HELP Nursing DX

hi all,

so i got my first patient...and i get that we have to do a dx...but here's the problem.

she has copd but that's status quo. on 02 sat pretty high on ra considering. lungs sounded junky on left side but again (according to prof this was found last semester)

so, where do i begin? i understand the impaired gas exchange but related to ?? and is impaired gas exchange sufficient??

example risk for falls...okay now what? my lady was in a wheelchair with a throw rug on the ground and basically an accident/ fall waiting to happen.

also, she wears glasses is legally blind and hard of hearing. so disturbed sensory perception visual as evidenced by glasses?

my question is how and where do i begin? i've looked up dx online and on this website. all are so very helpful but if i am finding/using another dx is that like cheating? also can someone explain to me as evidenced by vs. related to?

i'm just really struggling with the dx part. and don't know where to begin.

any help would be greatly appreciated!

the so much!

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. 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. what is your assessment? what does the patient say? what are the labs? what does the patient need? what is the most important to them now?

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.

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 them as a recipe to caring for your patient. your plan of how you are going to care for them.

from a very wise an contributor daytonite.......

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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: follow in order

1. 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)
   
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)
   

a dear an contributor daytonite always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.

care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis. some other helpful links.

https://allnurses.com/nursing-student...ml#post6283634

https://allnurses.com/nursing-student...te-225330.html

https://allnurses.com/lpn-lvn-nursing...ml#post6052759

https://allnurses.com/lpn-lvn-nursing...lp-665349.html

what is the patients major c/o? does she have sob/dyspnea? (ineffective breathing pattern?) has she fallen?(safety) what is copd? (impaired gas exchange?) is your patient alert? do they have o2? do they have a chronic cough?(ineffective airway clearance?)what would you need to teach the patient about home o2? (knowledge deficit) is this patient in acute care or long term? your patients complaints and needs is what drives the care plan. is she able to perform adl?(self care deficit) does she require assistance? why is she in a wheel chair? (impaired mobility) dyspnea or another diagnosis c/o. using another nursing diagnosis is fine if it applies to your patient.

here are some useful care plan sited with examples to follow

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

what assessment do you have?