i'm having difficulty coming up with how to word my r/t factor in my nursing diagnoses. i seem to have lost my grasp on how to do these properly. i would really appreciate any help and pointers i could get.
actual nursing diagnosis
(problem) - responses to health conditions or life processes that exist
in an individual and supported by manifestations, signs and symptoms.
potential, or risk, nursing diagnosis
- responses to health conditions or life processes that may develop
in a vulnerable individual supported by risk factors that contribute to their increased vulnerability.
the construction of a nursing 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 and resulting in the symptoms. pathophysiologies need to be examined to find these etiologies if the nursing diagnosis involves a physiological body process. 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, are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
your diagnoses have been resequenced in the correct order of priority according tp maslow's hierarch of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
) and placing actual diagnoses ahead of potential diagnoses. . .
risk of fluid volume deficit - this is not a risk if the fluid has already been lost
data: -pt. loss 400ml of blood during vaginal delivery
-pt. states that she has not been drinking many fluids - fluid must be lost in order to become a cause and symptom of this diagnosis.
-has drank around 720ml of fluids - this is an intervention and not a symptom
-pt. is breastfeeding - this is an interesting piece of assessment, but not a symptom
-h/h is 11.2/32
problem #1: deficient fluid volume
etiology: excessive blood loss during delivery
symptoms: h/h is 11.2/32 none other given, you need to look up the signs and symptoms of dehydration
impaired skin integrity
data: -pt. has 1st degree laceration in perineal area from vaginal birth
-pt. has swelling and bruising of the labia majora
-pt. has hemorrhoids that have compressed near her anus - this is not a symptom of impaired skin integrity
unless they are open and bleeding, oozing some kind of drainage. if they are causing pain, then diagnose acute pain
problem #2: impaired skin integrity
etiology: perineal trauma
symptoms: swelling and bruising of the labia majora
risk for constipation
data: -17h. post delivery and no bowel movement
-inadequate intake of fluids
-pain from hemorrhoids and laceration
-abdominal pain due to contracted fundus
-use of naids
problem #3: risk for constipation
etiology: decreased physical activity and inadequate fluid and fiber intake
symptoms: none; the presence of and signs and symptoms of constipation is an indication of an actual problem of constipation and the diagnosis needs to be changed.
risk for infection
data: -1st degree laceration in perineal area
-h/h is 11.2/32 - this is a symptom of deficient fluid volume
-pt. has swelling and bruising of the labia majora - swelling is evidence of the inflammatory response, not infection; bruising is evidence of rupture of blood vessels and bleeding into local tissues.
- is wbc count low after delivery?
problem #4: risk for infection
etiology: tissue trauma and blood loss
symptoms: none; when the signs and symptoms of infection are present then this diagnosis needs to focus on the patient at risk for the development of sepsis.