Help choosing the right diagnosis

Esme12, ASN, BSN, RN · Oct 5, 2014

Welcome to AN! The largest inline nursing community!

((HUGS)) you are making the same mistake all nursing students make...you are "choosing" a diagnosis first then trying to fit the patient into it. Care plans are all about the patient assessment...of the patient. 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.

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.

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 from our Daytonite

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.

Another member GrnTea say this best......

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.

assessment consists of gathering data about:

a health history (review of systems) - you've provided more than enough of that
performing a physical exam - you have none and this information is crucial to have
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what its side effects and potential complications are

Now tell me about your patient.

Esme12, ASN, BSN, RN · Oct 5, 2014

Now....what NANDA resource are you using?

ScarletJones Hi there,
I am trying to write my first care plan and pick the right diagnosis' for my patient. Just a little backround info - pt has ESRD - fluid overload, on hemodialysis, and has anemia.....hx of COPD , CHF, & skin Ca. When pt was admitted his chief complaint was SOB. My assessment was done after 3 days of pt being admitted - he was on 2L of 02 (sat 95%), resp were 24, high BP, high BUN/CREAT, low GFR, low hgb&hct. His I&O was balanced.
So heres where I am having a hard time ....take it easy on me I am a newb (7 weeks into my program)....I want to choose Excess Fluid Volume as my top diagnosis but wonder if Ineffective airway clearance should be number 1? I know the ABC's but his breathing has improved since admittance I feel like fluid volume is more important since that is causing all the chaos. I also chose Deficient Knowledge (pt does not understand importance of dialysis and his dx), risk for decreased cardiac output, risk for ineffective therapeutic regimen management, and ineffective protection:anemia.

What diagnosis does your assessment support? You have listed what he HAS now what does he NEED?

Each nursing diagnosis has a definition your patient must fit this "definition"

For example...Ineffective airway clearance is defined by NANDA as...Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

With the defining characteristics/symptoms of....Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed

With the relating factors (due to) of...

Environmental: Secondhand smoke; smoke inhalation; smoking:

Obstructed Airway: Airway spasm; excessive mucus; exudate in the alveoli; foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi:

Physiological: Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction

Now tell me how this applies to your patient. What evidence/proof (symptoms/labs/presentation) do you have that proves this applies to you patient right now. what are his lung sounds? Does he have a cough? is he dyspneic at rest? Can he lie down to sleep? how many pillows does he use? (RR rate 24)

NANDA for excess fluid volume: Increased isotonic fluid retention

Defining characteristics: Adventitious breath sounds; altered electrolytes; anasarca, anxiety, azotemia, blood pressure changes; change in mental status; changes in respiratory pattern, decreased hematocrit, decreased hemoglobin, dyspnea, edema, increased central venous pressure; intake exceeds output, jugular vein distention, oliguria; orthopnea; pleural effusion; positive hepatojugular reflex; pulmonary artery pressures; increased pulmonary congestion; restlessness; specific gravity changes; S₃ heart sound; weight gain.

relating factors: Compromised regulatory mechanism (renal failure); excess fluid intake; excess sodium intake

What is your patients weight? You mentioned I/O is ok....does he urinate? Does the balanced I/O include what they take off in dialysis? Does he have edema?

What else is important to a renal patient? What are his electrolytes? Is he Risk for Electrolyte Imbalance? What meds is he on? Does he have lines?

ScarletJones · Oct 5, 2014

I'm not going to lie - I am completely overwhelmed and keep going in circles.

To answer your questions - he is 234 lb (BMI of 36.65). He urinates without difficulty...no edema. His I&O does not include what is taken off in dialysis. His electrolytes are normal except for calcium (7.0).

What do you mean by "does he have lines?"?

ScarletJones · Oct 5, 2014

I'm thinking Ineffective Airway Clearance is not right for him - I initially thought so because of COPD and that he has SOB when hes ambulating but I did not hear any adventitious sounds when I assessed him ( he did have some when he was admitted though). He is on 2L of 02.

He is not dyspneic at rest, I did not observe any coughing, and he is able to lay down to sleep with 2 pillows.

I really feel a little confused to be honest. I think because he came in wit c/o SOB I want to tie it in.

ScarletJones · Oct 6, 2014

What about Ineffective Breathing Pattern r/t excess fluid volume AEB tachypnea, dyspnea, 02 therapy, and H/O COPD. ??

