04 Actual Vs Potential Problems 6g5x43

ACTUAL VS POTENTIAL - OVERVIEW During the assessment process of establishing and ing data about a client, the nurse reviews subjective data (information given to the nurse by the client or family/friends that can not be measured by others) and objective data (information that is measurable or observable). During this assessment or analysis phase of the nursing process, you examine and evaluate information, the data, that you obtained during the assessment phase. This allows you to analyze and draw conclusions about health problems. During analysis, you should compare the client’s findings with what is normal. From the analysis, you establish nursing diagnoses. A nursing diagnosis is an actual or potential health problem that the nurse is licensed to manage. Actual problems are issues that are real complaints or physiological processes that have gone wrong or are being interrupted by some disease or other cause. For Example: An actual nursing dx based on the info you gave would be more like "Ineffective Breathing Pattern related to (r/t) chest pain A "risk for" nursing dx might be "Risk for impaired skin integrity r/t pruritis (itching). A “at risk for “ problem is a potential problem due to the situation or disease process the patient is going through but has not happened yet. More examples for actual problems that we did in class are: The nurse cares for a patient on positive pressure mechanical ventilation. The nurse is MOST concerned if which of the following is observed? 1. The patient is confused and moves restlessly in bed. - confusion and agitation suggest hypoxemia this indicates an actual problem

2. There is edema in the patient’s extremites. - . positive pressure from ventilation causes decreased cardiac output, which causes fluid retention from increased aldosterone secretion - this is a potential problem because it has not happened yet. #1 is more of a concern. Actual problem is a higher priority

The nurse cares for patients on the medical/surgical unit. Which of the following patients should the nurse see FIRST? 1. A 69-year-old male itted for treatment of lung cancer with facial swelling and neck vein distention. actual problem that requires immediate action; indicates superior vena cava syndrome caused by tumor obstructing superior vena cava 2. A 45-year-old male itted for angina with an apical heart rate of 98 beats per minute after receiving sublingual nitroglycerin potential problem; nitroglycerin will vasodilate the arteries and veins and may cause temporary decrease in blood pressure and increase in heart rate (a compensatory response)

Look at “real harm” answers as the priority with “potential harm” answers as issues the patients could face as a result of the condition.. Could possibly face!!! Potential! Students must not “read into” the answers. to use the following when determining priority for which patient should be seen first. Determine priority by using 1. the ABCs - does it make sense!!!! 2. real vs. potential problems, 3. expected vs. unexpected, 4. chronic vs. acute.