"quote jen........here's some of the nursing diagnoses i can up with: (i just have the first part of the diagnosis, i am going to piece everything together in the end.)"
1. decreased cardiac output [he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). his ekg showed he has non-specific st and t wave elevations. troponin was normal.]
ok you know that he has chf. what is chf? i know congestive heart failure but what exactly chf. does this patient have right or left heart failure? is this patients chf from a weakened heart muscle from previous mi's or some form of cardiomyopathy caused by long with standing htn and diabetes or valvular disease? you need to know this before determining if this is what is causing his decreased cardiac output. do you know what a s3 is? why is that significant...... or is it significant in the presence of chf? let me google that for you congestive heart failure prognosis, symptoms, stages, causes, treatment - emedicinehealth
tachycardia. why does he have tachycardia? what is the origin of the tachycardia? is he tachycardic from being agitated from his confusion due to his head injury? what exactly is his head injury....epidural hematoma? subdural hematoma? diffuse axonal injury? (severe concussion) was this patient alert as a baseline prior to injury? let me google that for you
(i use this as an engine it's fun and gives great results)
or is the tachycardia volume related? could it be due to blood loss from the retroperitoneal bleed? what is his h&h? what is his retroperitoneal bleed come from/caused by? a pelvic fracture?
an o2 sat of 92% maybe normal for this patient unless he is in chf as evidenced by.......what? crackles? sob? jvd? lower extremity edema? where are his vital signs. what is this patients rr rate? is he in distress?
or is the tachycardia caused by pain.......
2. altered mental status [he was also being combative - should i maybe include that he's a risk to injure others? not a priority, but could be used in my concept map.]
again why is this patient altered? what is this patient pathophysiology of his injury? is this patients safety at risk?
due to his already history of a severe fall and his confusion/agitation? is his confusion from head trauma? let me google that for you
or could his confusion be from hypoxia? (unlikely with an o2 sat of 92% but it is worth investigating. is this patients safety at risk because of his agitation and confusion. would this be a priority with this patients present signs and symptoms? is this patients tissue integrity at risk due to possible further falls due to his confusion?
or could the confusion be caused by infection in the elderly? is this patient elderly?
3. altered tissue perfusion [he has numbness/tingling in both feet, black discoloration from diabetes, also has a pressure ulcer (but would that be tissue integrity rather than perfusion?) ]
why does this patient have numbness? is numbness always caused by poor circulation (perfusion) or could it be caused nerve damage (neuropathy?)diabetic neuropathy - mayoclinic.com
what is the black discoloration of this patients legs caused by? is this tissue perfusion/circulation or was it caused by pressure from lying on the floor for a period of time.....undiscovered for an extended period of time after his fall? (a common presentation in the elderly)
which brings up ....what are the patients labs? what is his h&h? what are his electrolytes, bun creat? what have his glucoses been? what cause this patient fall at home? what was his presentation to the ed? was it glucose related? what might you need to think of to plan for this patients discharge/placement? is his family involved? does he live alone?
4. infection [uti and mrsa]
where is the mrsa? is the patient being treated? is this a priority right now in the care of this patient?
5. pain [i'm not sure if i should include this as a priority because his pain was a 2/10. but to me, all pain is priority. i'm just not sure if my professor would agree.]
pain needs to always be addressed....but is it a high priority for this patient right now with his pain level a 2? which indicates his pain is pretty well controlled. remember priority is based on important news first. the basic abc's......if the ain't breathin they be leaving (to heaven that is.....)
i wanted to include ineffective breathing pattern possibly.. but i'm not sure. his spo2 was 92%, respirations were labored. crackles in both bases of lungs due to chf.. and diminished breath sounds. he was supposed to be on 2 l by nc, but he kept ripping it off when he became combative with the staff.
is his breathing pattern all that ineffective? or.........are his lungs so full of fluid that he can't get enough air? what would this patient need in order to breathe easier and possibly decrease his confusion/agitation? if this patient can't breathe would that make this a priority?
think if it was your family member......what would be important to you to be cared for first? which is causing the most risk to the patients life
look at maslow's to tell you which priority precedes the next.
the greatest priority is at the bottom (the largest platform)and work your way up
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? how many days post op? is the patient having pain? are they having difficulty with adls? what teaching do they need? what 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?
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.
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)
a dear an contributor daytonite always had the best advice.......check out this link.
you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.
care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis. some other helpful links.
nursing care plan | nursing crib
nursing care plan
nursing resources - care plans
nursing care plans, care maps and nursing diagnosis
understanding the essentials of critical care nursing