Nursing Dx

  1. Hey yall, I'm working on my first care plan and the nursing Dx have me stumped.

    My resident is in her 90s with Bipolar and major depressive disorder. She is mostly independent. She has minor cares with grooming, bathing, dressing. She transfers by herself and walks with a walker with no assist. Left side hearing aid, glasses. No major heart problems. I need to come up with 5 actual Dx but I have no idea where to start since she is so independent. The ones I had before did not work but it was due to the fact I must not understand how to apply it to a resident.

    Please help, ideas, anything would be nice.
    •  
  2. 9 Comments

  3. by   JillybeansRN2B
    Does she have any nutritional deficits or fluid intake? Could she be at risk for falls. Does she take any pain medication?
  4. by   arosario82
    SHe does take PRN for pain and intake is good. I cant do any risk Dx.
  5. by   akulahawkRN
    Quote from arosario82
    Hey yall, I'm working on my first care plan and the nursing Dx have me stumped.

    My resident is in her 90s with Bipolar and major depressive disorder. She is mostly independent. She has minor cares with grooming, bathing, dressing. She transfers by herself and walks with a walker with no assist. Left side hearing aid, glasses. No major heart problems. I need to come up with 5 actual Dx but I have no idea where to start since she is so independent. The ones I had before did not work but it was due to the fact I must not understand how to apply it to a resident.

    Please help, ideas, anything would be nice.
    I have bolded some potential places to start. If you have a current NANDA book that defines the various Nursing Diagnoses, there are some diagnoses that may fit what I've bolded. Now what you need to do is look at the definitions of the diagnoses and see if you have actual data that fits accurately.

    What you really need to do is look at all the data you've collected about this resident and be familiar with the nursing diagnoses to let the data drive the diagnosis. That's actually how medical diagnoses are made too. The data drives the diagnosis.

    Look at how those various things that I bolded present in your patient. Some of what I have bolded is a response to something too. It's not difficult, but thinking this way can be challenging at first.
  6. by   arosario82
    Thank you
  7. by   alexis_xoxo
    Keep in mid that nursing dx don't always have to be a bad thing. (I.e. Effective Role Perfermance)
  8. by   arosario82
    I didn't think about that thank you
  9. by   student_B
    Quote from alexis_xoxo
    Keep in mid that nursing dx don't always have to be a bad thing. (I.e. Effective Role Perfermance)
    This makes sense to me, but my Nursing Diagnosis Handbook (Elsevier, 11th ed.) has two pages of NANDA-I diagnosis and all are "negative" with the exception of the "Readiness for enhanced _____". E.g., Bathing/Dressing/Feeding/Toileting Self-Care Deficit and Readiness for enhanced Self-Care.

    Would something that's not a problem/negative be considered an assessment parameter rather than a Nursing Dx? I.e., "Patient is effective in role performance" in assessment vs. "Dx: Ineffective Role Performance r/t insufficient role preparation; physical illness; etc.".

    I'm still just getting the hang of writing up Nursing Dx's; takes me forever, but I'm learning a lot by writing out the interventions, rationales, and documentation notes.
  10. by   arosario82
    Okay I need some help understand which one to use for my resident.

    Imbalanced Nutrition or Impaired Swallowing??

    My resident stated she has problems swallowing sometimes and uses straws for fluids. she does have dentures, full top and partial bottom. I have to a complete write up of one but I'm not sure which one would be right? She does get both constipation and diarrhea. Watching her she does try to take smaller bites. She has GRED and IBS.
  11. by   HarleyGrandma
    I would start with what is going to kill her *now*, then work backwards on the priorities. (Not getting enough protein could make her sick eventually, but choking on food could kill her today). You'll eventually get the hang of it, and soon it will become second nature to 'write' care plans in your head as you assess patients.
    PS: Remember that goals are patient oriented, and interventions are nurse based.

close