Help with care plans

[driaeee]

in NYS our database paperwork to determine a nursing dx for our care plans includes patient harmonies and disharmonies to determine the diagnosis.... im having mental blocks. any tips to collectively look at the data to determine nursing dx for careplans?

[THELIVINGWORST, ASN, RN]

Well I know nothing about "harmonies/disharmonies" Whatever that crap is..lol

But it is often helpful for you to just look at the data first and then cluster and figure out what the biggest problem for the patient is. Usually the biggest problem will cause other problems to be exacerbated, so fix the biggest problem first. Also remember the problem comes before the nursing dx, not the other way around. Look in your diagnosis book and find the highest priority dx that applies to your pt.

for example: client has pain, sob, muscle weakness, and is immobile. My first thought is acute pain or chronic pain, then treating that should help with the sob and the immobility which is probably caused by the pain. Then once the pain and SOB is fixed, hopefully the client will be able to participate in physical therapy and the muscle weakness and immobility should improve.

I hope this helps :)