Help Prioritizing nursing DX

nurseprnRN, BSN, RN · Nov 12, 2012

I am assuming that you personally assessed those crackles (check spelling), edema, dyspnea, activity intolerance, and the like, right? I'm thinking not, and you pulled them out of a list somewhere, because there is one critical other sign of decreased cardiac output which is very important, and I don't see it mentioned here. Also, I dont see "getting winded" in the defining characteristics of any nursing diagnosis in my NANDA. :) If you didn't assess all these signs yourself, how do you know these nursing diagnoses apply to this patient? Come back with a quick answer and we'll chat. Meanwhile, consider this:

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. 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.

ALCANGEL1 · Nov 12, 2012

Its a fictional person given to me by my school so no i was not able to assess these things myself it would be a whole lot easier if it was an actual person

Esme12, ASN, BSN, RN · Nov 12, 2012

Welcome to AN! The largest online nursing community!

Think Maslows.......

Physiological Needs
These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.
Security Needs
These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health insurance, safe neighborhoods, and shelter from the environment.
Social Needs
These include needs for belonging, love, and affection. Maslow considered these needs to be less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.
Esteem Needs
After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.
Self-actualizing Needs
This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

.Hierarchy of Needs

For your care plan is this all the information they gave you?

The patient has severe CHF, chronic renal failure, diabetes. The pt. also has some redness on a spot where they could get pressure ulcers.

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...:) what care plan book do you use.

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

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
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.

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? There is not enough information about the patient to develop a good ND.

Esme12, ASN, BSN, RN · Nov 12, 2012

Care plans are all about the patient.....the assessment of the patient. The recipe on how to care for them that day so everyone knows how to care for them. It really bugs me when they don't give you good information on a fake patient and expect students to understand.

What is CHF? What does CHF do? What is important for the patient? What can you do for them and how can you prevernt complications...like skin breakdown.

ALCANGEL1 · Nov 12, 2012

Ok so the pt. was admitted with a dx of respiratory distress. Pt. has a history of renal failure, diabetes and hypertension. Pt. states she is a little out of breath especially when moving. She is overweight but does some exercise. She has a high BP, HR and RR. She has an SaO2 of 91%. She has a very high BNP which indicated heart failure. She also has a high creatinine level. She has crackles and edema. She needs assistance to walk and gets winded when walking short distances. She has some redness on her coccyx which is probably a pressure ulcer.

When a person has CHF the heart is not pumping blood around the body like it should be and therefor tissues and organs are not getting the blood they need and oxygen is not being delivered.

I am really trying to figure this out instead of trying to just pick care plans one of my books lists.

I have Carpanitos handbook of nursing diagnosis and nursing care plans by gulanick and myers.

ALCANGEL1 · Nov 12, 2012

I also wanted to put impaired gas exchange but that is caused by the fluid so can you put excess fluid volume as one nursing dx and impaired gas exchange as another?

nurseprnRN, BSN, RN · Nov 13, 2012

If the heart is not pumping well, would blood pressure be ELEVATED? OTOH, if BP is elevated, what does that tell you about the workload the heart is up against trying to pump blood out to arteries with high pressure in them? What might be the medical treatment for that, and how would you know it's working?

You can certainly have a patient who has excess fluid volume on board, and has impaired gas exchange at the same time. Look at the defining characteristics for each and you'll see why. Get your NANDA-I 2012-2014 to give you a better base to understand how that works. I like Carpenito and all, but the definitive resource is the current NANDA-I.

hodgieRN · Nov 14, 2012

I am need to come up with three nursing dx and I need to prioritize them and I am having problems.
The patient has severe CHF, chronic renal failure, diabetes. The pt. also has some redness on a spot where they could get pressure ulcers.
I picked 3 nursing diagnoses and put them in this order
1. Excess fuluid volume r/t CHF and renal failure as evidenced by edema, crackles, dyspnea, elevated BP, HR
2. decreased cardiac output r/t CHF as evidenced by increased HR, crackels, increased RR, dyspnea, edema
3. Activity intolerance r/t CHF as evidenced by getting winded when walking a short distance
Is that the order that you would put those three nursing dx in? Would you change any of them and perhaps remove 1 and add impaired skin integrity? Thank you.

Just my two cents.....

I think the excess fluid volume is pretty good.

Might want to tweak the decreased cardiac output a little. Like GrnTea said, there is a critical component to decreased CO you are missing. What happens when someone has decreased CO? Hint...blood perfusion. How does their skin look? Pulses? Any organ perfusion? How about B/p! What are some points you can say that support decreased cardiac out put? (Hint) Oxyg___tion

For Activity intolerance, don't use "getting winded." Getting winded means you are short of breath. The medical terminology for shortness of breath is.......... (I'll give you a hint........Starts with ---Dys

I also hope this makes sense b/c I am tired! Had a 12 hr shift and I'm going nite-nite. But in my opinion, there are some factors to think about when discussing decreased cardiac output. It effects so many different factors.

mariebailey, MSN, RN · Nov 14, 2012

As far as prioritizing, a patient may have an amalgam of common comorbidities, but your care plan will reflect their unique needs. If a different patient with the same medical diagnoses was not suffering an exacerbation of CHF but had symptoms of DKA, your priorities would change, wouldn't they?

Nursing Diagnoses 2012 - 2014.pdf

Esme12, ASN, BSN, RN · Nov 14, 2012

Ok so the pt. was admitted with a dx of respiratory distress. Pt. has a history of renal failure, diabetes and hypertension. Pt. states she is a little out of breath especially when moving. She is overweight but does some exercise. She has a high BP, HR and RR. She has an SaO2 of 91%. She has a very high BNP which indicated heart failure. She also has a high creatinine level. She has crackles and edema. She needs assistance to walk and gets winded when walking short distances. She has some redness on her coccyx which is probably a pressure ulcer.
When a person has CHF the heart is not pumping blood around the body like it should be and therefor tissues and organs are not getting the blood they need and oxygen is not being delivered.
I am really trying to figure this out instead of trying to just pick care plans one of my books lists.
I have Carpanitos handbook of nursing diagnosis and nursing care plans by gulanick and myers.

Again and I can't stree this enough.........

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

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)