Nursing Diagnosis DM

Nursing Students LPN/LVN Students

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can anyone help me...i need a nursing diagnosis for dm?? anyone...this patient has a hx of copd, chf and cva....

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Specializes in Peds HH, LTC.

These are only Possibilities, without me knowing the pt himself, any lab works, etc.

Ineffective tissue perfusion peripheral r/t impaired arterial circulation

R/F injury: hypoglycemia or hyperglycemia r/t failure to consume adequate calories, failure to take insulin

Ineffective health maintenance r/t deficient knowldge regarding care of diabetic condition

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Specializes in Pediatric/Adolescent, Med-Surg.

I agree, there are literally tons of diagnoses you could use here depending on what else is going on with your pt. Perhaps:

Risk for infection r/t compromised immune system

Ineffective perfusion r/t disease process a/e/b decreased pedal pulses, impaired healing of wound (for example)

Nurtion, imbalanced, more than body requirements r/t a/e/b BMI of ht/lb

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Specializes in med/surg, telemetry, IV therapy, mgmt.

when a doctor, car mechanic or homicide detective decide on their client's final problem (diagnosis, what is wrong with your car, who is the murderer) it is after a thorough investigation has been made. so, the first question i have for you is

  • did you do an investigation (assessment) of this person with dm and a history of copd, chf and cva?

my second question is

  • what abnormal information (signs and symptoms) sifted out ?

why am i asking?

  • because every nursing diagnosis has a set of signs and symptoms and you need to know which signs and symptoms your patient has that match up with the ones of the nursing diagnoses that are going to apply to him/her.

there is information on how to write a care plan on this thread in the general nursing student discussion forum: https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

a care plan is a written expression of the problem solving process. it contains 5 steps that you must follow in sequence to be successful:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

the first step, assessment, is quite extensive and involves doing the following:

  • a physical assessment of the patient
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

from what you have mentioned of this patient i suspect this will be a rather complex care plan because of the medical problems this person has. the reason for looking up information about the medical diseases is to double check your own physical assessment information that you collected to make sure you didn't overlook any signs or symptoms the patient might have exhibited when you were with the patient and just didn't realize what you were seeing. it is also important that you evaluated what the patient was and was not able to do adl-wise. docs do their thing; we do adls. adls-r-us.

after doing all that assessment you then start thinking about possible nursing diagnoses (nursing problems) as you begin to notice where the patient is needing the assistance of the nurse. abnormal data such as high blood sugars, numbness of the fingers and toes, the presence of open wounds on the feet or legs that don't heal well or problems with their eyesight in diabetics can all be translated into nursing diagnoses. to do that it is helpful to have some sort of nursing diagnosis reference. there are a number of ways to acquire this information.

i will help you determine this patient's nursing diagnoses, but not unless you post a list of their symptoms that you obtained from your assessment. so, go through the information that you gathered and that you remember and make a list of all the abnormal data that apply to this person because that is where you must begin.

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Risk for Unstable Blood Glucose

Ineffective Health Maintenance

Noncompliance

Risk for Infection

Adult Failure to Thrive

Like others have said, there are several Nursing DX you can use.

Do you have a Mosby's Dictionary? If so, you can look in Appendix 19 and look up the disease process your patient has and it gives you different Nursing DX you can use.......

I just look at the list of Nursing DX in the back of my text and go through each one thinking if it fits my patient. That helps me alot!

Hope this helps you some!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

please, please, please try to write a care plan doing it the way i suggest and following the steps of the nursing process. the reason is that you will learn so much about the disease process of the patient and how to think critically. that critical thinking (rational thinking) is going to be a huge help in getting you through subsequent nursing tests and especially the nclex. yes, you can use care plan books and the cross-reference indexes in the medical dictionaries. they will save you a lot of time searching for diagnoses. i will sometimes go page by page through my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 looking for a nursing diagnosis to fit one specific symptom because i just don't know what diagnosis it matches with. there are times when the care plan books and the cross-reference index won't have any suggestions for you. that is when you have to know how the nursing process works. the nursing process is also going to help you solve problems on tests by helping you decide the order of events that must occur in the solution process. it is not exclusive to care planning. this is all very rational in it's design and execution.

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Specializes in Med/Surg, LTC/Geriatric.
please, please, please try to write a care plan doing it the way i suggest and following the steps of the nursing process. the reason is that you will learn so much about the disease process of the patient and how to think critically. that critical thinking (rational thinking) is going to be a huge help in getting you through subsequent nursing tests and especially the nclex. yes, you can use care plan books and the cross-reference indexes in the medical dictionaries. they will save you a lot of time searching for diagnoses. i will sometimes go page by page through my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 looking for a nursing diagnosis to fit one specific symptom because i just don't know what diagnosis it matches with. there are times when the care plan books and the cross-reference index won't have any suggestions for you. that is when you have to know how the nursing process works. the nursing process is also going to help you solve problems on tests by helping you decide the order of events that must occur in the solution process. it is not exclusive to care planning. this is all very rational in it's design and execution.

you rock daytonite!! i don't know your whole background, but have you even been a nursing instructor/are one now? if not you should be! :) :nurse:

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Yes, this is the best way to go about it to learn more. I usually refer to Mosby's Dictionary only if I am not sure which to use. By the way, we are not allowed to use Nursing DX Handbooks (which I like better b/c it forces us to think outside the box) Critical thinking is so important and that is what the whole Nursing Process is about.

We also have to turn in pathophysiology for every patient. We use our textbooks to do this also, which helps out alot.....esp when Med Surg comes along!

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