Nursing Students Student Assist
Published Nov 4, 2004
gsunursingstudent
13 Posts
I need to formulate a Wellness Nursing Diagnosis, and have no clue about them or how to state them in my care plan ? Can someone help me ?? Thanks !
kathy_79
132 Posts
there are two types of nursing diagnosis:
1. acurate which are three parts
nursing diagnosis - problem stated
related to (r/t) - underlying cause, pathophysiology or/and psychosocial issue
as evidence by (aeb) - subjective, objective data
ex: impaired gas exchange
r/t sorth of breath, or decreased cardiac output, or excess fluid in lungs (or all of those)
aeb vs t 98.9 bp 138/80 rr 24 hr 70 ;
sat oxygen 92% (specify what was used- nc, mask, nb mask, venti mask or room air how many liter per minute or percent)
head to toe assessment: level of orientation: alert but disoriented 2x (place , person)
circumoval eyenosis, shallow breathing, sob on excretion, nasal flaming,
how is pt capillary refile, lab values, meds,
subjective describtion from pt, caregiver, family
never put current status here
it is active infection, actual, visible problem (need) of pt to "fix"
2. risk for
nursing diagnosis - problem stated "risk for...", no visible evidence just suspect for...
r/t - current status
never put aeb, there are no evidence, you suspect something to happen
ex: risk for infection
r/t surgical procedure or immunosuppresion, or both
current status vs; t, hr, rr, bp; awake or confuse (mental status); head to toe assessment, surgical site assessment, lab values, meds,
subjective data,
i put you sample what we use for out care plan:
Nursing Dx:
R/T
Objective data:
subjective data:
current status ____________________________________________________
hope it helps,
good luck to you and others, :)