Need a Nursing Diagnosis for GERD

[deemarys]

Hello,

I am working on a careplan, actually its almost done and I was questioning whether my nursing diagnosis fit.

My client is 79 and has Cerebral Palsey and GERD. She is oriented and makes her needs known by grunting and pointing. She has a habit of going straight to bed after eating meals which makes her vomit right away. I am trying to figure out if my nursing diagnosis should read:

High Risk for Imbalanced Nutrition less than body requirements related to inability to absorb nutrients

because of vomiting (IS THIS A COMPLETE NURSING DX)

OR

High Risk for Imbalanced Nutrition less than body requirements related to inability to absorb nutrients

because of vomiting related to GERD (THIS ONE SEEMS COMPLETE BUT NOT SURE IF I SHOULD ADD MEDICAL DX)

Thanks in advance for your input.

D

[Daytonite, BSN, RN]

we have discussed this patient and care plan before.

with "risk for" diagnoses the "related to" part of the diagnostic statement is why the patient is at risk for the problem (in this case, imbalanced nutrition: less than body requirements. . .not getting enough nutrition). i do not know or understand what you mean by inability to absorb nutrients. why don't you just say "vomiting after lying down immediately after eating"? that describes the problem to anyone who doesn't know this patient and reads the diagnosis. and that is the problem i have with this--it is already a problem so it can't be a potential problem which is what a "risk for" diagnosis is.

i believe this is an actual problem proven beyond a shadow of a doubt and not a potential problem as you are trying to make it out to be. i would diagnose this (and i've told you this before) as ineffective health maintenance r/t cognitive impairment, inability to make appropriate judgments and unwillingness to follow instructions aeb continually refusing to remain sitting upright after ingesting evening meal, consistently retiring to bed immediately after eating dinner resulting in the vomiting of the meal, not complying with the dietary plan of her physician and obtaining food insistent with her diet plan to eat elsewhere.

i can see that you are determined to do this care plan you own way. good luck with your ideas. i would mark this diagnosis you are considering as wrong.

[deemarys]

No, I do not want to do it my own way, thats why I posted for help again, Also this careplan was due a week ago and I withdrew it because I still knew it was wrong because of your input you provided me.

[NamasteNurse, BSN, RN]

A nursing diagnosis is written in the form of Problem, related to, manifested by...In your case it might be Risk for imbalanced nutrition related to lack of absorbtion manifested by vomiting stomach contents after meals. I think that's right anyway...? anyone else?

[Daytonite, BSN, RN]

You need to read the OPs other post on this patient and care plan to learn the entire situation and history about the patient. What I have stated is that the risk is long gone and the problem already exists. The problem is the patient's behavior and not her GERD. Read the other post.

[cleed2004]

I was always taught that using medical diagnosis' was not allowed in care plans.....so stating GERD as a manifested by would be incorrect.......I agree with the above post that the problem is pt's behavior after eating and not following instructions....not the vomiting itself....I am leaning towards the cognitive issues more than risk for impaired nutrition........GL!