where is the evidence to support the use of those diagnoses?
there is a process to diagnosing. we are given the nursing process to use as a tool to help us. here is an analogy that may help clarify how to practically use it:
you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).
you have to do a nursing careplan on thrombocytopenia.
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
- i don't know if this is a real or imaginary patient. one thing you should do is look up information about thrombocytopenia, its pathophysiology, signs/symptoms, usual tests ordered, and medical treatment. this patient will have some of those symptoms. maybe you overlooked some of them. here is where you can start looking for that information:
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data -
diagnoses are only proven and supported by the existence of symptoms. a detective never arrests the murderer until he has the evidence and the proof that the person did the crime. you are, in effect, doing much the same in nursing diagnosing. you are diagnosing nursing problems and you will be developing nursing interventions for them. you are looking for as much evidence as you can find before naming
that diagnosis. there is no monopoly on the use of symptoms. we can use some of the same symptoms to contribute to our assessment and diagnosis activities that doctors use.
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -
when you are new at diagnosing you need nursing diagnosis references to help you. every nursing diagnosis has a set of specific symptoms called defining characteristics
. just as the symptoms of the medical diagnosis of sepsis are fever, chills, restlessness, confusion, diaphoresis, anorexia, vomiting, diarrhea, pallor, hypotension, tachycardia, and oliguria, some of the defining characteristics of the nursing diagnosis of nausea
are "aversion toward food, gagging sensation, increased salivation, increased swallowing, report of nausea (by the patient), and sour taste in mouth (page 142, nanda-i nursing diagnoses: definitions & classification 2007-2008
). here is where you find this kind of information:
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free: