I need 3 nanda nursing dx, please help..

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i really need some help with process paper i have.. I'm having a bought time with them , I'm confused how to pick a dx, and the r/t as evidenced by parts..

my recent pt was a failed suicide attempt.

he jumped off a 4 story building and slit his wrist down to the bone, he sustained a pelvic fracture, suffers from a hx of depression, dm , htn, he's had multiple surgeries to fix his pelvis , and tendons ligaments and muscle in his wrist. he also is on a vent.

i need 3 nanda nursing dx, please help..

i thought at risk for impaired skin integrity , risk for suicide , and i can't think of a 3rd..help!!!

thank you!

Specializes in Pediatrics, Emergency, Trauma.

Tell us about your pt; systems-wise...

Do you have a care plan book with NANDA- approved diagnoses, or the NANDA book?

I think you need to take a step back and tell us mor about the pt. FIRST...

Let your assessment guide your nursing diagnoses and plan of care.

:yes:

he's currently sedated on propafol, on a g tube for feedings. he's has a closed drain in his left leg to drain blood from the site. he's received at least 10 blood transfusions . he has to have his urine checked every hour. he also has a a line in. v/s are stable.,

pmhx: chronic back pain, high cholesterol, depression x4 months , renal coif, diabetes , asthma, colitis , smoker.

he also received 3 unit of prbc in the or during surgery on the wrist , and 2 units of albumin.

he has bed sores on his left heel elbow and right clavicle . he has scrotal edema as well.

his rbc, are low (2.73)

i have the nanda book, I'm just unsure how to word things.

Specializes in Operating room..

Risk for infection.

i have that as one but related to ??

Specializes in Pediatrics, Emergency, Trauma.

So as of right now, your pt isn't risk for suicide...

Your diagnoses as well as your interventions are going to be in the NOW-his actual diagnoses; think about it; he has wounds, open areas, he's sedated, he's on G-tube feedings; he has actual needs right now?

You see where I'm going? :)

Specializes in Pediatrics, Emergency, Trauma.
i have that as one but related to ??

What do you think?

You gave us pretty good information based on your assessment...think about it... :)

Specializes in Operating room..

I'm not going to answer....you've already answered it in your previous posts.

you are both awesome thank you!!!!!!!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
he's currently sedated on propafol, on a g tube for feedings. he's has a closed drain in his left leg to drain blood from the site. he's received at least 10 blood transfusions . he has to have his urine checked every hour. he also has a a line in. v/s are stable.,

pmhx: chronic back pain, high cholesterol, depression x4 months , renal coif, diabetes , asthma, colitis , smoker.

he also received 3 unit of prbc in the or during surgery on the wrist , and 2 units of albumin.

he has bed sores on his left heel elbow and right clavicle . he has scrotal edema as well.

his rbc, are low (2.73)

i have the nanda book, I'm just unsure how to word things.

Welcome to AN! The largest online nursing community!

So I can better help....What semester are you?

Care plans are all about the patient and the patients problems. 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

  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.

Now...tell me about your patient.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
he's currently sedated on propafol, on a g tube for feedings. he's has a closed drain in his left leg to drain blood from the site. he's received at least 10 blood transfusions . he has to have his urine checked every hour. he also has a a line in. v/s are stable.,

pmhx: chronic back pain, high cholesterol, depression x4 months , renal coif, diabetes , asthma, colitis , smoker.

he also received 3 unit of prbc in the or during surgery on the wrist , and 2 units of albumin.

he has bed sores on his left heel elbow and right clavicle . he has scrotal edema as well.

his rbc, are low (2.73)

i have the nanda book, I'm just unsure how to word things.

What is renal coif? Do you mean renal colic?
he jumped off a 4 story building and slit his wrist down to the bone, he sustained a pelvic fracture, suffers from a hx of depression, dm , htn, he's had multiple surgeries to fix his pelvis , and tendons ligaments and muscle in his wrist. he also is on a vent.
How did he get "bedsores"/pressure wound on his right clavicle? Was he lying prone for an extended period of time? Are you sure the wound on his left heel is a pressure sore? One would think it got injured when he landed....feet first. You mentioned pelvic fracture...why does he have a drain to the leg? Did he sustain an injury there as well? What are his injuries total?

What complications can occur from multiple blood transfusions? What are his labs?

If this patient is on propofol they are on a vent...how are the ABG's? What are the vital signs? When did this occur? How many days post op? What does his lungs sound like? You mentioned diabetes....are the glucose reading within normal limits? They have tube feedings through a g-tube how do you determine ig they are receiving enough nutrition? Do they have a foley?

What nursing care does a severe pelvic fracture need? why does his urine need to be checked every hour?

TELL ME ABOUT YOUR PATIENT!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Risk for infection.

Out of all this information there is plenty more that are a priority. This patient NEEDS much more right now. Of course infection is important as these wounds are considered "dirty" as I am willing to bet the wrist laceration wasn't' with a sterile scalpel.

This patient has suffered severe multiple trauma....what would this patient NEED?

I am willing to bet this patient is still at risk for suicide for this was no casual attempt.

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