Help with care plans

[sydneyxmoon]

When setting a nursing diagnosis, I would think that I would want to use the admitting diagnosis to make a nursing diagnosis. But I just read I must assess and gather information first on my patient then create a nursing diagnosis. My patient was admitted to the ER for UTI, confusion, weakness and falls. Her Hx is HTN and COPD. I wanted to use impaired urinary elimination for my nursing diagnosis but from the looks of it, I need to use Maslows or circulation, airway, breathing first. If thats the case, i would use my nursing diagnosis for circulation. Whats driving me nuts is that that is not what she's in the hospital for. Her BP is stable, heart rate is stable, her lung sounds are clear although chest x-ray confirmed right lower lobe infiltrate. When i assisted her to the bedside commode, she had yellow foul smelling cloudy urine with dysuria. Im just really stuck on how to place that information i gathered into a nursing diagnosis. The majority of patients have HTN, so you would think all my nursing diagnosis would be on circulation since thats a priority. It just doesn't make any sense I'm lost!! someone help please I'm going crazy lol

[203bravo, MSN, APRN]

Nursing diagnosis is based on your nursing assessment and has nothing to do with the medical diagnosis. If a client is current having no circulation issues, even with a history of HTN well controlled with medications, then there would be no reason to have a circulation based nursing diagnosis.

Also, remember that the nursing diagnosis can change from day to day based on the client's condition and needs... Consider this: during your assessment the client is wheezing an moving very little air (the medical diagnosis for why is irrelevant) and you get orders for breathing treatments.. obviously impaired gas exchange (an ABC priority) is most important at this time.. after several hours of continuous breathing treatments they are breathing fine, no wheezing, SpO2 100%.. Impaired gas exchange is probably no long a nursing diagnosis and would the list would be re prioritized. If this were an ED patient and they were being discharged with inhalers and a nebualizer then a Knowledge Deficit may become your new priority nursing diagnosis.. The client would need education about their disease process, the nebualizer, as well as their new inhalers.

Same thing with admitted clients -- if during the nursing assessment a specific nursing diagnosis is no longer of concern, then it would be removed from the list and if the assessment revealed something new, then a new nursing diagnosis would be added to the list.

Just don't attempt to make your nursing diagnosis match the medical diagnosis. Especially if included in past medical history.. If a client has a history of asthma but is having no issues breathing at this time, then why on earth would you attempt to make Impaired Gas Exchange a priority nursing diagnosis by telling yourself "but they have a history of asthma and this would be an ABC priority."

PS - Impaired urinary elimination would be a first line Maslow physiological need - don't you think? :)

Practice practice practice and you'll get it down pat --- Best of luck.

[sydneyxmoon]

Exactly what I needed to know!! Thank you!