I need six nursing diagnosis - page 2

I had a earlier post I needed help, my patient assigned to me, admitted with ALOC, decreased speech and decreased interaction and a temp of 100.2 past hx cva -2002, seizure disorder, CAD HTN... Read More

  1. by   Daytonite
    Quote from cleo777
    Is this what it is like at all schools, non stop, with no sleep?
    Why aren't you taking time to sleep?
  2. by   cleo777
    Between classes, clinical's and homework, there is very little time, the research that is required takes hour's, This RN program is only 2 yrs is this the average time in all college's? This my third quarter and I don't think I can go no stop like this for another year +.
    All I can do is take one day at a time and see what happens!! Thanks for all your help, you really to explain, so it understood, you need to be a teacher!!!!
  3. by   Daytonite
    i suspect that the reason everything is taking you so much time right now involves a learning curve. you seem eager to learn. once you start getting the gist of how to think these things through these assignments will move along faster. you are learning all kinds of new things. eventually you'll begin repeating them. it's like this care planning business. part of them is about following the nursing process. get the different steps of the nursing process clear in your mind and you'll be able to get the mechanics of doing a care plan a lot easier. it is a skill and you will get better with practice. i have the first 3 steps fairly well laid out. you can print it out and keep it to follow for reference when you are sitting down to do a care plan:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) [font=arial unicode ms]
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (http://allnurses.com/nursing-student...al-227507.html)
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
      • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
      • always sequence actual nursing problems before potential (risk for) or anticipated problems
      • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements: see post #157 on thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
        • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.
  4. by   cleo777
    You are the best, it is a learining process and I am taking baby steps towards the learning. I finally have my assessment down pat, I know it doesn't look like it from the last info I gave you, but there were other factors involved that day. I am hoping this week is going to be a better week!!!!!
  5. by   cleo777
    Okay I have been looking this up and I just cannot put 2 and 2 together...
    they did a PT 27 higher than normal
    PTT 36 normal
    INR 2-5
    they did these tests on the patient we discussed yesterday!!!

    Why did they do them?
    Patient is not on blood thinners/only on hypertensives and dig
    Pt/Ptt is about clotting times, was the test done to see if pt was bleeding from somewhere, enternally?
    and if that is ruled out, why is the pt time/INR increased, I understand it is the time it takes for blood to clot but why on this patient...
  6. by   irkedoneSN
    I think BUN and creatinin levels along with immobility may call for Risk for impaired skin integrity related to impaired mobility secondary to left sided weakness? I think creatinine has something to due with skin and/or wound healing?
  7. by   Daytonite
    Evaluating his liver function.
  8. by   irkedoneSN
    Risk for skin impairment due to poor circulation related to immobility secondary to left sided weakness. That I think is better than my previous one...
  9. by   cleo777
    Yes, I did get it was evaluating the liver fuction, did you see my post on why they would of done a pt, ptt, inr on this pt, not on any blood thinners, and his pt is higher by about 10 secs?
  10. by   cleo777
    Also Daytonite thank you for all those webpages, especially the medline, it gets right to the point!!!!!!!!!!!!!!
  11. by   cleo777
    Self care deficit, this person cannot do nothing, looking for a client goal for this????????????
  12. by   GipsGrl
    Hi, do you have to do your care plan based on the nine needs? Do you have any other lab results?
    One that I can think of is Communication, Impaired: Verbal r/t- the progressive decline in cognitive function (which this is the def of dementia, but can't use the "word" dementia but can define it, because that is a medical diagnosis) AEB: slow response to verbal communication and commands. Hope this helps. Have a great day.
  13. by   cleo777
    I pretty much have all of them but i was looking for a goal, because i am using a self care deficit feeding....person cannot feed themselves, so I know need a goal
    I was thinking which can be a bad thing!!!
    Pt will receive one on one feeding for each meal? does this sound like a half decent goal?????????????