Nursing Diagnoses. HELP!!!

  1. 0
    This is my first semester of nursing. We have been going over nursing care planning. I am having trouble with nursing diagnoses. I can't grasp the concept. We have an assignment which requires us to come up with 15 nursing diagnoses with at least 3 biophysical, 3 psychosocial, and 3 educational diagnoses for the following case study:

    A 42 year old man was admitted to the hospital with a diagnosis of
    FUO (Fever of Unknown Origin). His assessment reveals: T- 103
    degrees F., P-110, R-24, and B/P 90/50. He is alert and oriented to
    time, place, person, and content. His skin is hot to touch.
    Crackles are noted in the bases of both lung fields. His abdomen is
    soft and non-distended. Bowel sounds are present in all four
    quadrants. He complains of malaise and just not feeling well. He
    states I have been having a high temperature every afternoon for
    the past 3 days. He has also had loose watery stools and vomiting
    for the past 2 days. He has gone to the bathroom and voided 150 cc
    of dark amber urine. He is having lower abdominal pain. He states
    my pain is a 6 on a scale of 0-10. The pain gets worse when he
    eats spicy foods and is relieved by taking Tylenol. He describes the
    pain as sharp and colicky. He has been taking Tylenol 500 mg by
    mouth every four hours for the temperature, and Immodium AD for the
    diarrhea. He is 5 feet, 10 inches tall and weighs 220 pounds. He
    states that he has got to get well, he is a nursing student and
    cannot miss school. He also is the sole supporter for his family and
    needs to work. His lab work reveals a WBC count of 15,000, a HGB of
    16 and an HCT of 42. Blood cultures and urine cultures have been
    collected. He states that he works as a computer programmer and does not get
    any regular form of exercise. He tries to eat a low fat diet, but
    loves his bowl of ice cream with chocolate syrup before he goes to
    bed every night. He usually has a bowel movement each morning. He
    normally voids about 5 times a day and does not have to get up in the
    middle of the night to go to the bathroom. He takes Ambien 5 mg as
    need for sleep, stating that he usually sleeps about 6 hours a night.
    The patient is married and has two children. He states that he
    had a vasectomy after his last child was born. He attends the
    Methodist Church every Sunday and says that his religion is a great
    source of comfort for him. He participates in a weekly Mens Bible
    study and says that he deals with stress by listening to music and
    praying. In addition to caring for his young family, he is the sole
    provider for his 78 year old widowed mother. His father died at the
    age of 50 from a heart attack.

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  2. 23 Comments...

  3. 0
    Nursing process is a roadmap for determining patient's needs and then planning, administering care, then evaluating whether or not it achieved the goal. As a nurse, you can't just do something because you thing it's a good idea. You have to be able to prove or show that whatever you do is not just something you made up on a whim.

    First, you assess. Then "The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs." The diagnosis reflects not only the medical condition but also the other complications (actual) or potential (risk for). The nursing diagnosis is the basis for the nurse’s care plan.

    The nurse can't use the doctor's medical diagnosis diagnosis of FUO (Fever of Unknown Origin). The nursing diagnoses have to be things that a nurse can do something about, is what my instructor said. So, use the assessment of the patient, and out of that pull your three + three + three nursing diagnoses.‎

    You have some clues: for example, I know that early 40s to 50s is when many men get into cardiovascular problems. So, here's a guy age 42 w/ sedentary lifestyle, 5'10" and 220# is probably overweight, you see some information about his diet, and "His father died at the age of 50 from a heart attack" which is a huge risk factor. You might pull a risk-for or an "educational diagnosis" (whatever that is, lol) out of there.

    Safety-related issues are always important.

    etc. Analyze the clues they gave you, and eventually you are expected to prioritize but at this stage might just have to identify needs of patient and convert that to nursing diagnoses.
    Last edit by Streamline2010 on Aug 29, '13
  4. 0
    Infection rt elevated temps aeb fevers and elevated WBC

    Sent from my iPhone using
  5. 0
    Risk for ineffective coping rt lack of support aeb no support in the home

    These are a few I could come up with off the top of my head.

    Basically find a nursing diagnosis and support it with ur assessment

    Remember u can't use a medical diagnosis in your nursing dx

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  6. 0
    Ok so reading through this, what pops out at you as being the priority. What is his main complaint, what will kill him faster than anything else. Then work down the list.

    The crackles with fever and elevated wbc, infection process?
    The diarrhea, nausea and vomiting, dark amber urine=dehydration?

    start looking into the education he needs, eats spicy foods and pain worsens? Yep, one there.
    It is for stuff that if you give him the information, that he could change in his life and then the symptoms would get better.

    Psychosocial, how is he coping with the stress of the outside environment/stressors? Does he stress about his own mortality when thinking about his father's early death? And coping with the added stress of being a nursing student along with work and taking care of his family while he is sick, potential for alteration in coping?
  7. 3
    I'll go ahead and try to quickly explain what an ND is. It is a tool for developing your critical thinking skills; identifying a patient's primary problems, the evidence supporting your assessment, and you will eventually be expected to identify appropriate interventions for the problem. Quick note of advice, always think your ABC's first, or use Maslow's hierarchy to help you prioritize.

