Help with priority..

MilliePieRN · Oct 30, 2012

Or if there is a different one that would be better, I'd be happy for the advice.

Esme12, ASN, BSN, RN · Oct 30, 2012

You are falling in that trick bag of looking at the medical diagnosis for your nursing diagnosis. Many students do......

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)

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? This givens me no information about what your patient needs, what brought them to the hospital...what is their complaint? What is their history?

what doe this tell me about your patient assessment? About what they need......

My pt is a double lower leg amputee, post op 3 weeks. She has osteomyelitis (will finish her abx in 2 days), type 2 insulin dependent diabetes, and a healing stage 4 sacral pressure ulcer.

YOu say she has pain.....how does NANDA describe pain? What defining characteristics does your patient have that is consistent with the NANDA definition?

If you had bilateral amputation of your lower extremities what would be important to you? Would you have a Disturbed Body image? Would you have Acute Pain? Would you have Impaired physical Mobility? Does the Stage 4 decubiti mean Impaired Skin integrity?

Would you have an Activity intolerance and a risk for falls because of the amputation?

kansasredneckwomen · Oct 30, 2012

I personally would go with a psychosocial. Having both lower legs amputated! That is a huge, life changing ordeal! How will that effect her mind? Her social life? Her independence? Good luck!

nurseprnRN, BSN, RN · Oct 30, 2012

If I look in my NANDA-I 2012-2014, which every nursing student should have whether or not the faculty remembered to put it on the bookstore list (free 2-day delivery for students at Amazon), I can see a barrel of possible diagnoses for this patient....but since I didn't assess her, I can't really say. But you could, if you flipped through the pages. As my friend Esme says, you assess first, diagnose second. You wouldn't think much of a physician who bounced into your room and said, "You're anemic! My plan is to give you a transfusion. Now, let's check your blood count." Right?

But if you look through the NANDA-I 2012-2104, you'll see possibilities like, oh, ineffective self-health management, risk for unstable blood glucose levels, constipation, impaired bed or physical mobility, fatigue, readiness for enhanced knowledge, disturbed body image, impaired social interaction.... and I'm only halfway through the table of contents. Do NOT use any of these unless you can look at the defining characteristics and state with certainty that you have assessed that they exist for a given diagnosis. But that's the idea.

STUDENTS ALL: If you don't have this book, get it immediately and open your eyes to the power that we have... and make your care planning orders of magnitude easier and better.

mjbarnes · Oct 31, 2012

What about risk for injury? Simple, but it works.

MilliePieRN · Oct 31, 2012

Thanks everybody.

I went with Risk for infection. I did have thorough assessment data and was not just pulling dx out of a hat based on theoretical information. I just didn't know how much at risk for infection (as opposed to impaired physical mobility) she would actually be since she is currently on abx. I knew they were both important, just was unsure which one be a higher priority, I ended up choosing infection because the pt has been bedridden for a long time and isn't too interested in changing that.

AgentBeast, BSN, RN · Oct 31, 2012

More than likely Disturbed body image . . . but lacking in any supporting evidence based on what little info you've provided.

ChipNurse · Nov 1, 2012

I have to do a concept map with 3 nursing diagnoses and I'm waiver on my third one. (I am a first year student , this is my 2nd clinical patient).
My pt is a double lower leg amputee, post op 3 weeks. She has osteomyelitis (will finish her abx in 2 days), type 2 insulin dependent diabetes, and a healing stage 4 sacral pressure ulcer.
My assigned dx is Impaired Tissue integrity and need two more dx.
My second is Pain (she is constantly in pain)
I am wavering between risk for infection and impaired physical mobility for my 3rd. What do you think? At this time, is she at that much of a risk for infection since she is on abx and showing no signs of infection? Thanks for you help :)

The patient would not be a *risk* for infection. The patient *HAS* an infection. Osteomyelitis is an infection of the bone and the pt is on antibiotics. So- not a risk. If you wanted to do an infection dx... it would be INFECTION r/t blah blah blah AEB blah blah blah