Can someone help with a nursing diagnosis?

LadyinScrubs, ASN, RN · Apr 11, 2012

veronica378, greentea answered a similar request not far below yours. it is so spot on, that i am just copying and pasting greentea's response.

"medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis. i might be missing something but i don't see anything that tells me she is ready for enhanced communication. if you want to use that as a diagnosis, you have to say why you think so.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes."

veronica378, from what i hear you say, you have a patient with a dx of xyz and based on that dx you are going to use a nursing dx of abc but you are having problems with it because you are stuck on as manifested by.

instead of just picking out a nursing dx because it sounds good, find a nursing diagosis that fits the problems your pt is encountering. how do you know what the problems are--you to do an assessment, look at the labs, and see what is not right. base your nursing nursing diagnosis on that information and design interventions to help your pt with those problems, which are evidence based (i.e., as evidenced by)..

Esme12, ASN, BSN, RN · Apr 11, 2012

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

the medical diagnosis id the disease itself. it is what the patient has not necessarily what the patient needs.the medical diagnosis is what the patient has and the nursing diagnosis is what are you going to do about it, what are you goingto 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.

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.

care plans must be chosen from the "approved" script....nanda. i think the biggest mistake is that you need to let what the patient says, does and feels (the assessment) dictate what you do next. you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition.

a great an contrinutor daytonite (rip) always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

https://allnurses.com/lpn-lvn-nursing...ml#post6052759

https://allnurses.com/lpn-lvn-nursing...lp-665349.html

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 plan:

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)

make sure you follow these steps first and in order and let the patient drive you diagnosis not try to fit the patient to the diagnosis you found first.

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

Esme12, ASN, BSN, RN · Apr 11, 2012

Hi, I'm new to this website and I think it's a great place for info. Can someone give me a little help with my nursing diagnosis. A little background first. Patient is having a bowel resection within the next few days and has an active infection (pneumonia), she is also anemic and her religious belief forbids blood products. So I think the most important diagnosis would be Risk for shock but it's the related to part that always gets me, mine seem to never be good enough for my instructor I can't include the surgery because she hasn't gone through it yet, but what about risk for shock related to active infection and low RBC count secondary to anemia? Any thoughts? Thanks in advance.

Do you have a care plan book? You will need one.

Firat you need to know the pathophysiology of the disease process. Why are they having a bowel section? What are the symptoms? What is the patients complaint? They won't perform surgery, unless an emergency, with pneumonia. Is she still febrile? What is your assessment? Does she have a knowledge deficit about the surgery? Can you do some post o teaching pre op? What complications can she suffer from bed rest prior to surgery? what was she admitted for? what comorbidities? What is the Patient complaining of....what is SHE saying? What are the labs? what is the most important to take of RIGHT NOW.

I need much more information to help you....

nurseprnRN, BSN, RN · Apr 11, 2012

...and you need much more information to help yourself, op!

(and thanks, ladyinscrubs)