Nursing Diagnosis
Content
Nursing Diagnosis: Osteoarthritis, osteoporosis, high blood pressure
(HTN), rheumatoid arthritis, hx of transient ischemic attack (ITN)
Nursing Diagnosis: Chronic pain related to tissue distension by
accumulation of inflammatory process and destruction of joints can
be evidenced by complaints of pain and fatigue when mobilising.
Expected results, patient will be able to rest and participate in
activities according to ability and to show pain relief/control.
Nursing Interventions:
1. Continue monitoring the level of pain in the joints
2. Record complaints of pain, record the location and intensity
(scale 0-10). Write down the factors that accelerate the pain
and the signs that accompany it (verbal and/or non-verbal)
(rationale: to assist in determining the need for pain
management)
3. Administer pain relief as prescribed if patient exhibits pain
(rationale: to act as an anti-inflammatory and mild analgesic
effect in supressing the acute inflammatory system)
4. Advise to change position frequently (rationale: to prevent the
occurrence of general fatigue and joint stiffness)
5. Assist patient to wash feet once a week during the evening
(rationale: heat increases muscle relxation thus reducing pain
and stuffness in the morning)
6. Encourage the patient in engaging in activities of appropriate
entertainment (rationale: to provide stimulation, incease selfconfidence and avoid social isolation)
Nursing Diagnosis: Impaired physical mobility related to skeletal
deformities and pain, characterised by inability to independantly
mobilise. Expected results, patient will maintain the function of the
body, demonstrate techniques that enable the continutation of
activities, and maximise their independence with self-care.
Nursing Interventions:
1. Assistance of one with ADLs
2. Facilitate patient self-care and independence with ADLS, such
as practicing good hygiene, dressing and feeeding (rationale:
ADLS that can be done dependantly should be encouraged to
excercise joints)
3. Encourage patient to maintain an upright posture and sitting
height, standing and walking (rationale: to maximise joint
function and maintain mobility)
4. Change positions frequently. Demonstrate and assit with
transfer techniques and use of mobility aids such as zimmer
frame (rationale: to eliminate presure on the tissue and
5.
6.
7.
8.
increase circulation, facilitate self-care and pt. independence,
and proper transfer techniques prevent shearing abrasions of
skin)
Discusss and provide safety needs such as raised chairs and
toilet seat, use of handrails by the toilet, proper use of
mobility aids and wheelchair
Provide a safe environmen such as lack of cluster in room, bed
at the lowest level (rationalte: helps prevent accidental
injuries and falls)
Collaboration: consult with physiotherapist (rationale: to
formulate activities based on individual needs and
preferences)
Provide foam matress (rationale: to reduce pressure on fragile
tissue in reducing the risk of further immobility)
Nursing Diagnosis:
Acute pain related to inflammation and infection of the urethra as
evidenced by complaints of abdominal pain and discomfort when
urinating. Clinicial lab tests from an MSU shows presence bacteria E.
Coli.
Intervention:
1. Assess pain, noting location, intensity (scale of 0-10), and
duration (rationalte: to provide information to aid in
determining choice or effectiveness of interventions)
2. Encourage increased fluid intake (rationale: increased
hydration flushes bacteria and toxins)
3. Investigate report of bladder fullness (rationale: urinary
retention may develop, causing tissue distension - bladder or
kidney – and potentiates risk for further infection)
4. Monitor urine colour changes, odour, input/output volume and
pattern
5. Provide comfort measure such as helping pt. assume position
of comfort. Suggest use of relxation technique and deep
breathing exercises (rationale: promotes relaxation, refocuses
attention and may enhance coping abilities)
6. Administer anti-bacterial as prescribed (rationale: reduces
bacteria present in urinary tract)
7. Discuss the importance of good hygiene, to wipe from front to
back and to wash hands thoroughly after toileting.
