First Nursing Diagnosis

[springchick1, ADN, RN]

I had my first clinical today. All we did was hospital and unit orientation,no patient care. Part of our paperwork for the day is to do a patho report and mine is on COPD. We also have to come up with 2 nursing diagnosis. I'm still trying to figure the whole nursing diagnosis out but these are the two that I picked for a patient with COPD:

Ineffective airway clearance

Impaired gas exchange

Are those good options? And GrnTea, I know your going to ask and yes I do have a NANDA Nursing Diagnosis Handbook:cheeky:

[StudentOfHealing]

Did you take care of a pt with COPD?

omg ... thinking back to clinical experience...

there's like SO many diagnoses to choose from.

Think of all the things COPD it can affect!!!! (:

here are some....

Activity

Nutrition

Skin Integrity

so on ! .........

Good Luck.

[springchick1, ADN, RN]

We didn't actually take care of any patients today. We were just told to take our patho report and find 2 ND that would fit a patient with that disease. Thanks for the help!

[StudentOfHealing]

np.

We do care plans before we see our patients... meaning minimal assessment data... meaning faulty care plans... in MY opinion.

Recall that your nursing diagnosis is drive by assessment data... its drive by the RESPONSE the patient has.

Usually you can clumo certain n. diagnoses with m. diagnoses but remember ... nursing diagnoses are not bound to medical diagnoses.

Each patient is unique!

[nurseprnRN, BSN, RN]

OP, you might approach your faculty and say that you read that NANDA-I requires at least one defining characteristic to make a evidence-based diagnosis. Therefore, ask if they would like you to offer if/then diagnoses based on hypothetical assessment findings, like, "If my COPD patient were very underweight and needed help simply turning over in bed, I would use "Impaired bed mobility related to malnutrition, activity intolerance, and deconditioning, as evidenced by decreased serum proteins, shortness of breath on minor exertion, and inability to turn from side to side without assistance."

"If my COPD patient had painful white plaques in his mouth, I would use "Impaired oral mucous membrane related to infection (thrush, side effects of steroid therapy) and mouth breathing, and as evidenced by (describe what thrush plaques look like), stomatitis, and bad taste in mouth."

Cite the page numbers. :)

This will accomplish three things, at least. It will make your classmates think of more than the easy "impaired gas exchange," will give you great practice in thinking outside the box, and get your faculty to realize that they can teach nursing diagnosis in its glory immediately because even new students can understand it if they get off to a good start.

Gold star for having your book already! :flwrhrts:

[lmustudent]

Actually, I have used both of those before. Activity intolerance may be a good one also. Goals for COPD can be incentrive spirometer but make sure to make goals measureable. In example, patient will use incentive spirometer within 2 hourse of surgery. It has taken me three semesters to finally get that there is a method to the madness behind care plans. Good luck.

[Esme12, ASN, BSN, RN]

Look up what COPD is and the common symptoms....then look up in your Nursing Care Plan/Diagnosis book which you think might apply to a patient that you would be caring for......I don't like it when school do this because a care plan is all about the assessment and what the patient needs......so when you do a care plan on a real patient it puts you in the mid set to get a diagnosis and fit the patient into it instead of getting a set of symptoms/assessment and finding what the patient needs......sigh

OP .....You have a great start for the purpose of this assignment!

It is necessary to have a good care plan book. I use Aclkey. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

What care plan book do you have? Bedsides GrnTeas NANDA I book....a care plan book will help you with interventions and outcomes.For future reference.....

Care plans are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?

YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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 the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. 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.

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:

ADPIE

1. 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)
   
2. 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)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

THese sheet may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.