Nursing diagnosis

Nurses General Nursing

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First, I apologise if I am in the wrong place. I am a bit computer illiterate, and am not sure how to navigate yet.

I have a student question.

I have a final exam due tomorrow. I am first quarter. For my exam, I had to do an assessment, and list two nursing diagnosis. I do not know how to write the diagnosis.

my patient presented with loss of balance, disturbed vision, severe head pain.

He had already been diagnosed with diabetic neuropathy, and COPD.

He has never had any hospitalizations or surgery.

He is independent, his house is tidy and neat. His stress reduction technique is to take a long drive. However....

He drinks at least 12 beers per day, has no appetite, forces himself to eat at least one meal per day, usually dinner that he prepares himself.

He now needs a walker for balance, has fallen several times. He was just recently diagnosed with 2 brain tumors on the cerebellum secondary to lung and liver cancer.

I know that he is at risk for falls, due to the loss of balance and drinking.

I have no clue how to write a diagnosis... can you help me please to put it in perspective. ??

Thank you...

This is slightly off topic, but do any of you actually use a nursing diganosis in your practice? How does it fit in? And why does it fit in? We all know the reason the patient is there, what is called the medical diagnosis, but is it true we all learn about disease process in school. I understand that nurses are not allowed to diagnose, but what is wrong with taking the medical diganosis and knowing the nursing roles related to that. Does anyone truely follow nursing careplans or is stuff made up by non practicing theorist that "think" up ways to "empower" nurses?

No, I've never used a nursing diagnosis since I graduated. In my mind, they are a waste of time. I've heard the arguments that they "teach you how to think," but personally I never found them useful. I wish nursing school would focus more on the common disease processes and nursing actions associated with them than on endless writing of nursing care plans.

I passed. (insert happy dance here)

I was holding my breath but I made it through foundations with a B+.. Oh man, I don't know how I did it.

Thank you very much for all your help and wonderful advice. I could not have done my assessment without your help. All of the advice was great, I have written it down, for future use, if you don't mind.

Thank you....SUMMER TIME FUN...

How about nutrition problems related to his alcohol intake and stated lack of nutrition (less than 1 meal per day)?

Specializes in med/surg, telemetry, IV therapy, mgmt.
this is slightly off topic, but do any of you actually use a nursing diganosis in your practice? how does it fit in? and why does it fit in? we all know the reason the patient is there, what is called the medical diagnosis, but is it true we all learn about disease process in school. i understand that nurses are not allowed to diagnose, but what is wrong with taking the medical diganosis and knowing the nursing roles related to that. does anyone truely follow nursing careplans or is stuff made up by non practicing theorist that "think" up ways to "empower" nurses?

they've used nursing diagnosis at every single facility i've been working at! nurses do diagnose within the scope of their nursing practice. they don't diagnose medical conditions, but they do diagnose nursing conditions. what stuff are you referring to that was "made up" by non practicing theorists? the fact is that if you understand the nursing process you can format a plan for nursing care on a piece of paper. other formats for care plans include concept mapping and clinical pathways of care. i don't hear too many people trashing on them and i know that clinical pathways of care are commonly used in many facilities as their form of care plan. however, in the event that you never took a class in the legal aspects of healthcare, you need to know that title 42 of the u.s. federal law (medicare conditions of participation) mandates that a written plan of care by an rn must be included in the medical record of every patient in a facility that receives medicare reimbursement. and, just to stir up the waters, jcaho also agrees.

we all follow the nursing process in our practice. if we didn't, how is it we would be doing our jobs properly? what did we learn in school if not how to reason out patient problems using the nursing process and thinking critically? (assess, determine the problem, intervene) hello!!!

Impaired physical mobility R/T perceptual and/or cognitive impairment as manifested by visual disturbances and history of falls; Secondary to brain tumor and alcohol abuse (12 beers per day).

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