Quote from nurse training
i am having some difficulty with this one:
mother: 40 years old
gravida: 4 para: 3 abortion: 1 (spontaneous)
she had a spinal
38 weeks gestation
infant male weight: 6.14 lbs
daughter age 10
son age 16
pt was able to ambulate w/o assistance and there was no s/s of infection
she is bottle feeding
i was thinking something to do with her children and accepting this new child or something to do with her not breast feeding... any help with this would be great! thanks <3
let the patient drive your diagnosis 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? is the patient having pain? what are you doing for her pain. are they having difficulty with adls? what teaching do they need? do you want to push fluids? what does the patient say? what are the labs? what does the patient need? what is the most important to them now? what do you look for in a postpartum patient that has had a c-section? what are the complications from c-section/post op? what do you look for post spinal anesthesia? if she is bottle feeding......what help may she need to ensure bonding? what does she need to do to dry her milk?
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 them as a recipe to caring for your patient. your plan of how you are going to care for them.
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.
daytonite...........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
. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- 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)
daytonite always had the best advice.......check out this link.