Sep 29, 2007, 10:52 PM
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You must follow the nursing process, the steps of which are:- Assessment
- Determine Problem (Nursing Diagnosis)
- Planning (developing goals and interventions)
- Implementation
- Evaluation
A diagnosis is the resulting decision or opinion that you make after you have performed the process of examination or investigation of the facts. So, first you must go through the assessment data that you collected from the patient's medical record, from the physical assessment you did and from talking with the patient. What did you find out that wasn't normal? What's going on with this patient's incision? What kind of mobility does the patient have? Those abnormal things become this patient's symptoms (NANDA calls them defining characteristics) and they become the basis for any nursing diagnoses that you end up using for this patient. You also want to look at the underlying reason for the patient's bypass. What led to this surgery in the first place? What was going on? Since this is a surgical patient you also have to consider all the complications of surgery that can occur as well. That is important information to know that will have an impact on the patient's treatment. What drugs and treatment have the doctor ordered for this patient? Why? All this information provides you with clues to help you determine what this patient's nursing problems, goals and interventions are going to be. It is not enough information for any of us to help you when all you provide us with the patient's medical problem. That tells us nothing of this patient's nursing needs and you and we are nurses, not doctors.
Each nursing diagnosis has a defined set of criteria that your patient must meet in order for you to diagnose your patient with it. This is why it is a very good idea to have a book of care plans or a book of nursing diagnoses to use as a reference to help you out here. There are also two websites where you can get information on as many as 75 specific nursing diagnoses, but you have to have an idea of which ones you want to look at in order to link into them. Before you decide upon any nursing diagnosis you need to verify that the definition of the nursing diagnosis fits your patient's problem and that your patient has at least one or more of the defining characteristics (symptoms) that is listed with that nursing diagnosis. Your nursing interventions and goals will be directly related to those defining characteristics (abnormal assessment data, symptoms) that your patient has. So, without knowing what your patient's symptoms are I cannot give you any advice on interventions.
For more information about this see the posts on these threads:If you are still having difficulty coming up with nursing diagnoses for this patient, please post a list of this patient's abnormal assessment data (symptoms, defining characteristics) as well as some information about the underlying reason of the anemia and I will help show you how to pick the nursing diagnoses.
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