the way we diagnose is that we do a thorough assessment of the patient to determine what their abnormal symptoms are and then compare them with known diagnostic references (when we are new at this) so decisions are made correctly. this is an analogy of how that is done incorporating the steps of the nursing process:
you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).
the steps of the nursing process to follow as you complete the problem solving for this patient are:
- 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)
- 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
- 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.
- http://allnurses.com/forums/f205/med...es-258109.html - medical disease information/treatment/procedures/test reference websites
- 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:
- 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
- interventions are of four types
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- 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)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
this patient has these medical diseases: pancreatitis, diabetes (type i or ii?), and hypertension. assessment activity needs to include reading about the pathophysiology, signs/symptoms, tests and medical treatment ordered for these conditions and any potential complications of them. this information is needed for the development and understanding of the nursing diagnostic statements and the etiology behind the problems (nursing diagnoses). it is also important to find any symptoms that might have been overlooked in the patient. it takes many years to become proficient in this art so any assistance is going to be helpful for you in learning as well as treating your patients.
you have posted 2 symptoms, but i have been a med/surg nurse a long time and can't help thinking there might be a lot more that you might have missed:
- severe abdominal pain
- where is this pain located? what brings it on? does it ever go away? since this patient has pancreatitis is he npo? is there a history of alcoholism? are blood sugar levels being assessed?
- nanda diagnosis: acute pain, but i have no basis to determine the etiology or specifics of the defining characteristics
- high cholesterol levels
- how out of whack are they? how high is the blood pressure? what is going on what this man's heart and how is it possibly related to the cholesterol, hypertension and the diabetes?
- nanda diagnosis: imbalanced nutrition: more than body requirements, but i have no basis to determine the etiology or specifics of the defining characteristics