first quarter down/ nursing process ?

phuretrotr · Jun 21, 2013

Well the nursing process gives information about for your nursing diagnosis, what you will do about it, and if your/doc's plan works. For example:

- Assess: You have a patient with the medical diagnosis of pneumonia. The patient says that they are having trouble breathing. The respirations for the patient is 25 breaths per minute. Also, there are crackles in the patients lungs upon auscultation.

Assessing the patient gives you information on what the patient needs most at this time and helps create a nursing diagnosis to improve the patients current status.

- Diagnosis (Nursing): Ineffective airway clearance related to excessive secretions secondary to pneumonia as manifested by respirations 25 breaths per minute, crackles in lungs, and clients report of difficultly breathing.

This is your nursing diagnosis that would be a priority for this patient. This nursing diagnosis is related to the medical diagnosis, however this may not always be the case. Sometimes, when a patient has difficulty breathing, they will experience some anxiety or restlessness, and that would also be a nursing diagnosis that could be used (you can't use anxiety per-say because it is a medical diagnosis).

- Planning: I am not really strong in this section, but I'm sure someone else will jump in and answer it if you need help with it. I just don't want to give you wrong information.

- Intervention: This is what you will be doing for you patient to try to resolve the priority nursing diagnosis. You may administer a breathing treatment or some other form of treatment ordered by the Dr. to clear up the excessive secretions which are causing the problem.

- Evaluation: After you do your interventions in order to try to resolve the ineffective airway clearance, you will evaluate your patients status now and see if their condition has improved or not. So you would check respirations, the lung sounds, and the clients report of any more difficultly breathing. From there, the nursing diagnosis will remain if the condition has not improved and perhaps different or the same treatments will be continued. Or, the condition will resolve and the nursing diagnosis is not longer the priority because the patient will not have ineffective airway clearance anymore.

Does that make sense?

Esme12, ASN, BSN, RN · Jun 21, 2013

OK......you are falling into the same hole that trips most new students. You find the diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do 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? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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.

I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition (nanda list as contributed by vickirn (assistant administrator)

nursing diagnoses 2012 - 2014.pdf‎

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

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)

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.

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.

Look here as well......Nursing process.

SubSippi · Jun 26, 2013

You should be able to make nursing diagnoses on a patient without having any clue what his or her medical diagnosis is. When you assess your patient, what do you find? For example, listen to the lung sounds. If you hear crackles, you know that means there is fluid present, leading to the ND of ineffective gas exchange. Do you hear wheezes? Then, possibly ineffective airway clearance? Are the patient's respirations high, low, or too shallow? Ineffective breathing pattern. Check the capillary refill...if it's more than three seconds, a ND would be ineffective tissue perfusion. Are they overly anxious? Ineffective coping.

What you don't want to do, is go in and look at their chart, see a medical diagnosis of pneumonia, and assign them a ND of ineffective gas exchange based on THAT. All nursing diagnoses should be based on YOUR assessment. All patients are different, and an illness will manifest itself a little differently in every person. This is why a nurse's assessment is so important. Otherwise, every person with a certain condition would be treated in the same way. You have to be able to rely on your own judgement, not just lab values and doctor's orders.

I had a clinical instructor once who would have us assess a patient and come up with nursing diagnoses before we were allowed to look in the chart. It was very helpful in teaching me the value of an assessment. We all loved doing that because it made us more confident in making our own judgements...to be able to see certain things in a patient, then go back and look in the chart and see that we were right!

classicdame, MSN, EdD · Jun 27, 2013

the nursing process is based on a theory by Ida Jean Orlando that she called the Dynamic Nurse-Patient Relationship. If you understand the theory title you will see that it has NOTHING really to do with the medical diagnosis. It is all about you and the patient working together.

nurseprnRN, BSN, RN · Jun 28, 2013

well I have three more to go, the first three were exhausting and overwhelming...
We lost about ten classmates who didn't pass finals....
I'm on break for two weeks and I've stayed in these books to refresh and prep for what's next....
So I have a question.....
I'm confused about the nursing process as it pertains to the diagnosis...
Is it a feed off of the doctors DX or is the nurse actually making a diagnosis of needs as it pertains to the clinical DX?

Neither of the above. Students always think that nsg dx is secondary to or dependent on medical dx, and this is completely untrue. It is true that for many, but definitely not all, nursing diagnoses the medical diagnosis may be a cause of the things you see in your nursing assessment (like acute pain may be the result of surgery or a fracture or burn, chronic pain as a result of diabetic neuropathy, or poor tissue oxygenation as a result of anemia or lung disease). However, as a nurse, you are not being asked to supplement the medical plan of care-- you are being asked to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care. This is the nursing student's biggest learning challenge.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in... the nursng process of assessment, planning, and delivering/delegating nursing care.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. I strive to think of multiple ways to say it. Yes, nursing needs to know about medical diagnoses and is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.