Week 8: The Nursing Diagnosis

Nursing diagnoses are the terms in which your nurse will think.  A nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs (American Nurses Association, 2015). When a nurse does an assessment on a patient, they then determine a plan of care based on your overall health status.  Some examples of nursing diagnoses that are under consideration for shingles are…

•   Impaired Comfort…
•  Acute Pain…
•  Social Isolation…
•  Risk for infection…
•  Readiness for enhanced immunization status… (Ackley, Ladwig, 2014). 

With these diagnoses, the nurse then determines if they are an actual diagnoses (this is occurring with the patient in the moment), or potential (the patient is at risk for this diagnosis). Then the nurse must figure out what the diagnosis is related to.  This essentially means, what is causing the diagnosis.  Then the nurse must make a plan to intervene on the diagnosis and determine what outcome is appropriate for the patient.  Then finally, the nurse will implement their intervention.  Below I have created a table that explains the process for one nursing diagnosis.  Keep in mind that for each patient, there can be an unlimited amount of nursing diagnoses to care for.

Nursing Diagnosis	Actual or Potential	Related to…	Plan and Outcome	Nursing Intervention
Risk for infection…	Actual…	Related to infectious particles inside of rash	Implement infection precautions.  Outcome is to limit the spread of infection.	Implement personal protective equipment to be worn by staff. Educate patient about the infectivity of the condition, and when they are no longer contagious. Teach patient how to properly wash hands. Place dressing over ruptured rash. Educate patient and family about Shingles vaccine.

(Ackley, Ladwig, 2014)

In this instance, risk for infection is the nursing diagnosis.  This is an actual diagnosis because the patient can spread the infection if the rash has not scabbed over.  This can put healthcare workers and family members at risk for contracting the virus if they are not careful.  This infectivity is related to having the active virus inside the pustules of the rash.  The nurse will plan to limit the spread of infection to others, in which the desired outcome is that nobody else becomes infected.  In order to achieve this desired outcome, the nurse will have to elicit many interventions.  Some of these interventions are located in the last column above. 

This link below is a case study for a patient with Shingles.  Here they show the nursing process along with the plan of care.

• http://wps.prenhall.com/wps/media/objects/737/755395/herpes_zoster.pdf

This link describes the nursing process which includes the nursing diagnosis that I have explained here.

• http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html

REFRENCES:

Ackley, B., Ladwig, G. (2014). Nursing Diagnosis Handbook. Elseiver, 10^th Edition. Page 105.

American Nurses Association. (2015). The nursing process. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html

Week 7: How nurses can help you!

Since individuals with shingles do not usually require inpatient care, much of the nursing care includes education for the patient, and pain management techniques.  It is important for the nurse to assess your level of pain.  They will ask you the intensity of your pain (rating from 0 to 10, 0 being no pain and 10 being the worst pain you have ever felt in your life).  Along with intensity, the nurse will want to know the location, quality, and aggravating and relieving factors of this pain.  Once the nurse knows the condition of the pain, and then she can appropriately administer the medications she has on hand.   To improve the pain reduction, nurses can teach how to apply wet dressings, or calamine lotion on the hurting tissue (Nursing Crib, 2009).  There are also relaxation techniques that the nurse may teach such as guided imagery and deep breathing.  Guided imagery is a technique that directs and focuses the imagination (Health Journeys, 2015).  Here are two websites that you can learn more about the techniques of guided imagery now!

•       http://sevencounties.org/poc/view_doc.php?type=doc&id=15672&cn=117
•      http://www.healthjourneys.com/WhatIsGuidedImagery

http://www.self-guided.com/guided-imagery.html 

These nurses will also help you with the delivery and timing of your medications. They will explain what you need to take, why you need to take it, how it works inside of the body, and specific side effects to look for.  If you are using an ointment to control the rash, then they will teach you proper application (Nursing Crib, 2009). 

Nurses will teach you how to prevent the spread of this virus.  Some of this teaching may include proper hand washing (Nursing Crib, 2009).  Hand washing is the single best way to prevent transmission of infectious disease.  When washing your hands with soap and water, first wet your hands in warm water.  Making sure to keep your hands lower than your elbows, lather the soap on all surfaces of your hands for 30 seconds (palms, backs of hands, between fingers, thumbs, fingernails). Rinse until all soap is off and then dry hands.  Turn off faucet with another paper towel. 

http://msutoday.msu.edu/news/2013/eww-only-5-percent-wash-hands-correctly/

Since this may elicit an emotional experience for the patient, nurses will also assess for emotional distress.  They will be there to listen and guide you in the appropriate direction with your thoughts and feelings.  They will explain the pathophysiology of the disease to make sure you understand the process that is occurring within your body.

