Nursing Diagnosis

Nurses General Nursing

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Specializes in Ortho/trauma acute care/med surg.

Hello all I am stumped with Nursing Diagnosis, I have tried and tried to grasp on to this concept but I just can't seem to get it, can someone please help me? When I am given a case study and need 2 actual nursing diagnosis I can't seem to get it correctly, please if anybody has any advice I really need it right now. My case study is about a 50 year old with hx of CAD, MI, hyperlipidemia, and hypertension, admitted with right side hemiparesis with facial droop. Please help I don't want the answer per se just send me in the right direction. Thank you guys so much:banghead:

Specializes in Oncology/BMT.

Since this patient in experience an acute crisis, focuse on the current problem. Try to come up with at least one actual problem and one potential problem. You can even include a knowledge deficit (don't forget about that one).

I suggest that you make a list of the signs and symptoms, pathophysiology, and immediate complications of a stroke. Use the list to guide your thinking.

Specializes in Ortho/trauma acute care/med surg.

Thank you for replying

Specializes in Infection Control.

Someone told me that when I'm stumped to try and work backwards.

Example: The TIME MEAUSURED OUTCOME (The Goal)l for this dx would be:

Pt will feed herself safely during hospital stay.

What INTERVENTIONS (stuff that I can do) support this outcome?

I can:

*assess pt's abililty to feed herself at this time

*ensure pt has dentures, hearing aids, and glasses in place

*ensure proper body position

*set up tray so that all containers are opened and placed so that pt

can utilize left hand to feed herself

*sit on unaffected side at eye level

*allow pt to participate in feeding as able; provide verbal/visual cues; provide praise for all feeding attempts; increase tasks as able

*encourage pt to keep food on the unaffected side of mouth with a rocking motion to deposit food

*be prepared to intervene if choking occurs; have suction equiment ready

Hm-m-m-...so now I'm sensing the NURSING DX (the problem) has to do with:

feeding selfcare deficient related to CVA as evidenced by right side hemiparesis.:yeah::yeah::yeah:

I struggled with the Nursing DX all through school:banghead:. I hated them:scrying:.

Now I look at the doctors orders :Dand take my cues from them.

For example; If there's an order for Contact precautions because the patient has MRSA in a wound I know I can do one on Knowledge deficit.

New onset diabeties is good for knowledge deficit in performing acuchecks and insulin injections.

If there's an order for IS I can write on Impaired Gas Exchange

Pain is always a good one. You want the outcome to be that the "pain will be tolerable during hospital stay"

I kinda like doing them even though my nursing verbage still needs improving.

Good luck:yeah:You cn do it!!!!

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