nursing diagnosis for care plan

CT Pixie, BSN, RN · Oct 2, 2012

We'd need a bit more info on the pt other than her dx. I personally think there are way better nursing diagnosis you could do other than disturbed body image. Remember ABC...how is her 02 sats, coughing? productive or not? what's her resp status in terms of SOB, dyspnea, lab values etc, ABG's. She has two medical dx that impact on her breathing..COPD AND Lung Cancer. In terms of priority its ABC and Maslow, her body image won't mean a lick if she's not breathing and circulating blood.

SarahBean87 · Oct 2, 2012

elevate head? nursing intervention? (small intervention but still an intervention)

CopperTail87 · Oct 2, 2012

That would be a good psychosocial diagnosis. You could also use Hopelessness. Death Anxiety, Impaired Gas Exchange d/t chemotherapy drugs, Nausea, Imbalanced Nutrition: Less than body req., d/t depression and chemo therapy... There's a lot I could write down lol. If you're focusing on a specific area such as the depression, cancer or VRE let me know and I try to write back and be more specific :)

Hope this helps!

CopperTail87 · Oct 3, 2012

I also agree with CT Pixie. Make your priority diagnosis based on your ABCs. When it comes to pt safety physiological interventions are considered priority over psychosocial.

Esme12, ASN, BSN, RN · Oct 3, 2012

Welcome to AN! The largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. 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.

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.

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. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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: ADPIE

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

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 the medical disease, a physical condition, a failure 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 goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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 this 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. Although your patient isn't real you do have information available.

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. 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. 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 step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis (ex:confusion) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 3, 2012

"I have a patient who has lung cancer, VRE, COPD, DEPRESSION. I NEED A NURSING DIAGNOSIS AND HELP WRITING A CARE PLAN FOR HER? i THOUGHT ABOUT WRITING, DISTURBED BODY IMAGE r/t RADIATION THERAPY AEB LOSS OF HAIR?"

Your patient has these diagnoses but what do they need? What is your assessment? What does the patient complain of? Do they have pain? Are they able to eat? Can they care for themselves? How old are they? How is the family dealing with the diagnosis? Can they breathe?

What does THE PATIENT say. What do THEY NEED to make it so KNOW how to care for them....how to make their life better.

nurseprnRN, BSN, RN · Oct 3, 2012

If I had a dime for every student who said, "I have medical diagnosis X, what is the nursing diagnosis for this?" I could retire happy.

Nursing diagnosis is not the result of medical diagnosis alone, although a medical diagnosis can be one defining characteristic. There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. (I can't think of another way to say this.) This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.

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.

That's why we can't give you an answer-- there isn't one. Even though a few people have speculated on possible ones, you cannot cannot cannot use them unless you have supporting data from your own assessment of the patient. What data support those diagnoses? Also, we don't give you an answer because we don't do your homework for you to copy off the list and hand in. SO.... What do YOU think, and why do you think so?