i may be critical, but i am not mean. i read every word you post and spend time and impart what little knowledge of care planning i have. i spend a great deal of time with care plan posts. you will get out of them what you put into them. i can only work with the information that people give me, so part of my problem is that many times students aren't even aware of what it is that they are doing incorrectly.
with diagnosing. . .every nursing diagnosis just like every medical diagnosis has a list of patient behaviors called cues or symptoms that we can observe (they will be given to you in a case study) and are characteristic of that specific nursing problem. nanda calls these cues or symptoms defining characteristics
. a related group of cues and symptoms (defining characteristics
) becomes a specific nursing problem and is given a label called a nursing diagnosis.
case studies specifically place key cues and symptoms into them so that students will, hopefully, be led to choose certain nursing diagnoses and nursing interventions and goals.a nursing diagnosis reference will have the definition, defining characteristics and related factors for each nursing diagnosis. this is called the taxonomy. many of the newer care plans
books will contain this information. the newer editions of taber's cyclopedic medical dictionary
have this information in the appendix. i have taken case studies that students have posted and shown how they are diagnosed by using the nursing process many times on allnurses. there may be a couple of them on this sticky: http://allnurses.com/general-nursing...ns-286986.html
- help with care plans.
when i am working with any nursing diagnosis i am always looking at a copy of the nanda taxonomy to make sure that the etiology and defining characteristics are correct in the diagnostic statement. a completed diagnostic statement should be like a photograph that captures and memorializes the nursing condition of that patient for all who read it to know
the construction of the 3-part diagnostic statement follows this format: [font=arial unicode ms]
p (problem) - e (etiology) - s (symptoms)
- problem -
this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary
has this information.
- etiology -
also called the related factor
by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
- symptoms -
also called defining characteristics
by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
- - - - - - - - - - - - - - -
excess fluid volume r/t compromised regulatory mechanism aeb dyspnea and +2 pedal edema
what is the compromised regulatory mechanism you are referring to? you really should identify it. you need to know the pathophysiology that is going on. are you suggesting that it is related to the chf?functional urinary incontinence ?? is that better than impaired urinary elim?? i'm having so much trouble with r/t and aeb with this careplan
... my case study is very detailed.. too detailed to write.. but i can write some...84 yo female resides at a nursing home for the last 2 years. she was independently at home until she was no longer able to manage in her home after a hospitalization for copd exacerbation. she has ben 02 dependant for the past 2 years. presently she is being treated for a uti. as tolerated, she attends pt daily. hx: emphysema, htn, type 2 dm, oa, gout, cad, hypothyroidism, chf, pneumonia.
the definition of functional urinary incontinence
is inability of usually continent person to reach toilet in time to avoid unintentional loss of urine
(page 91, nanda international nursing diagnoses: definitions and classifications 2009-2011
). "function" has to do with how something is performed. this diagnosis (remember nursing diagnoses are about problems) has to do with the action of urination. this type of incontinence, or problem, is when the person can't get to the bathroom in time to be continent. the related factors that are listed for this are:
- altered environmental factors [i would take this to mean physical restrictions posed by the physical surroundings which might be things such as stairs, poor lighting, the bathroom now being a long way away]
- impaired cognition
- impaired vision
- neuromuscular limitations [this would include someone with oa and gout]
- psychological factors
- weakened supporting pelvic structures
the suggested aebs for this are:
impaired urinary elimination
- able to completely empty bladder
- amount of time required to reach toilet exceeds length of time between sensing the urge to void and uncontrolled voiding
- loss of urine before reaching toilet
- may be incontinent only in early morning [the implication to me is that the patient moves slower in the morning, wouldn't you say? people with oa have that as a symptom]
- senses need to void [again, the implication being that they can't get to the toilet fast enough]
is defined as dysfunction in urine elimination
(page 98, nanda international nursing diagnoses: definitions and classifications 2009-2011
). dysfunction of the action of urination means an abnormal or incomplete action or process (urination). functional urinary incontinence
what the dysfunction was and started with the premise that the patient was essentially continent but others things, all of them external to the gu system, caused the incontinence. this diagnosis is used when the causes of the dysfunction are located in
the gu system and it includes a whole bunch of things. the related factors that are listed for this are:
- anatomical obstruction
- multiple causality
- sensory motor impairment
the suggested aebs for this are:
this is all historical and none of it reveals any assessment data that pertains to nursing problems. the medical disease information should be explored because it provides pathophysiology for the etiology of some of the nursing diagnoses you will end up using.