Help with Nursing Diagnosis for Lab Class

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Hello, I am in Health Assessment class and for lab we have to do SOAP notes after each chapter we perform on our lab partners. This week we are on the neurologic system. My partner denied having any neuro problems like headaches, seizures, tremors, numbness, stroke, etc. All of her cranial nerves were intact when tested and all reflexes responded appropriately. I have to come up with a nursing diagnosis and plan of action but I'm not sure what diagnosis I would use for her being healthy in the neurologic system. Can anyone help?

Thanks

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Maybe a wellness diagnosis?

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Yes thats what I was thinking but I wasn't sure how to write it out. We haven't really covered how to do the wellness diagnosis for patients.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What care plan book do you have? Do you have the NANDA book? NANDA defines the wellness nursing diagnosis as "describ[ing] human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. this readiness is supported by defining characteristics. as with all diagnoses, nurse-sensitive (sensitive to nursing interventions) outcomes are identified and nursing interventions are selected that will provide a high likelihood of reaching the outcomes."

There is a list there in the NANDA book with the defining characteristics...wellness diagnoses are no different. it helps to have a nursing diagnosis reference book that lists the definition, related factors, and defining characteristics for each diagnosis.

Advice from a beloved member daytonite (RIP)......

with the "readiness for enhanced" (wellness) diagnoses the related factor, or cause, is pretty much the same--a desire to improve (whatever the area of health is). The reference will list the defining characteristics (symptoms). For this diagnosis it will be statements and actions by the patient to want to improve an already adequate diet that they want to make even better.

Your interventions would focus on what a good, well-balanced diet should be. Give them fda food guidelines, teach them how to read food labels on cans and what is most important to know and pay attention to on the labels, good carbohydrate choices to make, whole grain vs refined grains, importance of fiber, the different kinds of fats and which they should include in their diet, the best type of protein to include in their diet, vitamin and minerals to include in their diet.

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Thank you so much. And no I do not have the NANDA Book. These SOAP notes are only for practice bc we will not actually learn how to write a diagnosis until next quarter in Fundamentals. But they are worth 5 points each so I still wanted to do good. Thanks again for your response! ?

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Get the book now and be ahead of the game!

NANDA-I 2012-2014, $29 from Amazon, free two day delivery (and they have it for Kindle too)

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Ok great thanks!!

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Ok great thank you!!

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