about nursing diagnoses. . .
- there are officially 188 of them per nanda
- a nursing diagnosis is actually a nursing problem that we nurses are going to try to resolve, improve or stabilize
- every nursing diagnosis has a list of symptoms which nanda calls by the term defining characteristics
- to assign a nursing diagnosis to a patient, the patient needs to have at least one or more of the defining characteristics
before you can even begin looking for nursing diagnoses, and because you are a student, there is some preliminary work you have to do first.
- most importantly
- 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)
- collect data from the medical record (information from the doctor's history and physical, the doctor's progress notes, test result information, and notes by ancillary healthcare providers such as physical therapists and dietitians
- look up the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for cellulitis and it sounds like she also has a problem with either urinary incontinence, mobility and some kind of gyn problem (they don't do d&c's without a reason). this includes knowing about any medical procedures that have been performed on the patient (the d&c), their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
- you can find this information on the weblinks listed on this thread:
then, you need to make a list of all the abnormal data you discover about this patient. this abnormal data is actually her symptoms that you will need to be the evidence supporting any nursing diagnoses that you end up using. just like a doctor diagnoses a person with pneumonia because they have a fever, yellow purulent sputum they are coughing up, crackles and rhonchi in their lungs, shortness of breath, and an infiltrate on their cxr, we are going to also need evidence to support every nursing diagnosis we tack onto this patient.
it is a good idea to use a nursing diagnosis reference to assure that you are diagnosing correctly. you need a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda.
- 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.
- there are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
then, your nursing interventions and goals address those specific symptoms.
some symptoms of this patient's cellulitis that you should have seen were
- skin redness, warmth, tenderness and pain of the lower extremities (signs and symptoms of inflammation)
- possible weeping of serous fluid from the skin
from those, the following nursing diagnoses can be extrapolated:
impaired skin integrity r/t tissue inflammation and body secretions aeb redness, warmth, tenderness of the skin of the lower extremities and continuous serous weeping from the swollen skin on the lower legs.
hyperthermia r/t infectious process aeb temperatures of. . .
acute pain r/t tissue inflammation aeb edema in lower extremities
that should get you started, but there is still a lot of work that you need to do on this care plan. a care plan is the documentation of our problem solving of nursing problems. the nursing diagnosis, honestly, is only a very small part of the care plan, but for some reason the single thing that students get the most distressed over. when you understand what drives the choice of the diagnosis it makes choosing them much easier.
there is information on writing care plans
(and how choosing nursing diagnoses fits into that) on this sticky thread in the general nursing student discussion forum