Life history of the older person:
Married in her early 30s
Had a son and later adopted a girl 3 years later
Children were outgoing and husband a happy optimist (always
smiling and joking) so the house was never quiet and always
full of life
Hard-working and described as ‘always running around’ –
helped care for the elderly in her village then later a factory
worker before signs of athritis was exhibited
Loved to use her bicycle when commuting
Highlight the areas that are important in the older person’s
life that may influence his view of his care now and the
future:
Activities lead by the volunteers and physiotherapy sessions
are important to her as it provides stimulation and maintain
her independence
Looking at the older person’s care in general, what areas
are you going to improve and why?
Give more encouragement in fluid intake as she has been
recently diagnosed with UTI but urinary output is still low
Encourage to eat with the other ward residents to help
promote a meaningful social network and provide
opportunities for social interactions
Do you think all the members of the staff in your ward are
person-cented? Please explain your answer:
It is most apparent during handover and MDT, where I saw
health care providers discussing how some patients had
certain preferences and opinions about the care that was
delivered to them at present, and those staff members
changed some parts of the care plans in accordance to the
patient’s feelings/desires/values/family situations/social
circumstances/lifestyle. They saw the person as an individual,
taking into account theor preferences and expressed needs,
and worked together to develope appropriate solutions.
Services and care plans were flexible with patients and their
families to find the best way to provide their care
Ward staff were extremely observant with the patients’
relationships surrounding their families and were willing
involve the family members to discuss certain matters in
relation to the patient’s health.
What have you learned from this exercise?
Person-centred care is a key component in developing high
quality healthcare. I realised that many important aspects of a
patient’s over-all health could have been easily missed if the care
being delivered was being seen through a purely medical point of
view. Putting people at the centre of their care, I feel, has helped
people be more active in looking after themselves, improves the
quality of the services available and reduces some of the
pressure on health and social services. Taking a holistic approach
to assessing people’s needs and providing care, including
families where appropriate, and making sure that the services
are accesible, flexible and easy to navigate are crucial factors in
defining what those services are fundamentally trying to achieve,
and this is being done in partnership with patients and carers.
(HTN), rheumatoid arthritis, hx of transient ischemic attack (ITN)
Nursing Diagnosis: Chronic pain related to tissue distension by
accumulation of inflammatory process and destruction of joints can
be evidenced by complaints of pain and fatigue when mobilising.
Expected results, patient will be able to rest and participate in
activities according to ability and to show pain relief/control.
Nursing Interventions:
1. Continue monitoring the level of pain in the joints
2. Record complaints of pain, record the location and intensity
(scale 0-10). Write down the factors that accelerate the pain
and the signs that accompany it (verbal and/or non-verbal)
(rationale: to assist in determining the need for pain
management)
3. Administer pain relief as prescribed if patient exhibits pain
(rationale: to act as an anti-inflammatory and mild analgesic
effect in supressing the acute inflammatory system)
4. Advise to change position frequently (rationale: to prevent the
occurrence of general fatigue and joint stiffness)
5. Assist patient to wash feet once a week during the evening
(rationale: heat increases muscle relxation thus reducing pain
and stuffness in the morning)
6. Encourage the patient in engaging in activities of appropriate
entertainment (rationale: to provide stimulation, incease selfconfidence and avoid social isolation)
Nursing Diagnosis: Impaired physical mobility related to skeletal
deformities and pain, characterised by inability to independantly
mobilise. Expected results, patient will maintain the function of the
body, demonstrate techniques that enable the continutation of
activities, and maximise their independence with self-care.
Nursing Interventions:
1. Assistance of one with ADLs
2. Facilitate patient self-care and independence with ADLS, such
as practicing good hygiene, dressing and feeeding (rationale:
ADLS that can be done dependantly should be encouraged to
excercise joints)
3. Encourage patient to maintain an upright posture and sitting
height, standing and walking (rationale: to maximise joint
function and maintain mobility)
4. Change positions frequently. Demonstrate and assit with
transfer techniques and use of mobility aids such as zimmer
frame (rationale: to eliminate presure on the tissue and
5.
