Help with Nursing diagnoses

What was your assessment of your pt?

What is going on NOW, besides the risk for falls dx?

What was your systems assessment?

We had to choose one assessment, so I chose cardiovascular and located and auscultated the apical pulse and did a peripheral vascular assessment. pt has some pitting oedema around ankles, feet were a much paler and maybe very slightly bluish compared to rest of legs, capillary refill was about 2 seconds but toes were still very pale not much colour. He seems in good spirits otherwise, alert mentally, wife visits every afternoon, is determined to walk again and has physiotherapy twice a week. He doesn't have any concerns about his health apart from occasional L) sided hip pain from sitting in wheelchair too long and I noticed he quite often has SOB even without exertion

Look up any of the nursing diagnosis threads that GRNTEA has posted on and you will find some great information to help you!

I read a post of GRNTEA's where she was saying you don't PICK a nursing diagnosis, you look at your assessments and write a diagnosis based around that. I think I have been trying to pick a diagnoses rather than develop my own. Thanks :-)

My suggestion is to list your head to toe assessment. Then think what pops out to you, what is the biggest problem. Then connect that back to the nursing diagnosis. You are correct that you need to base your nursing diagnosis on your assessment. If you can't back it up with your assessment, then it's not a good one. Remember to focus on what presents the biggest problem, abc.

Also, risk for diagnoses are not priority. I have three diagnoses off of the top of my head that aren't "risk for".

I don't think we are allowed to have that many "risk for" especially when you have at least one thing that the pt stated jumps out as a present problem that you can do a lot for. You have another thing that you assessed that you can do for (btw, what was the measure of the pitting edema? Just curious since we have to state whether +1, +2, etc.).

Also, what is his nutritional status? Do you have to do the nursing Dxs based on the sole system you assessed? That's pretty rough and not super comprehensive.

We had to do a comprehensive assessment based on subjective information from pt and info from pt notes. Then we had to choose one physical assessment and explain our rationale as to why we chose it. With my pt's history I figured cardiovascular was appropriate. Our nursing diagnoses are meant to be derived from all the info we have gathered not just the physical assessment. I'm starting to look at it in a different way.. Now I'm thinking pain in L) side r/t extended periods in wheelchair (he also had a hip replacement in that side in 1999 wondering if that's related?) Oedema r/t insufficient peripheral circulation? I'm sorry I am a total newbie at this, this is my first "real" patient and I appreciate all and any help I can get :-)

You stated above that your assessment revealed pt is SOB without exertion. Now compare this SOB and pain in the left side extremity and ask yourself, which of these is likely to kill my patient? When prioritizing nursing dx, look at the assessment data and always ask yourself what will kill the pt FIRST and FAST. Answering that question makes prioritization very easy.

Another thing to nudge you; why should you care that pt's ankles are slightly bluish and edematous? What's at stake here? Pt may be elderly and cardiovascular system is whack but slightly bluish ankles and edema aren't normal physiology in any age group.

I feel like my pt is in heart failure, I feel my 3 priority nursing Dxs should be the pain that he stated to me he was having in his hip, his oedema and SOB. At my nursing school the head of nursing told us to prioritize by what will kill them first. But my clinical leader at the rest home said that is not how to prioritize in a rest home setting! As far as I'm aware his edema and SOB isn't even being addressed. Is this normal practice?

Also he is not DNR. On his notes it says investigate and treat any serious health conditions

Also he has been prescribed an inhaler for intermittent wheeze even though he is not asthmatic. He has been in the rest home a year now and told me he never used an inhaler till he was in the rest home. I'm starting to think he may have cardiac asthma? Apparently taking an inhaler for cardiac asthma is very dangerous as it can cause increased heart rate and arrhythmias (which my pt had last month!) I'm really worried about him