help...

Nurses General Nursing

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okay nursing diagnosis...ots been a long time since i have actually written them...

does it go like this:

Altered Health Maintenance secondary to (and then my reasons like tobacco use, or lack of self testicular exams?) is that how they are set up or can someone fill me in?

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Specializes in Med/Surg, Urg Care, LTC, Rehab.

Nsg diagnosis..... related to..... as evidenced by....

so.......

altered health maintenance related to non-compliance of diet as evidenced by elevated glycosated hemoglobin

or

altered health maintenance related to over-consumption of alcohol as evidenced by elevated liver function tests and statements by client of drinking causing problems with work attendance

or sumpin like that. i hate careplans!

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Specializes in critical care.

care plans is the reason why i don't want to work in a hospital that does paper charting because in computer charting, care plans are premade & all you do is to edit it.

the care plan goes:

can be actual or potential alteration in comfort related to ...something like surgery, chest pain as evidenced by...facial grimace, yelling... then enumerate objective like decrease pain level.... then plan like changing position in bed...divertion...meds etc & don't forget, notify md....

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, jdrake_rn!

just noticed your posts for help with nursing diagnosis and care planning after doing a search of the forums. i can tell from the questions you are posing that you are indeed stuck with this stuff and from the answers you've gotten you can see that many experienced nurses don't want to even touch care plan writing after they get out of school. :o but, enough of that. let me help you. i saw your other post about this patient.

a nursing diagnostic statement starts with the nanda diagnosis: ineffective health maintenance (nanda no longer uses altered health maintenance as their approved terminology. unless this is how your instructors want you to word this particular diagnosis, use the official nanda title which i have now given you.)

the second part of the statement consists of the related factors, or cause, of the diagnosis. nanda has also clearly listed those out for this particular diagnosis. you can either use their exact wording or compose similar wording of your own. these are the related factors:

  • ineffective family coping
  • perceptual/cognitive impairment (complete/partial lack of gross and/or fine motor skills)
  • lack of, or significant alteration in, communication skills (written, verbal, and/or gestural)
  • unachieved developmental tasks
  • lack of material resources
  • dysfunctional grieving
  • disabling spiritual distress
  • lack of ability to make deliberate and thoughtful judgments
  • ineffective individual coping

any one or more of these is placed after the nursing diagnosis and the words "related to", or the letters "r/t".

the third part of the nursing diagnostic statement consists of the assessment data that supports the nursing diagnosis. an easier way to define this is just to merely say that you list the symptoms that define the diagnosis. these are called the defining characteristics by nanda and should be items that will fall under these categories, such as:

  • demonstrated lack of knowledge regarding basic health practices
  • demonstrated lack of adaptive behaviors to internal/external environmental changes
  • reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas (this refers to gordon's functional health patterns)
  • history of lack of health seeking behavior
  • expressed interest in improving health behaviors
  • reported or observed lack of equipment, financial and/or other resources
  • reported or observed impairment of personal support systems

all the above information comes from

nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 90.

this is how i would write your diagnostic statement: ineffective health maintenance related to lack of ability to make thoughtful judgments about regular health practices as evidenced by continued regular tobacco use and consistently ignoring to perform regular self-testicular exams. how does that strike you?

please check out the nursing student forums on allnurses, particularly these two forums:

you will often find questions on care planning posted there. you are also more likely to get better constructive help with formulating nursing diagnoses and developing care plans on those forums.

here are three threads that you should definitely check out since they specifically pertain to the class you are currently taking. i am sure you will find some information and weblinks there that will be helpful to you:

see you on the student forums! welcome to allnurses! :welcome:

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