Care Plan

a diagnosis is merely determining what your patient's nursing problem(s) is/are. diagnosing is the result of logical problem determination. you must systematically break down information you obtain from the patient's medical history, physical examination, and laboratory tests and reassemble it into patterns that fit well-defined groupings of symptoms that describe nursing diagnoses. you use your knowledge of the person's diseases and their treatment, the nursing process and a nursing diagnosis reference to help you.

step 1 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 - you need to look up information about these diseases, particularly their signs and symptoms and complications. did you see ant of these signs and symptoms in your patient? maybe you missed some of them. what symptoms is the doctor already treating (what drugs is the patient getting)? does the patient have any of the complications of diabetes? it is important to know what these signs and symptoms are because it is the signs and symptoms that lead you to the nursing diagnoses. you can find weblinks to information about these diseases on this thread

• https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

what adls is the patient able to accomplish by herself? which ones does she need help with? can she move without assistance? is she continent?

• advanced dementia
  
• diabetes mellitus
  
• gi bleeding
  
• alzheimer's disease

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - you need to make a list of the abnormal assessment data

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your list of abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

step #3 planning (write measurable goals/outcomes and nursing interventions)

you really haven't provided much information for me to give you much more help. you can see examples of how nursing diagnoses are determined when putting together a care plan on this thread:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans