In need for 3 nursing diagnoses

Daytonite, BSN, RN · Sep 20, 2009

you already listed your some of your objective cues, but some are missing.

lower extremity edema - how do you suppose this edema has occurred?
hemoglobin - 112
rbc count - 3.9 x 10^12 - what is the significance and meaning of this finding?
wbc count - 17.3 x 10^9 - what does this elevated wbc count mean? does it have any correlation with the pneumonia?
neutrophil count - 0.73

if this patient has pneumonia and pulmonary congestion you need to look up the signs and symptoms of these conditions to find the objective cues (symptoms) she would be displaying in order to determine what nursing problems she has connected with the pneumonia and pulmonary congestion before you can go any further with this assignment. once you have that list of respiratory symptoms (cues) add them to the ones above. then, you can start determining what your three nursing diagnoses are going to be. you will match the list of cues you have with a specific nursing problems and give those nursing problems names (nursing diagnoses).

stormbeige · Sep 20, 2009

Hello,

Thanks for the quick reply. I forgot to mention that she has undergone episiorrhaphy.

I wanted to use the following nursing diagnoses:

Fatigue r/t increased energy requirements of labor.

Impaired urinary elimination r/t surgical trauma.
Risk for injury r/t invasive procedures and perineal tears with precipitous labor.

I wanted to use lower extremity edema as one of my cues but i cannot completely state my nursing diagnosis:

can it be like this??

Impaired physical mobility r/t pain and weakness after labor as evidenced by lower extremity edema?

I am not sure if it is correct.. I am having problems stating my nursing diagnoses. Very grateful for your help. Thanks.

Daytonite, BSN, RN · Sep 20, 2009

i am having problems stating my nursing diagnoses.

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem
- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of
taber's cyclopedic medical dictionary
has this information.
etiology

- also called the
related factor
by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms
- also called
defining characteristics
by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

- - - - - - - - - - - - - - -

fatigue r/t increased energy requirements of labor.

where are your symptoms that prove the existence of the fatigue?

impaired urinary elimination r/t surgical trauma.

are you sure that surgical trauma (the episiotomy) is the cause of the impaired urinary elimination? or is it the resulting body response to the surgical trauma? read about what the body does in response to trauma. the baby coming through the birth canal does a lot of trauma to the surrounding tissues as well that leads to the inflammatory response and potential urinary problems.

risk for injury r/t invasive procedures and perineal tears with precipitous labor.

how can this be a risk if invasive procedures have already been performed? "risk for" means you anticipate a potential problem will occur. what invasive procedure do you expect to occur with delivery since the patient has already delivered? this diagnosis makes no sense.

impaired physical mobility r/t pain and weakness after labor as evidenced by lower extremity edema

if the patient has pain, why not diagnose acute pain? what is the pain a result of? after pains and contractions? the episiotomy?
weakness is a symptom of the nursing diagnosis of fatigue.
edema is not an impairment of someone's physical mobility, so you aeb evidence is faulty.
did this patient have hypertension or pre-eclampsia associated with her pregnancy? is that related to her edema? look at her electrolyte and protein levels. look at her blood pressures. is she overweight?

when new at diagnosing use some kind of guide that has the nanda taxonomy until familiar with commonly used diagnoses that you use frequently. the appendix of recent editions of taber's cyclopedic medical dictionary has this information as well as nursing diagnosis reference books. they list the definition, defining characteristics (symptoms) and related factors (causes) for each nursing diagnosis. some of this information can be found on these websites for about 80 commonly used nursing diagnoses:

stormbeige · Sep 21, 2009

hello,

thanks for the help... really appreciated it a lot..

i have made some revisions of my nursing diagnoses: kindly make comments about it and if it is wrong, kindly state the correct one.. thanks.

[color=olive]acute pain r/t tissue trauma and birth process, intensified by fatigue

objective cues:

pain scale of 7/10 ("tolerable pain") as verbalized by the patient
irritability
sleep disturbances
decreased in appetite
weakness

[color=olive]impaired urinary elimination r/t mechanical compression of the bladder and effects of regional anesthesia (we have interviewed the patient 16 hours after delivery and she stated that she has not voided and there is a presence of lady partsl discharge)

objective cues:

decreased urinary frequency

[color=olive]deficient fluid volume r/t decreased oral intake, bleeding and diaphoresis

objective cues ( we have not obtained the current weight of the patient)

lack of appetite
fluid loss due to bleeding during lady partsl delivery
presence of lower extremity edema

i realized that i have not gathered a lot of information. next time, i will assess my patient very well. thanks for all the info..

Daytonite, BSN, RN · Sep 21, 2009

[color=olive]acute pain r/t tissue trauma and birth process, intensified by fatigue [acute pain r/t tissue trauma and birth process]

objective cues:

pain scale of 7/10 ("tolerable pain") as verbalized by the patient
irritability
sleep disturbances
decreased in appetite - this is not an element of pain
weakness - this is fatigue and fatigue is not an element of pain. it is also a symptom of dehydration. - see deficient fluid volume

[color=olive]impaired urinary elimination r/t mechanical compression of the bladder and effects of regional anesthesia (we have interviewed the patient 16 hours after delivery and she stated that she has not voided and there is a presence of lady partsl discharge) - i gave you a hint about the inflammatory response before. the baby coming through the lady partsl canal causes a lot a tissue trauma (see how your body feels after a 5-8 pound baby is pushed through it) which in turn causes all kinds of micro tears of the tissues and sets the healing process in motion which includes the inflammatory response whose steps occur in this order: redness, heat, swelling and then pain as a result of the swelling. depending on the degree of swelling, surrounding structures, such as the bladder can be involved. you have to know this inflammatory response for tissue damage and all infection processes. see https://allnurses.com/general-nursing-student/histamine-effect-244836.html [impaired urinary elimination r/t inflammatory response and effects of regional anesthesia]

objective cues:

decreased urinary frequency - if her urinary frequency is decreasing, then it is normalizing and the problem is going away. you want urinary frequency as an objective cue for this problem to exist.

[color=olive]deficient fluid volume r/t decreased oral intake, bleeding (body fluids lost during lady partsl delivery) and diaphoresis - the related factor for this diagnosis must explain how fluid was lost from the body. decreased oral intake is not a fluid loss. you haven't explained the pathophysiology of the peripheral edema yet either to account for its existence. [deficient fluid volume r/t loss of body fluids during lady partsl delivery and diuresis]

objective cues ( we have not obtained the current weight of the patient)

lack of appetite (this has nothing to do with losing of fluids. it relates to imbalanced nutrition which is not an issue here.)
fluid loss due to bleeding during lady partsl delivery - this is really the related factor. its symptom is the low h&h counts and that is what you should be reporting as the objective cues
give the symptoms of dehydration or diaphoresis to account for your related factor of diaphoresis such as poor skin turgor or (now) dry skin
presence of lower extremity edema - needs to be rewritten as "retention of fluids in body tissues" to account for where the body fluid has gone, however, i do not think this even fits here as an objective cue.
weakness - this is a symptom of deficient fluid volume (dehydration) and belongs with these objective cues for this diagnosis

this peripheral edema is probably a cardiac problem. unless you can figure out how it is a fluid loss, don't use it as a symptom of fluid loss.

stormbeige · Sep 21, 2009

[color=sandybrown]thanks a lot! i really learned a lot.. .i can now make my nursing care plan.

if i can finish it early, maybe i can send it to you so that you can make comments about it for my improvement...

donnabade · Jul 31, 2010

read NANDA!