Help with Nursing diagnoses

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Hi All, I have been a first year nursing student for about 8 months now, and am currently on my first clinical placement - Eeek! - So our placement is in a rest home and we all have a resident who has kindly allowed us to undertake a comprehensive assessment of them and practice our physical assessment techniques too! :-) So far so good except we are now expected to write care plans and prioritise 3 nursing diagnoses. So far my top three are risk for decreased cardiac tissue perfusion r/t aging process. Risk for falls r/t wheelchair use secondary to CVA and Risk for complications due to immobility r/t L) sided hemiparesis secondary to CVA. My patient has a history of IHD, hypertension and PAF. Is on B blockers etc and Glyterin spray for angina and had a recent episode a month ago of tachycardia and chest pain and was rushed to hospital. I'm just wondering if my diagnoses are on the right track? Some other students said because his cardiac condition was stable it is no longer a priority? Any help would be so greatly appreciated! Thank you :-)

No care plan book, not allowed to use NANDA Dxs either

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Specializes in Complex pedi to LTC/SA & now a manager.
No care plan book, not allowed to use NANDA Dxs either

NANDA-I is the international standard not being allowed to use NANDA is ridiculous.

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Not a great idea to approach it that way with your instructor.
Haha I probably wouldn't say it in that exact way but I think I have a valid point so I will bring it up with her
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NANDA-I is the international standard not being allowed to use NANDA is ridiculous.

That's what I thought. Our instructors at school tell us to use NANDA, but my clinical instructor isn't a part of the teaching facility .. An instructor from school was filling in for a few days on clinical placement and even she said his peripheral oedema and dyspnea is cardiac related and I made good links with assessment findings and pt history. I'm so confused as to why dyspnea and oedema wouldn't be priorities. My clinical instructor suggested I make his boredom in the rest home a priority, he hasn't mentioned he's bored but I supposed if I probed him about it he would probably say he is, he did mention the rest home is like being in prison

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Specializes in Pediatrics, Emergency, Trauma.

So what's else could be a priority diagnosis that is not cardiac and is another priority over his "boredom"?

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No care plan book, not allowed to use NANDA Dxs either

Just wondering....are your clinical experiences completely separate from the rest of your program? If not, I think you should let someone know that you are being told NOT to use NANDA diagnoses. I doubt your school wants the students confused that way. No one should be "making up" nursing diagnoses. If the clinical experience is separate, then my advice is to do the best you can to turn in a care plan that follows your clinical instructor's guidelines and don't worry about it. It will all start to make more sense when you move into med-surg and write proper care plans with NANDA Dxs. In the meantime, keep reading all GRNTEA's posts on care plans! They are invaluable! Good luck!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Oh I wish GrnTea or Esme were around to help here! They can make things so much more clear....

Sorry I have been sick and flat in bed.....I have just entered the land of the living I won't be on long but I'm here....It's nice to look at the world from an upright position...LOL

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I would have thought anxiety r/t to dyspnea? But when I mentioned to my pt he seems like he's short of breath all the time he just said it was fine, sometimes it gets much worse than that, he seemed to accept SOB as part of his life, does this have to be the case? Is there anything that can alleviate it for him? I haven't taken his Sap02 yet so will do that tomorrow.
I know I am late to the party....I have been sick....better late then never...:up:.

Care plans are all about the patient assessment. What the patient needs based on YOUR ASSESSMENT of THE PATIENT as you think about what the other co-morbidity exist and how they affect YOUR PATIENT.

You are talking about dyspnea...what evidence do you have that proves that your patient is SOB? What is the respiratory rate? What do the lung sounds like? You haven't even taken an O2 sat so you haven't completed a comprehensive assessment. Does this patient have COPD? CHF? Diabetes? HTN? Past history of MI?

Looking at your patient assessing your patient, gathering all of that vital information is all apart of that vital critical thinking nursing process....I need more information to help you.

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.

So in the future.........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 patient......in 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.

check out this thread....https://allnurses.com/nursing-student...085-page2.html

Attachment 12727Critical Thinking Flow Sheet for Nursing Students.docAttachment 12727Attachment 12727Critical Thinking Flow Sheet for Nursing Students.doc

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
No care plan book, not allowed to use NANDA Dxs either
I"m confused....you are in a nursing program that is not using the standard of practice? You are not allowed any NANDA resources? That makes no sense....how are you supposed to know the definitions and defining characteristics that develop your care plan? I would be speaking to a program director.
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
That's what I thought. Our instructors at school tell us to use NANDA, but my clinical instructor isn't a part of the teaching facility .. An instructor from school was filling in for a few days on clinical placement and even she said his peripheral oedema and dyspnea is cardiac related and I made good links with assessment findings and pt history. I'm so confused as to why dyspnea and oedema wouldn't be priorities. My clinical instructor suggested I make his boredom in the rest home a priority, he hasn't mentioned he's bored but I supposed if I probed him about it he would probably say he is, he did mention the rest home is like being in prison
Are you in the US?
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Hi! Sorry I have had exams and haven't been on for a while! Thanks so much for all your help, and no I am not in the US, I'm in New Zealand. Our clinical instructor isn't a tutor at school so your right I might talk to someone at school and tell them we are being told not to use NANDA. Because we are told to use it at school.

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