Back2SchoolRN · Oct 6, 2014

Gases exchange can be compromised w/ fluid overload. and COPD, SOB could be a sign, also O2 sat 95% on O2, not room air.

ScarletJones · Oct 6, 2014

Hi! Thanks for the reply....We were told not to use impaired gas exchange unless we had evidence of abnormal ABG's to support it.

Esme12, ASN, BSN, RN · Oct 6, 2014

Hi! Thanks for the reply....We were told not to use impaired gas exchange unless we had evidence of abnormal ABG's to support it.

You are right....technically

I asked his weight meaning...has it gone up or down. He should be on daily weights.

You still haven't given me your ASSESSMENT of the patient. What I mean by this is...the patient admitted with ESRD and SOB. He has a hx of fluid overload, on hemodialysis, and has anemia.....hx of COPD , CHF, & skin Ca ....patient is alert and oriented. Color pale skin warm and dry. Lungs/chest equal expansion bilaterally rales/ronchi bilaterally. resps sl rapid patient c/o dyspnea at rest. O2 sat 95% O2 per NC @ 2lpm. Bilateral 3+ pitting edema noted to lower extremities....you get the picture.

What are the labs? What are the electrolytes? Potassium, Magnesium, Calcium. What exactly is the H/H? What exactly is the Bun Cr? are they going up or down? Is the patient on DVT prophylaxis? Is the patient alert? Is the patient on a monitor? Have they had an echo completed? What is ESRD? What are the complications? The patient has CHF what does his echo show?

Tell me about your patient

Esme12, ASN, BSN, RN · Oct 6, 2014

I'm thinking Ineffective Airway Clearance is not right for him - I initially thought so because of COPD and that he has SOB when hes ambulating but I did not hear any adventitious sounds when I assessed him ( he did have some when he was admitted though). He is on 2L of 02.
He is not dyspneic at rest, I did not observe any coughing, and he is able to lay down to sleep with 2 pillows.

Right...it isn't...he really has nothing obstructing his airway.

I really feel a little confused to be honest. I think because he came in wit c/o SOB I want to tie it in.

Many students do this...it's normal. Your day to day care plan is your "recipe" on how to care for the patient...today. What you need to be aware of so you can be on the watch for it. Does he become SOB with activity? what did he complain of?

Here are some possibilities....

Activity Intolerance Is he SOB with activity? Does he c/o fatigue?

Risk for Bleeding Is he on anticoag's? Is he on DVT protocol with anticoag's?

Ineffective Breathing Pattern Is he SOB with activity?

Decreased Cardiac Output Has he had a echo? What is his ejection fraction?

Risk for Electrolyte Imbalance He has ESRD What is his potassium, Mag, Phosphorus, Calcium? Is he on diuretics? Renal patient are particularly at risk for electrolyte imbalances so are patients on diuretics.

Excess Fluid Volume Is there edema? What does the CXR show? Is his weight up or down for him?

Risk for Infection Does he have lines...an IV? Does he have a temporary access for dialysis? A foley?

Deficient Knowledge (specify) what does he need education about? Is the dialysis permanent?

.....now which ones do you have proof of? Do you see where this is going?

firstinfamily, RN · Oct 9, 2014

With ESRD he may be anemic from lack of erythropoietin, which would affect his hgb and hct thus the ability of the hgb to carry oxygen leading to SOB. What about "potential for:" inadequate oxygenation? He apparently is not SOB at rest but with ambulation, so he needs supplemental oxygen indicating he has a problem with oxygenation. I would address the breathing first because to me, it is the most important----he will not sustain life without breathing!!! Then I would address the "potential for fluid and electrolyte imbalance" he can have these corrected with dialysis and electrolyte replacement therapy. I would correlate my physical assessment as Esme 12 has suggested. Good Luck!!! Believe me, someday you will get comfortable with care plans!!!

ScarletJones · Oct 10, 2014

Thank you all so much for your help. I had to turn in my assignment and am awaiting feedback from my instructor. I've been meaning to come back to this thread with more info....just having trouble finding time to sit and concentrate with everything going on.

The most challenging part of school so far for me is managing study time with my 3 children (2 are under 2 ).

I'll be back with more info and questions....thank you all once again - truly appreciated from this newb :)