Help me with ED progress note.. I`m so lost! -- and diagnosis - page 2

I`m completely new to ED in this rotation and i`m very nervous.. now I have a bunch of paperwork too and I`m stuck on this: I had a patient who was pregnant, 15 wks, and fell down the stairs. she... Read More

  1. by   hodgieRN
    The medical diagnosis is Fall and Abdominal Pain (the abd pain should have a diagnosis that's more specific if you can find the actually injury). A medical diagnosis can include mechanism of injury like motor vehicle accident or assault, but there is usually a list of injuries included in the diagnosis. Unless there is a medical reason that contributed to the fall like syncope, Fall is appropriate b/c it was an wasn't caused by another disease process, but it describes the mechanism of injury. A pt admitted to the hospital with a head bleed also has Fall as the medical diagnosis. It's the reason they have the bleed, so it is included. As for "abdominal pain," a more definitive diagnosis is needing b/c something is causing the abd pain. This is why other people are asking the symptoms, test results, etc. The symptoms and injuries help drive the differential diagnosis (which is the elimination process of what you suspect is going on). Something is causing the abdominal pain such as bleeding, miscarriage, uterine rupture, etc. But if there is no definitive injury, abd pain can be sufficient if there's no specifics. Even the word cramping can be a diagnosis, but it would be better if there was more information. Abd pain in pregnant pt's should have the reason named, but in general, Abd pain can be a medical diagnosis under certain conditions.
  2. by   Esme12
    Quote from Student2001
    I`m completely new to ED in this rotation and i`m very nervous.. now I have a bunch of paperwork too and I`m stuck on this:

    I had a patient who was pregnant, 15 wks, and fell down the stairs. she was feeling "cramps", with 2-5/10 pain, normal vitals (with the exception of her HR, which was a little high- 118 and 140/90 BP but she was anxious). I`m having a hard time thinking of a MEDICAL DIAGNOSIS/impression for this.. anyone have any ideas? -- for some reason it is asking for that, and I didn`t see it on their chart.

    I have already filled out a assessment form for this- where i wrote down things like what meds i gave and her vitals, neuro, resp, and GI/GU assessment, so I`m lost about what to include in the progress note since I assumed that I already have everything..

    what do i include in the progress note?

    i wrote " pt fell down 6 stairs onto carpeted surface. Has not had prenatal exams. has hx of miscarriage. c/o sharp "menstrual crampish" pain. She was given Zofran and Ns 0.9%. Has had ultrasound- results to be determined. Pt appears to be less anxious and stated that the cramping has gone down.

    I`m also supposed to think of a nursing diagnosis.. i supposed risk for fall/ safety.. and then i`ll make up some interventions.

    Please.. ANYONE.. i know my progress note is a mess.. if someone can guide me through this I would SO appreciate it!!
    Welcome to AN! The largest online nursing community!

    patient who was pregnant, 15 wks, and fell down the stairs. she was feeling "cramps", with 2-5/10 pain, normal vitals with the exception of her HR, which was a little high- 118 and 140/90 B/P
    You need to address any apparent injury this patient suffered.....any abrasions, bruising, obvious deformities. Does she have bowel sounds is her abdomen soft or firm and tender. Is her pain pain constant? Intermittent? Is the any discharge? Did she have a loss of consciousness? What is her OB history? How many times has she been many live births? When was her LMP....when is her EDC. Did you listen to fetal heart tones to check on the baby?

    Your medical diagnosis is pregnancy, fall, abdominal pain.

    Your patient complains of pain. Her SAFETY should be of concern. She appears to have deficient knowledge about prenatal care and pregnancy.

    See where this is going?

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, 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)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient?
    Last edit by Esme12 on Nov 8, '12
  3. by   Virgilio
    Lol, does ED mean Emergency Department? I'm still a pre nursing student and I immediately thought of "male health issues"!
  4. by   Esme12
    Yes it means emergency Department.
  5. by   nurseprnRN
    (I'd be suspicious if someone told me she "fell down the stairs" and now is worried about miscarriage. I'd look for bruising or other injury on other parts of her body that would be suggested by that mechanism of injury. Finding none, I'd tell her that. That opens up a whole 'nother scenario for assessment. "Clumsiness" that "always happens" with pregnancy...multiple losses... uh, huh. Sure. Who says so? My feelers are up.)

    Ahem. You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period (although it is perfectly appropriate to have "disease process" as a defining characteristic for many). This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.

    Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

    For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)

    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.