Nursing NANDA help please ...

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:uhoh3::uhoh3:I'm in my first year and it's my first care plan. Geez, I'm soo sleepy. I have a pt in a long term care facility. I've narrowed it down to possible NANDA situations but cant put my finger on the priority or how to write the NANDA. We only have to have one.

Diarrhea for two days because of medications, but I fiugre I have no control over that or can't seem to find 3 interventions due to the medication that has to be administered.

Pt is known for weight loss, but for that NANDA I am not sure how to even write that one, I can't seem to find the NANDA for weight loss, all I have is Nutritional Inadequate intake but what would my r/t be? Aging? EWould that address the weight loss?

And my third NANDA I figured would be risk of dehydration r/t hypernatermia.

can someone help me? I'm on my last nerve with this nanda. I just finished 16 pgs for my care plan and my brain is fried now. Iguess I'm just having trouble figuring which Nanda is more important and how to write the NANDA

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oh yes, my pt doesn't eat much either. am i violating hippa here?

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I think I narrowed it down to two after talking to myself for an hour. the weight loss or the hypernatremia.

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okay so I think this. imbalanced nutrition:less than body requirements r/t loss of appetitie secondary to polypharmacy. how does that sound? sorry if i talk it out it helps. now for short term goals and long term goals. any ideas?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you are so on the right track! you are letting nanda hang you up. do you have a nanda reference, or a book of nursing diagnoses to help you out here? what you must understand is that nanda has merely supplied us with a taxonomy (a big word meaning a classification--an arrangement or ordering of the nursing diagnoses into some kind of logical groupings). they very conveniently have added descriptions of each diagnosis and provided symptoms (nanda calls them defining characteristics) for each as well as related factors (etiologies). this is just information to assist us in making sure we have diagnosed someone with the correct nursing diagnosis. that's all the nanda taxonomy and nursing diagnosis stuff is. ultimately, a nursing diagnosis is a label that identifies the patient's problem. but, you have to know how to apply the information.

a nursing care plan is nothing more than a problem solving process. we follow the nursing process in determining these problems. everything begins with the assessment information that you gathered. you separate out the abnormal data. that abnormal data becomes your patient's signs and symptoms (in nanda language, the defining characteristics).

diarrhea for two days because of medications, but i fiugre i have no control over that or can't seem to find 3.

your patient's symptom (nanda terminology: defining characteristic) is diarrhea. that's what you work with and that's what you direct your goals and interventions toward. yes, there are things we can do as a nurse for diarrhea. is the patient's dehydration and hypernatremia related to the fluid loss because of the diarrhea? that's important to know because it will affect how you diagnose the patient. if diarrhea has continued for some time there might be symptoms of dehydration. but, only you know that since this is your patient. if diarrhea is a side effect of a medication, a nurse would notify the doctor of this (one intervention). other things you do for diarrhea are monitor the frequency, amount and character of the stools, monitor intake and output as well as for signs and symptoms of dehydration, monitor electrolyte levels, provide the patient with oral fluids, avoid fluids that are high in sugar as they tend to aggravate diarrhea, sometimes a clear liquid diet will help reduce frequent diarrhea, and make sure the patient is washing their hands after using the bathroom. the nanda nursing diagnosis that would apply here is diarrhea r/t adverse effect of medication aeb [defining characteristics listed in the taxonomy include: abdominal pain, at least 3 loose liquid stools per day, cramping, hyperactive bowel sound (did you listen to the patient's bowel sounds?), urgency] (page 71, nanda-i nursing diagnoses: definitions & classification 2007-2008).

pt is known for weight loss, but for that nanda i am not sure how to even write that one, i can't seem to find the nanda for weight loss, all i have is nutritional inadequate intake but what would my r/t be? aging? would that address the weight loss?

this is a common nursing problem in nursing homes. imbalanced nutrition, less than body requirements is the nursing diagnosis that is normally used for this. these are the defining characteristics (symptoms) that nanda lists with this diagnosis. did you patient have any of them?

  • abdominal cramping
  • abdominal pain
  • aversion to eating
  • body weight 20% or more under ideal
  • capillary fragility
  • diarrhea
  • excessive loss of hair
  • hyperactive bowel sounds
  • lack of food
  • lack of information
  • lack of interest in food
  • loss of weight with adequate food intake
  • misconceptions
  • misinformation
  • pale mucous membranes
  • perceived inability to ingest food
  • poor muscle tone
  • reported altered taste sensation
  • reported food intake less than rda
  • satiety immediately after ingesting food
  • sore buccal cavity
  • steatorrhea
  • weakness of muscles required for swallowing or mastication

the related factors for this diagnosis are:

to determine the related factor you have to know what the underlying etiology of the patient's weight loss is. is this patient just not eating enough food (inability to ingest food)? is the patient confused or demented and doesn't have the cognitive ability to remember to eat (psychological factors)--this is a common problem among many of the nursing home residents. you should also look at a book on normal aging. with aging people lose the ability to taste and sometimes food just doesn't taste like it used to so they don't eat it because the enjoyment is gone. that could be a biological or psychological factor.

from what i am finding as i am answering your questions is that many of your patient's symptoms may be related and included into one nursing diagnosis. i was confused. i thought you only needed one nursing diagnosis, but you talk about three. before you pick any nursing diagnoses you should look at your list of abnormal assessment data (all the patient's symptoms) and see which ones kind of group together and might be included in one diagnosis.

i always was taught to prioritize diagnoses by maslow's hierarchy of needs. nutrition is on of the ones that is right at the top of the list.

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

for more information on writing care plans and nursing diagnoses see these sticky threads:

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Thanks so much, Sorry it took so long to write back. I got an NI mostly because I have messy handwriting and my nursing notes were not exactly in order. I'm a little upset with the nursing notes since we were not really taught what to do for nursing notes. So now i'm looking it up to find examples and how two's. Mostly everything I have to pay for. Grrrr. Those sheets really helped me.

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