Help! My first Care Plan! Diagnosis help needed!

Nursing Students Student Assist

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I am embarrassed to post such a fundamental question but how do you arrive at a diagnosis. I had my first clinical last week and interviewed my patient. I received the report from the patient's Nurse and I have written down much info from the patient's folder (but I do have to go back to attain more).

Do I simply take the symptoms and look them up in a NANDA database and choose one that I think is best?

What is the best source of NANDA DIAGNOSES'? Is there a specific book or website?

Thank You.

Confused & ******** My Pants,

Scott

with all that data you collected, what struck you?..what stuck out? what did you think was important?

to get you started...what were the client's VS? how about their labs? any levels out of the ordinary? what about the medical diagnosis? how old was the person? did your client get out of bed during your shift? if not, why?

all of your data collection via assessment, the chart, what the client tells you, what you get in report, etc will help you come up with a nursing dx

sparks and taylors is a good resource

Cox's Clinical Application of Nursing Diagnoses is a great book with all the diagnoses and possible interventions.

When choosing a diagnosis, think back to yourself about the pts condition. What did he or she have? Did it cause weakness (risk for falls)? Was he or she vomiting (imbalanced nutrition)? Anxious (anxiety)? Pain is always a good dx for a pt unless your instructor advises against is. Knowledge deficit is usually always excellent. IF you have a stubborn pt, ineffective therapeutic regimen could be one.

Just think of his or her disorder and what consequences it places on their body and their lives.

Good luck.

Very helpful. Thanks very much!

I found a few highly rated Nursing Care Plan books but they were published in 2005 and 2006. Is this okay or do you think I would be cheating myself out of updated info concerning Diagnoses and NIC and NOC?

alot of nursing dx have changed since 2007- i would get an updated book, i use nursing care plans by gulanick/myers, and the sparks and taylor book that was mentioned above. but dont forget that it has to be tailored to YOUR pt. a book will not give you all the answers, they are just general interventions. for example if your pt has pneumonia and your intervention is encourage cough & deep breathing that is a great intervention as long as they are A&O, and they can follow commands. If they cannot follow commands you cant teach and encourage coughing and deep breathing... so just remember to keep your patient in mind when looking at the interventions, does this apply to my patient?, how will this help my patient?, will my patient benefit from this intervention?, and most importantly - IS THIS SAFE FOR MY PATIENT?!?!? Also dont be afraid to come up with your own interventions, you can always put in any intervention that is your own or one that you had found and changed. :) good luck!!

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