    Example: You have a patient with a COPD exacerbation.
    Part 1: Ineffective airway clearance- This is your Nursing diagnosis. Not to be confused with a medical diagnosis. Simply put, you are stating the obvious problem but it is beyond your scope of practice to create a medical diagnosis of COPD. But there are many interventions you can do without an MD to help this patient, which we will get to later.
    Part 2: Related to COPD- Insert medical diagnosis here. There are probably other variations that I don't remember, but I'm keeping it simple for now. This is where you identify the cause behind your nursing diagnosis.
    Part 3: As evidenced by *dyspnea *increased secretion *increasing oxygen requirements etc. - This is where you list the symptoms, or evidence behind your nursing diagnosis. The list could go forever, but you generally list the most pertinent one, individualizing the diagnosis for your particular patient.
    When you get to care plans you will be expected to list interventions for your patient. Including titrating oxygen per orders, delivering treatments, pulmonary toileting, keeping the head up 30 degrees. And again my list could go on. This is why you are in school. I have been a nurse for 3 years. I don't make care plans at work. But I can still create a nursing diagnosis off the top of my head because that model is how I learned to identify a problem and treat it within my scope of practice.

    I would recommend finding a nursing diagnosis handbook. A quick search on amazon, there were several for $20 or less, if you specify your search for textbooks about 5 years old you can go pretty cheap, and I promise you they haven't changed much! I don't even remember what publisher I used, probably either Mosby or Pearson, but mine was an excellent guide not only for understanding what a nursing diagnosis is, but how to use them for developing care plans etc. It should provide comprehensive lists of accepted NANDA diagnoses and interventions. Unless nursing school has changed drastically in the past 3 years this a resource you will use throughout your schooling. It will save you so much time that you would otherwise spend on google or waiting for people to respond to your posts on AN!! I hope this helps and good luck with school!

    Edit: So I thought that you could use a known medical diagnosis in your "related to" part, but apparently might be wrong. That is where using your appropriate textbooks/resources comes in handy
    Last edit by beckster_01 on Aug 30, '13 : Reason: clarification
    PalmHarborMom, elprup, and Esme12 like this.
  8. 2
    There are some nd that can be appropriate for most all patients. Ineffective healthcare maitenence/management, discharge care plans, and ineffective pain managrment. Also, because he has voided so little, look at care plans about fluid as well. In this patient there is a risk of spiritual distress as well.

    One of the best things that you can do is to get yourself a nursing diagnosis book. You can also find loads of examples online of care plans. The concept is not easy, however, simply put a nursing diagnosis is how a nurse looks at specific problems with a patient that is something that a nurse can intervene on, and what is the goal? What can you do as a nurse to assist the full function of this patient?
    Be sure that you are setting up the plans per the assignment requirements. It usually is problem/intervention/timelined.

    Good luck!
    PalmHarborMom and VickyRN like this.
  9. 0
    The best way to ask for help here is to first give YOUR first thoughts/ideas of appropriate answers to whatever you are struggling with. That way, folks can see where your mind is focused and help you work through the issue.

    I can't speak for everyone, but most of us would prefer to see a student put effort into the homework problem, rather just ask for the answers. So far, you have posted the homework question in 2 different forums, but I don't see any of your own thoughts/potential answers.
  10. 1
    Welcome to AN! The largest online nursing community!

    Members have been kind to you an given you suggestions but this will not help you understand the process.

    You may find this helpful.....Nursing Proccess & Critical Thinking Guide |

    simply put

    Assessment- You asses where the patient currently is.
    Dianosis- Your create you nursing diagnosis
    Plan- You and you patient create goals and a strategies for the patient to obtain those goals
    Implementation- You implement your plan
    Evaluation- you come back later and evaluate if the goals where me

    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/care map: ADPIE. From our beloved Daytonite....RIP

    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/care map/case study is nothing more than the written documentation of the nursing process you use to solve one or more of a patients nursing problems. These are done in different formats but contain similar information. 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. Tune 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.

    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 a medical disease, a physical condition, a failure to be able 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 aims as a problem solver is to collect as much data as you can get your hands on.......the more the better. You will have to be a detective and always be on the alert and lookout for all times. That is within the spirit of step #1 of this whole 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. 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 the 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.

    Care plan reality: Is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

    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.

    #2. 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.

    #3. 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 the next step of the process which is

    #4. Determining your patients problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    #5. How are all your interventions changing/helping this patient.

    You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.

    For example: As a contributor to AN....Daytonite said best.

    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).

    Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

    Critical thinking involves knowing:

    1) the proper sequence of steps in the nursing process
    2) the normal anatomy and physiology of the human body
    3) how the normal anatomy and physiology are changed by the medical and disease process that are going on
    4) the normal medical treatment that the doctor(s) are likely to order to treat 5) the medical and disease process going on
    6) the nursing interventions that you have learned for the things that support 7) the medical and disease process that is going on
    8) making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are

    Critical Thinking Flow Sheet for Nursing Students
    roser13 likes this.
  11. 0
    Now....what care plan book do you have? I use Ackley: Nursing Diagnosis Handbook, 10th Edition.

    For all care need to 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.

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