Nursing diagnosis

Nursing diagnosis

Types of nursing diagnosis:

  • Problem focused: Ineffective breathing pattern.
  • Risk: Risk for infection.
  • Health promotion: Readiness for enhanced family coping.
  • Syndrome: Chronic pain syndrome.

Writing diagnostic statements:

  • One part: Readiness for enhanced breastfeeding.
  • Two part: Risk for infection related to compromised host defenses.
  • Three part: Impaired physical mobility related to decreased muscle control as evidenced by inability to control lower limbs.
Nursing basics

Nursing basics

Vital signs:

HR: 60 – 100

BP: 120/80

RR: 12 – 20

SpO2: 95 – 100 %

T: 36.5 – 37.5

Pain: 0 – 10

GCS: 3 – 15

Normal pupil size: 2 – 4 mm

Pulse pressure: > 40

MAP: 70 – 100

Systolic pressure: The pressure inside the artery when the heart contacts + pumps blood through the body.

Diastolic pressure: The pressure inside the artery when the heart is at rest + is filling with blood.

Medication overview

Medication overview

Bronchodilators: Promotes bronchial expansion, increases transfer of gases, decreases wheezing.

Cardiac glycosides: Increase force of contraction, decrease heart rate, increase cardiac output.

Coronary vasodilators: Dilate arteries, decrease preload + afterload, decrease myocardial oxygen consumption.

Diuretics: Increase urine output, decrease hypervolemia, BP, edema, ICP.

Laxatives: Promotes the passage of stools.

Opioids: Decrease the transmission of pain impulse.

Opioid antagonists: Reverse opiate, induce CNS depression and decreased respiratory function.

MENSTRUAL CYCLE

MENSTRUAL CYCLE

Menstrual cycle – 28 days cycle

The menstrual cycle is complex and is controlled by many different glands and its hormones.

Duration:

The average length of the cycle lasts from 24 days to 32 days. This is calculated from the first day of the period to the day before the next period starts.

How it is controlled?

The menstrual cycle is controlled by the hypothalamus which prompts the pituitary gland to produce certain chemicals to make the ovaries to produce estrogen and progesterone.

Phases of menstrual cycle:

There are four phases.
1. Menstruation
2. Follicular phase
3. Ovulation
4. Luteal phase

Menstruation:

It is the elimination of the thick lining called the endometrium of the uterus. The menstrual fluid contains blood, endometrial cells and mucus. The average duration of each period is from 3 days to one week.

Follicular phase:

It starts from the first day of the menstruation and ends with ovulation. With the help of the hypothalamus, the pituitary gland releases follicle stimulating hormone, which stimulates the ovary to produce 5 to 20 follicles.

Each follicle houses an immature egg. Only one follicle matures into an egg and the others die. This process occurs around day 10 in a 28 days cycle. The growth of the follicle stimulates the thickening of the endometrium for possible pregnancy.

Ovulation:

It is the release of the mature egg from the surface of the ovary. It usually occurs mid-cycle around two weeks or so before menstruation starts. During the follicular phase, the developing follicle causes a rise in the level of oestrogen.

The hypothalamus in the brain recognises these rising levels and releases a chemical called gonadotrophin-releasing hormone (GnRH). This hormone prompts the pituitary gland to produce raised levels of luteinising hormone (LH) and FSH.

Within two days, ovulation is triggered by the high levels of LH. The egg is funnelled into the fallopian tube and toward the uterus by waves of small, hair-like projections.

The life span of the typical egg is only around 24 hours. Unless it meets a sperm during this time, it will die.

Luteal phase:

During ovulation, the egg bursts from its follicle, but the ruptured follicle stays on the surface of the ovary. For the next two weeks or so, the follicle transforms into a structure known as the corpus luteum.

This structure starts releasing progesterone, along with small amounts of oestrogen. This combination of hormones maintains the thickened lining of the uterus, waiting for a fertilised egg to stick (implant).

If a fertilised egg implants in the lining of the uterus, it produces the hormones that are necessary to maintain the corpus luteum. This includes human chorionic gonadotrophin (HCG), the hormone that is detected in a urine test for pregnancy.

The corpus luteum keeps producing the raised levels of progesterone that are needed to maintain the thickened lining of the uterus.

If pregnancy does not occur, the corpus luteum withers and dies, usually around day 22 in a 28-day cycle. The drop in progesterone levels causes the lining of the uterus to fall away. This is known as menstruation. The cycle then repeats.