6.
7.
8.
increase circulation, facilitate self-care and pt. independence,
and proper transfer techniques prevent shearing abrasions of
skin)
Discusss and provide safety needs such as raised chairs and
toilet seat, use of handrails by the toilet, proper use of
mobility aids and wheelchair
Provide a safe environmen such as lack of cluster in room, bed
at the lowest level (rationalte: helps prevent accidental
injuries and falls)
Collaboration: consult with physiotherapist (rationale: to
formulate activities based on individual needs and
preferences)
Provide foam matress (rationale: to reduce pressure on fragile
tissue in reducing the risk of further immobility)
Nursing Diagnosis:
Acute pain related to inflammation and infection of the urethra as
evidenced by complaints of abdominal pain and discomfort when
urinating. Clinicial lab tests from an MSU shows presence bacteria E.
Coli.
Intervention:
1. Assess pain, noting location, intensity (scale of 0-10), and
duration (rationalte: to provide information to aid in
determining choice or effectiveness of interventions)
2. Encourage increased fluid intake (rationale: increased
hydration flushes bacteria and toxins)
3. Investigate report of bladder fullness (rationale: urinary
retention may develop, causing tissue distension - bladder or
kidney – and potentiates risk for further infection)
4. Monitor urine colour changes, odour, input/output volume and
pattern
5. Provide comfort measure such as helping pt. assume position
of comfort. Suggest use of relxation technique and deep
breathing exercises (rationale: promotes relaxation, refocuses
attention and may enhance coping abilities)
6. Administer anti-bacterial as prescribed (rationale: reduces
bacteria present in urinary tract)
7. Discuss the importance of good hygiene, to wipe from front to
back and to wash hands thoroughly after toileting.
Life history of the older person:
Married in her early 30s
Had a son and later adopted a girl 3 years later
Children were outgoing and husband a happy optimist (always
smiling and joking) so the house was never quiet and always
full of life
Hard-working and described as ‘always running around’ –
helped care for the elderly in her village then later a factory
worker before signs of athritis was exhibited
Loved to use her bicycle when commuting
Highlight the areas that are important in the older person’s
life that may influence his view of his care now and the
future:
Activities lead by the volunteers and physiotherapy sessions
are important to her as it provides stimulation and maintain
her independence
Looking at the older person’s care in general, what areas
are you going to improve and why?
Give more encouragement in fluid intake as she has been
recently diagnosed with UTI but urinary output is still low
Encourage to eat with the other ward residents to help
promote a meaningful social network and provide
opportunities for social interactions
Do you think all the members of the staff in your ward are
person-cented? Please explain your answer:
It is most apparent during handover and MDT, where I saw
health care providers discussing how some patients had
certain preferences and opinions about the care that was
delivered to them at present, and those staff members
changed some parts of the care plans in accordance to the
patient’s feelings/desires/values/family situations/social
circumstances/lifestyle. They saw the person as an individual,
taking into account theor preferences and expressed needs,
and worked together to develope appropriate solutions.
Services and care plans were flexible with patients and their
families to find the best way to provide their care
Ward staff were extremely observant with the patients’
relationships surrounding their families and were willing
involve the family members to discuss certain matters in
relation to the patient’s health.
What have you learned from this exercise?
Person-centred care is a key component in developing high
quality healthcare. I realised that many important aspects of a
patient’s over-all health could have been easily missed if the care
being delivered was being seen through a purely medical point of
view. Putting people at the centre of their care, I feel, has helped
people be more active in looking after themselves, improves the
quality of the services available and reduces some of the
pressure on health and social services. Taking a holistic approach
to assessing people’s needs and providing care, including
families where appropriate, and making sure that the services
are accesible, flexible and easy to navigate are crucial factors in
defining what those services are fundamentally trying to achieve,
and this is being done in partnership with patients and carers.
