i want you to think about these questions i am now going to ask you
- how does a doctor diagnose a medical condition in someone?
- how does a nurse diagnose a nursing problem in someone?
- is there a difference in how these two diagnoses are arrived at?
a doctor diagnosed that uti in your patient by taking a history of the patient's urinary system (asking questions about their voiding) and listening to what the patient had to report. the doctor also did some type of examination, did vital signs and ordered a ua and possibly a c&s of the urine. some other labwork might have been done as well. this was assessment. after considering the findings, some abnormal data surfaced and some signs and symptoms became evident that suggested to the doctor that the patient's symptoms fit the profile of a uti (urinary tract infection). it was a logical decision making action that followed a step-by-step process--the medical decision making process.
the nurse receives the patient and also does an interview and history of the patient. the nurse focuses their assessment not only on the physical symptoms they have but also on their response to the illness and how it has affected their ability to perform their adls (activities of daily living). the nurse looks at what the doctor documents and orders. part of the nurse's responsibility is to carry out the doctor's orders. another part of the nurse's responsibility is to help the patient get through their day and live with the symptoms of their medical disease/condition. after considering the findings, some abnormal data surfaces and some signs and symptoms (nanda calls them defining characteristics) become evident that suggests to the nurse that the patient's symptoms fit the profile of a several different nursing diagnoses. every nursing diagnosis, like every medical diagnosis, has a set of signs and symptoms. it was a logical decision making action that followed a step-by-step process--the nursing process.
is there a difference in how these two diagnoses are arrived at? no. what is different is the set of diagnoses used by each. we nurses do not use medical diagnoses to define nursing diagnoses. we have the nanda taxonomy that does that for us. you need a nursing diagnosis reference to help you when you are new at diagnosing. there are currently 188 nursing diagnoses that have definitions, defining characteristics and related factors already worked out for you. where can you find this information? nanda doesn't just give it away:
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
prioritizing doesn't enter into a written care plan until you have looked at all the evidence you have assembled. and then, you consider maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
the fist thing you need to do in sitting down to work on this care plan is to look up and read about utis and sepsis. do not assume that a uti is simple. if it were, this patient would not have spent 3 days in the hospital for sepsis! sepsis is a serious matter and 3 days didn't fix the problem. she is hardly out of woods. she got 3 days of the "big guns" (ivs) but i'm sure she's going home on 7-14 days of some big time atbs, right? this is a medical treatment! so, what were the signs and symptoms of the sepsis? what did the chart have to say on this? i think this is still a problem that needs to be addressed and monitored for. she also needs to be watched for the side effects of the atbs she is on. at the end of your post you said something about her having some pain? what was that about? uti is likely to be a reoccurring problem. discharge planning includes diet, allowed physical activity, medications they will need to take, treatments and tests they need to be doing after discharge, follow up appointments with doctors have been made and patient knows about them, referrals to any outside agencies or support groups have been made, and teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient. this thread has weblinks to all kinds of websites where you can find information about medical diseases and conditions:
happy care planning!