help with diagnosis

hi, geoffreyz, and welcome to allnurses! :welcome:

well, you've done a pretty good job of describing this lady's medical conditions, but you are a nurse and that doesn't help you too much with determining her nursing diagnoses. that is because medical diagnoses and nursing diagnoses are two different animals. the information that we nurses base nursing diagnoses on is slightly different from the information that doctors base medical diagnoses on.

a diagnosis, any diagnosis, is the decision or opinion you reach after you have made an examination or investigation of the facts. for us nurses, and, in particular, nursing students, that investigation includes the following:

• collecting data from the patient's medical record
  
• doing a physical assessment of the patient
  
• assessing the patient's ability to perform adl's (activities of daily living)
  
• looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

all of that information is needed to complete a comprehensive care plan. and, as you become more experienced, you will find that all that information is necessary to critically think and solve patient problems. this process is something you need to master because you will be doing it as a nurse until the day you retire from nursing. this is what employers will be paying you for--your ability to problem solve, which is what the nursing process is. this is going to be a rather long and complex care plan because of the patient's problems.

• femoropopliteal bypass 2 weeks ago
  
• history of peripheral vascular disease
  
• a diabetic ulcer on leg which is infected with mrsa
  
• unstable insulin dependent diabetic
  
• history of smoking 15 cigarettes a day
  
• intravenous access in place for antibiotics

first off, this is a surgical patient. there is a surgical wound that needs attention and potential complications of anesthesia and surgery that you must take into consideration. that's several nursing diagnoses right there. you have pvd (peripheral vascular disease) that is most likely the underlying cause of the status ulcer, not to forget that it is probably also a complication of the diabetes. you've got an active infection (what are the patient's signs and symptoms of this infection?) which is also causing blood sugar problems. there is a new nursing diagnosis you can use for the unstable blood sugar--risk for unstable blood sugar (r/t infectious process)

you must follow the nursing process in writing a care plan. determining nursing diagnoses is part of step #2 of the process. you have to do step #1 first. and step #1 is the most important step. screw that up and it affects the remainder of the steps and the results. the steps of the nursing process are as follows:

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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

you can never have too much assessment data. what you are always on the lookout for is abnormal data. as a nurse you should be like a detective and always looking for these abnormal assessment clues to help you assess and problem solve. it's a never-ending endeavor. the abnormal stuff becomes your patient's symptoms. this abnormal data can also be the patient's response to their medical disease or condition, so this includes their behavior. in step #2 of the nursing process you are going to make a list of this abnormal data, or symptoms. these are your patient's nursing problems. what you are going to do with that list is turn those symptoms into nursing diagnoses.

every nursing diagnosis has a list of symptoms that goes with it. nanda calls them defining characteristics because these define, or describe, the nursing problem. so does the definition of the nursing diagnosis which you should also read to make sure that describes the problem your patient is having. those 3 and 4 word nursing diagnoses are actually shortened labels. the real patient problem is described in the definition which you will find in the nanda information.

to tag a patient with any nursing diagnosis, the patient must have one or more of the defining characteristics (symptoms) of that diagnosis. this is no different from the way doctors diagnose medical diseases. we need to take the same care when applying a nursing diagnosis to someone. the symptoms have got to be there. for this you need to have a nanda reference. most current care plan books that have nursing diagnoses in them also contain this nanda information. there are two websites that you can access for free that have the nanda information for about 75 of the most commonly used nursing diagnoses:

• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
  
• http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/

now, here's the importance of this list of symptoms. besides needing it to choose nursing diagnoses, it is also needed to develop the goals and nursing interventions for the care plan. a patient with a stasis ulcer might have any of these symptoms:

• shiny, thin skin
  
• erythema around the ulcer
  
• necrosis of the tissue in the ulcer
  
• deep erosions
  
• smelly, purulent drainage
  
• black eschar around or over the lesion

your nursing interventions are going to be aimed at treating these symptoms. your goals are intimately linked with the interventions because they are the results you expect to occur when the interventions have been performed as ordered. without knowing this assessment information, you wouldn't be able to logically include any of that information in your careplan. you'd be pulling your hair out taking pot shots at what you hope would be the right interventions and having no logical linkages to symptoms. make sense? everything in your written care plan has a link to the assessment data which is why that assessment data is so important.

you asked, can you help me establish some nursing diagnosis for this lady? my answer is "no". not based on the information you have provided. you need to list the patient's abnormal data (symptoms). then, we can begin to determine some nursing diagnoses.

there is information on writing care plans on these threads:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing discussion forum)
  
• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum
  
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)