Nursing diagnosis help

  1. 0
    My client had diabetes mellitus and his morning accucheck was 172. For breakfast he had a sausage, egg and potatoes bowl, orange juice and a cinnamon roll.

    So for my nursing diagnosis I was thinking either ineffective self health management or risk for unstable glucose level.
    I was considering possibly knowledge deficit but he told me that he didn't think orange juice was ok to have but since it was on the menu he figured they (the hospital cafeteria) knew what he could and couldn't have.

    What does anyone think of those?
  2. 29 Comments so far...

  3. 0
    I am always confused by this.....do you have a focus of the week that you must choose about diet or health management for your focus? Care plans are all about the assessment....what they need.

    What does your patient need? Why are they in the hospital? What do they complain about? for me to sat that your patients diet places him at risk there isn't enough information.

    What can't a diabetics have that breakfast? Regardless of his glucose....what insulin are they on? The cinamon roll seem excessive but how would that put him at risk?
  4. 0
    Well the only reason I was trying to use one about his diet was because his blood sugar was the only thing of my assessment that was abnormal. His heart rate was 69, respirations 18, bp 119/74, no pain, stats 97 on room air. His lungs were clear, no edema, no pain, no elimination problems, no neurological problems, no mobility issues, no shortness of breath when I was there.

    He was admitted for chest pain and shortness of breath but he denied having any when I did my assessment. He literally didn't have any issues other than his sugar was a little high and then he drank orange juice so I was thinking maybe orange juice wasn't the best thing to have.

    I've never had a patient that had absolutely no abnormal anything. Please help
  5. 2
    What were his labs like??? Family and health history??? What other factors in the assessment you can look at to conclude a nursing diagnosis???

    For example, what did they find with his symptoms? Like Esme said, what type of insulin is he on??? Has he transitioned from non-insulin to insulin dependent??? What has his trends in his Blood Glucose???


    These factors help decide what nursing diagnoses a patient has...if his history is remarkable, then look into the wellness category.

    Remember, you can choose NANDA wellness diagnoses as well; there are actual, risk and wellness diagnoses-do you have a NANDA book?
    Last edit by LadyFree28 on Sep 27, '13
    Esme12 and GrnTea like this.
  6. 1
    There is only one NANDA-I book. Get it at Amazon, 2012-2014 edition, $29 with free two-day delivery for students.
    Esme12 likes this.
  7. 0
    I think the biggest thing you've yet to tell us is why is the patient even in the hospital? How are his labs?
  8. 0
    Quote from StephenAndrews
    I think the biggest thing you've yet to tell us is why is the patient even in the hospital? How are his labs?
    The OP stated the pt was admitted with Chest Pain and SOB; hasn't told us lab values yet.
  9. 0
    He was there waiting for an echo. His labs were ca 9.1, K 4.2, MG 1.9, po4 3.7, Na 142, hemoglobin 13.9, hematocrit 46%, BUN 15, creatinine 1.1, troponin 0.1
  10. 0
    He had no skin issues, no immobility, no pain, no shortness of breath, no apparent depression or anxiety that I observed and he never gave any indication that he was having social issues, his wife was at his bedside the whole time, he was alert and oriented, his lungs were clear, bowel sounds were normal, no diarrhea, constipation, no voiding issues. He did say he had pneumonia about 3 months ago but X-rays were clear and he wasn't taking any antibiotics. No cough.

    I ended up talking to my instructor and she agreed to let me do a risk for diagnosis. He was on diuretics, two anytihypertensives and an antidepressant so I chose risk for falls.
  11. 0
    I always like Risk for Infection with elevated blood glucose.


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