Implementa- tion encompasses all nursing interventions directed toward solving the patients nursing problems and meeting healthcare needs. While you coordinate implementation, you also seek help from other care- givers, the patient, and the patients family. Implementation requires some or all of the following types of interventions: Determine: assessing and monitoring e. Implementation isnt complete until youve documented each intervention, the time it occurred, the patients response, and any other pertinent information.
Make sure each entry relates to a nursing diagnosis. Remember that any action not documented may be overlooked during quality assurance monitoring or evalua- tion of care. Another good reason for thorough documentation: It offers a way for you to take rightful credit for your contribution in helping a patient achieve the highest possible level of wellness. After all, nurses use a unique and worthwhile combination of interpersonal, intellectual, and technical skills when providing care.
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Provide a trapeze or other assistive device whenever possible. Analyze your findings. Encourage caregiver to participate in a support group. Instruct the patient or family member to label home thermostats with large numbers and to use black or bright contrasting colors to indicate appropriate temperature settings.
In the physical examination of a patientinvolving inspection, palpation, percussion, and auscultationyou collect one form of objective data about the patients health status or about the patho- logic processes that may be related to his illness or injury. Express confidence in their ability to respond to childs needs.
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