With all of this teaching, the nurses should elicit a teach back method.  The nurses will ask you to show them what they have taught you, or you teach them the medication schedule.  This makes sure you understand all of the proper treatments and methods of prevention that you should be practicing.

References:

Health Journeys. (2015). The 3 principles of guided imagery. Retrieved from

http://www.healthjourneys.com/WhatIsGuidedImagery

Mills, H., Reiss, N., & Dombeck, M., (2015). Visualization and guided imagery techniques for stress reduction.  Retrieved from http://sevencounties.org/poc/view_doc.php?type=doc&id=15672&cn=117

Nursing Crib. (2009). Herpes zoster (Shingles). Communicable Diseases. Retrieved from http://nursingcrib.com/communicable-diseases/herpes-zoster-shingles/

Photos:

Borchgrevink, C., Henion, A., (2013). Eww! Only 5 percent wash hands correctly. Michigan State University. Retrieved from http://msutoday.msu.edu/news/2013/eww-only-5-percent-wash-hands-correctly/

Self guided. (2009). Guided imagery for relaxation and stress management. Retrieved fromhttp://www.self-guided.com/guided-imagery.html

Treatment, but most importantly- Prevention!

Although Shingles can clear on its own, early treatment is vital in order to reduce its painful effects.  If people do not seek immediate treatment, then their risk for chronic pain, numbness, itching, and tingling increases significantly (ADA, 2015). Within 72 hours of diagnosis, a provider should prescribe a certain type of Anti-Viral (ADA, 2015).  It is important to understand that since a virus causes this condition, you CANNOT take an antibiotic.  Antibiotics only treat bacterial infections.  This is a common misconception.  The most commonly prescribed medications for shingles include Acyclovir, Valacyclovir, or Famciclovir (Mayo Clinic, 2014).  Below I have created a chart to show how each of these medications acts to fight the virus, as well as the most common side effects that you may experience. 

Drug Name	Mechanism of Action	Common Side Effects
Acyclovir	Interferes with viral DNA synthesis.  Inhibits viral replication, viral shedding, and reduced time to healing lesions.	·      Dizziness, headaches ·      Diarrhea, nausea, vomiting ·      Joint pain
Valacyclovir	Rapidly converts to Acyclovir (See above)	·      Headaches, agitation, confusion ·      Nausea, abdominal pain
Famciclovir	Inhibits viral DNA syntheses. Decreases duration of herpes zoster infection and deceases viral shedding.	·      Headache, dizziness, fatigue ·      Palpitations ·      Diarrhea, nausea, vomiting

(Davis Drug Guide, 2015)

In addition to treating the virus, providers should also treat the patient’s pain, and itching.  For the itching, wet compresses, calamine lotion, and oatmeal baths may help (CDC, 2014).  For the pain, your provider may prescribe a variety of medications.  Before jumping into oral medications, providers may have you try numbing agents, creams, or corticosteroid injections as the site of rash outbreak. Depending on the description of your pain, a provider may also prescribe oral medications like non-opioid analgesics such as Tylenol or Advil, opioid analgesics such as Oxycodone, or adjuvant analgesics such as antidepressants (Amitriptyline) or anticonvulsants (Gabapentin) (Mayo Clinic, 2014).  

Although there are treatments for Shingles, it is best for your health to prevent the reactivation of the virus in the first place.  The best way to do this if you have already caught the chicken pox it to receive the Shingles vaccines.  The Shingles vaccine, Zostavax, reduced the risk of Shingles by 51% (CDC, 2014).  The CDC has laid out basic criteria of who should and should not receive the vaccine.  For this information, please visit http://www.cdc.gov/vaccines/vpd-vac/shingles/vacc-need-know.htm

References

American Academy of Dermatology. (2015). How do dermatologists treat shingles? Shingles: Diagnosis, Treatment, and Outcome.  Retrieved from https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/q---t/shingles/diagnosis-treatment

Centers for Disease Control and Prevention. (2014). Prevention and treatment. Shingles (Herpes Zoster). Retrieved from http://www.cdc.gov/shingles/about/prevention-treatment.html

Davis Drug Guide. (2015). Retrieved from http://www.drugguide.com/ddo/

Mayo Clinic. (2014). Treatments and drugs. Shingles. Retrieved from http://www.mayoclinic.org/diseases-conditions/shingles/basics/treatment/con-20019574