Can I put risk of aspiration? The patient was given an NG Tube for feeding because he was at risk for aspiration. Can I put that he is at risk for aspiration due to mechanical irritation of Esophageal Varices?
Oct 5, '08
A nursing diagnosis has to do with a problem that a patient has. It is based on the symptoms the patient is displaying that are discovered during your assessment. A "Risk for" diagnosis isn't even a problem. It is an anticipated problem that you think the patient might get.
If this patient has esophageal varices, there are other problems going on. Was the patient bleeding? Is the patient an alcoholic? Is there liver disease?
Oct 5, '08
The patient is in end stage liver disease, renal failure, hepatic encephalopathy, anemia, jaundice, hepatic portal hypertension causing E + G Varices all due to cirrhosis/ Chronic Hep C. He has SO many problems, but only a few that we are still treating so that limits what I can do for NDs because I have to have outcomes and interventions.
For example, they are giving him lactulose to cause diarrhea to help waste base and get him closer to balance. Can I use diarrhea as a ND if it is something his treatment plan is actually trying to cause?
This stuff is so confusing!!
Oct 6, '08
they are giving him lactulose to cause diarrhea to help waste base and get him closer to balance. can i use diarrhea as a nd if it is something his treatment plan is actually trying to cause?
this stuff is so confusing!!
yes, use diarrhea and or deficient fluid volume.
these are complex patients because they are end stage. this is why it is so important to use the nursing process to help you organize what you are doing. there is a lot of cross over between the physiological diagnoses you can be using because the pathophysiology is so closely related and interacting to cause the symptoms that are manifesting. diagnosis is always based on the symptoms the patient has.
the nursing process as it pertains to care planning:
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- a physical assessment of the patient
- assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
- data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
- knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
- 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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
- planning (write measurable goals/outcomes and nursing interventions)
- goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
- improve the problem or remedy/cure it
- stabilize it
- support its deterioration
- interventions are of four types
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
- care/perform/provide/assist (performing actual patient care)
- teach/educate/instruct/supervise (educating patient or caregiver)
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
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