hi, ingie3 and welcome to allnurses!
first of all, i want to point out to you that allnurses has two sticky threads that address care plans
and have help in them on writing care plans:
the choice of any nursing diagnoses is made after doing a thorough assessment of your patient and sitting down and sorting out the abnormal data. (steps 1 and 2 of the nursing process). a doctor doesn't diagnose someone with cancer without first assessing and developing a list of the symptoms that lead to the diagnosis. a car mechanic doesn't diagnose your car with needing new brake pads until they have inspected the brakes and seen that the old pads are pretty much worn away (symptom) and you've told him that every time you step on the brakes they squeak (symptom). the same goes for nursing diagnosis. you don't put a nursing diagnosis on any patient until you've determined the symptoms they are having. nursing diagnoses have their own set of symptoms that nanda has called defining characteristics
, just to be fancy about it. the definitive work that has these listed is nanda-i nursing diagnoses: definitions & classification 2007-2008
published by nanda international. there are currently 188 nursing diagnoses. most of the currently printed nursing care plan books and nursing diagnosis books include the information that is in this small nanda publication i just referenced above.
what are the specific symptoms
of this patient's hyperemesis? what did her lab work reveal? what did you find when you did your physical assessment of her? the abnormal information you got when you read through her medical record and did her physical assessment is what forms the basis for the choice of nursing diagnoses you pick. you need to have a care plan book or a book of nursing diagnoses to use as a reference to make sure you are choosing the nursing diagnoses correctly. each nursing diagnosis has a list of symptoms (nanda calls them defining characteristics
) and your patient must have one or more of those symptoms to be able to use that particular nursing diagnosis. the definition of the nursing diagnosis must also fit the patient's circumstances as well. then, your nursing interventions (step 3 of the nursing process) address each one of those symptoms as you develop nursing interventions and goals for them. in effect, your entire care plan in based upon the abnormal assessment data (symptoms or defining characteristics) you discovered. that is why your brain is frazzled. you are going into this entire process of writing the care plan backwards. reverse gears and start it the way i am telling you and you will find that things will proceed much more logically and with less confusion and exhaustion on your part.
you have dual problems here because your patient is not only diabetic, but pregnant as well. you also need to pull in knowledge of the underlying normal process of pregnancy as well as the pathophysiology of this patient's specific type of diabetes (you don't say if she is type i or type ii). i would also be very careful of labeling any patient as being non-compliant, particularly in the use of the nursing diagnosis of noncompliance since you must have the behavioral defining characteristics (symptoms) to support it.
so, the first thing you need to do here is to sit down and make a list of all your patient's abnormal assessment data. just to make sure you've not forgotten anything (students, i find, often don't see abnormal items that are right in front of their faces). i would recommend that you review what a normal assessment of a pregnant mother should be and make sure you didn't forget anything. if you do find you overlooked something, write it down right away on your abnormal data list. don't forget to include the assessment of adls. then, see if any of these abnormal assessment items look like you can sort them out by maslow's hierarchy of needs (physiological needs first, then safety/security, love and belonging, self-esteem and finally self-actualization). this will also help you in prioritizing the list of nursing diagnoses that you come up with. right off the bat, you should see something related to nutrition pop up.
here are some websites to help you get some information to contribute to this care plan:
then, if you still need more help in choosing a nursing diagnosis, print your list of symptoms (defining characteristics) and i will help show you how to choose nursing diagnoses for them.