Need help with nursing diagnosis...

  1. Not sure if this is the right place to post questions about class, this is my first posting.

    Okay, so my pt. has a Hx of resolved pneumonia, Hx of smoking, very low SpO2 at room air, needs her nasal cannula to breath.. she uses a bedside commode, she does not ambulate outside of room. She says she ambulates in room, but I think she only uses the potty, she says she urinates 10 days a day qhr. She has a wound that is wrapped with gauze on right foot, she has MRSA. I believe she is getting the pneumonia back again.

    I was thinking if it would be okay to do a

    risk for falls r/t impaired physical mobility & wound on right foot
    risk for falls r/t impaired physical mobility due to wound on right foot
    risk for falls r/t impaired physical mobility, MRSA positive & wound on right foot
    risk for falls r/t impaired oxygenation?
    risk for falls r/t low oxygen supply

    I don't know, please help.. suggestions are welcome, I was thinking the second one sounds good, but I'm not sure
    If you want more info please let me know, thank you

    Also on her chart it says that she has cellulitis.. so would it be better..

    risk for falls r/t impaired physical mobility & cellulitis on right foot
    Last edit by meeks123 on Aug 9, '12
  2. Visit meeks123 profile page

    About meeks123

    Joined: Aug '12; Posts: 52; Likes: 9


  3. by   jjrodriguez
    Low oxygenation doesn't really have to do with risk for falls directly, so take out the last 2. I can't see anything that directly relates to risk for falls, other than low activity level. I wouldn't say she has impaired physical mobility, rather limited mobility. So, if you want to do Risk for falls, I would probably state it as:

    Risk for falls R/T wound on foot.

    However, I am more concerned about her returning pneumonia. Have you thought about Impaired gas exchange or Ineffective breathing pattern? Also, consider Impaired skin integrity or Infection R/T the wound.
  4. by   NursingStudent005
    Do you have access to and then Gulanick. It is a very helpful website that helps you construct nursing diagnosis
  5. by   NursingStudent005
    I definitely would go with the Impaired gas exchange and also the Risk of infection. Make sure when you are doing a nursing diagnosis you end them with at least three defining characteristics.
  6. by   meeks123
    Sorry, forgot to state that we're supposed to make a bunch of diagnosis for the pt.
    I was trying to figure out how to do the risk for falls one.

    I already did one for the respirations, & I think it sounds good enough.
    If you could double check it, that would be nice..
    I wasn't sure if I should use hypoxia, but then isn't that the definition of having such a low O2?
    1. Ineffective breathing pattern r/t hypoxia aeb by labored breathing & O2 saturation levels of 61% in room air.
  7. by   Esme12
    welcome to an! the largest online nursing community!

    the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

    the third is a good care plan book. i use ackley: nursing diagnosis handbook, 9th edition and gulanick: nursing care plans, 7th edition

    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:
    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)
    a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

    just like you need a recipe care to make a cake from scratch. a care plan is your recipe card to caring for your patient and what to look for while you are caring for them.

    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 your assessment of the patient. 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.
    • from our beloved daytonite: nursing community | nurses | nursing students

    • in determining a problem you should always use the nursing process. first, look at the assessment data you have. . .
    • severe post-op chest painin determining a problem you should always use the nursing process.
  8. by   Esme12
    okay, so my pt. has a hx of resolved pneumonia, hx of smoking, very low spo2 at room air, needs her nasal cannula to breath.. she uses a bedside commode, she does not ambulate outside of room. she says she ambulates in room, but i think she only uses the potty, she says she urinates 10 days a day qhr. she has a wound that is wrapped with gauze on right foot, she has mrsa. i believe she is getting the pneumonia back again.
    so what does she have for problem now? what co-morbidities does the patient have that affect her health right now. does she have lung/cardiac disease xausing her hypoxia? a history of pneumonia won't make her hypoxic right now. os sat (impaired gas exchange) 61% ra is pretty low. is she sob? (ineffective breathing pattern) does the hypoxia also make her intolerant to activity? (ineffective breathing pattern) does she have trouble with her adl's...bathing, drsg?(self care deficit) why does she have a foot wounds? (impaired tissue integrity) is she diabetic? is she compliant with her medical care? (knowledge deficit)

    what does you patient need/complain about right now. does she have pain? what is your assessment of the patient right now.

    activity intolerance
    ineffective breathing pattern
    impaired gas exchange
    bathing self-care deficit
    impaired tissue integrity
    alteration in comfort

    a nursing diagnosis listing from a an administrator.....vickyrn
    nursing diagnoses 2012 – 2014

    domain 1 – health promotion
    deficient diversional activity
    sedentary lifestyle
    deficient community health
    risk-prone health behavior
    ineffective health maintenance
    readiness for enhanced immunization status
    ineffective protection
    ineffective self-health management
    readiness for enhanced self-health management
    ineffective family therapeutic regimen management.........etc

    further listing....
  9. by   nurseprnRN
    How did you determine that she was at risk for falls? If you did an assessment and saw something that told you that, there's your answer.

    Alas, many nursing students pick a nursing diagnosis off a list and then try to cram the patient facts into it. This is exactly backwards. Worse yet, they often pick a nursing diagnosis they think fits the medical diagnosis. That isn't just backwards, it's sideways with a double twist (too much Olympics lately, sorry).

    Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

    For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

    Medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. This is not to say that nursing diagnosis doesn't use the same information, so read on.

    Nursing diagnoses are derived from nursing assessments, not medical ones. So to make a nursing diagnosis, a nursing assessment has to occur. For THAT, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

    Medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "Activity intolerance related to (because the patient has) congestive heart failure/Duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." However, your faculty will then ask you how you know. This is the dread (and often misunderstood) "as evidenced by."

    In the case of activity intolerance, how have you been able to make that diagnosis? You will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to SpO2 85% with turning in bed."

    So, you don't think of a diagnosis for your patient and then go searching for supporting data. You collect data and then figure out a nursing diagnosis.

    I hope this is helpful to you who are just starting out in this wonderful profession. It's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

  10. by   Unique X
    Start off with the following:

    1. Impaired gas exchange
    2. Ineffective breathing pattern
    3. Ineffective airway clearance
    4.Activity Intolerance

    5. Acute Pain
    6.Impaired physical mobility

    Key in priorities....ones that will impact the patient the most.