help on nursing dx

Esme12, ASN, BSN, RN · Oct 11, 2012

Welcome to AN! The largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. 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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

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 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. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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

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 (ex:confusion) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 11, 2012

Female with alzheimers disease among many other things going on. I need a second nursing dx and I was wondering if anxiety would be appropriate or if I would have to literally see her and observer her being anxious... this is hard when all you have it the chart to look at.

What does the chart say? What did the history and physical say about the patients mentation/capabilities? What is the medical history? What meds are they on? So.......... what does this patient NEED by your assessment? What are her co-morbitities? What is Alzheimer's? How does Alzheimer affect the patient? What would a patient with Alzheimers need? Where on the Reisberg scale is this patient? Looking at this scale what would the patient need? Are they safe? Are they agitated? Can they swallow? Can they perform their ADL's independently or at can they perform them at all? What about the family and the patients caregiver?

Do you have a care plan book? What book do you use? I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition. Which NANDA diagnosis applies to this patient? NANDA list as contributed by vickirn (assistant administrator) nursing diagnoses 2012 - 2014.pdf‎ The biggest thing about a care plan is the assessment, of the patient. the second is knowledge about the disease process. First to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

The seven stage Global Deterioration Scale, also known as the Reisberg Scale, includes the following dimensions: (Alzheimer's Disease: Symptoms, Stages and Coping with Alzheimer's Disease)

Stage 1 – No impairment. Memory and cognitive abilities appear normal.
Stage 2 – Minimal Impairment/Normal Forgetfulness. Memory lapses and changes in thinking are rarely detected by friends, family, or medical personnel, especially as about half of all people over 65 begin noticing problems in concentration and word recall.
Stage 3 – Early Confusional/Mild Cognitive Impairment. While subtle difficulties begin to impact function, the person may consciously or subconsciously try to cover up his or her problems. Expect to experience difficulty with retrieving words, planning, organization, misplacing objects, and forgetting recent learning, which can affect life at home and work. Depression and other changes in mood can also occur. Duration: 2 to 7 years.
Stage 4 – Late Confusional/Mild Alzheimer’s. Problems handling finances result from mathematical challenges. Recent events and conversations are increasingly forgotten, although most people in this stage still know themselves and their family. Experience problems carrying out sequential tasks, including cooking, driving, ordering food at restaurants, and shopping. Often withdraw from social situations, become defensive, and deny problems. Accurate diagnosis of Alzheimer’s disease is possible at this stage. Lasts roughly 2 years.
Stage 5 – Early Dementia/Moderate Alzheimer’s disease. Decline is more severe and requires assistance. No longer able to manage independently or unable to recall personal history details and contact information. Frequently disoriented regarding place and or time. People in this stage experience a severe decline in numerical abilities and judgment skills, which can leave them vulnerable to scams and at risk from safety issues. Basic daily living tasks like feeding and dressing require increased supervision. Duration: an average of 1.5 years.
Stage 6 – Middle Dementia/Moderately Severe Alzheimer’s disease. Total lack of awareness of present events and inability to accurately remember the past. People in this stage progressively lose the ability to take care of daily living activities like dressing, toileting, and eating but are still able to respond to nonverbal stimuli, and communicate pleasure and pain via behavior. Agitation and hallucinations often show up in the late afternoon or evening. Dramatic personality changes such as wandering or suspicion of family members are common. Many can’t remember close family members, but know they are familiar. Lasts approximately 2.5 years.
Stage 7 – Late or Severe Dementia and Failure to Thrive. In this final stage, speech becomes severely limited, as well as the ability to walk or sit. Total support around the clock is needed for all functions of daily living and care. Duration is impacted by quality of care and average length is 1 to 2.5 years.

Disturbed thought processes, organic mental disorder secondary to Alzheimer's disease

Nursing Resources - Care Plans

Nursing Care Plans, Care Maps and Nursing Diagnosis

http://www.delmarlearning.com/companions/content/0766822257/apps/appa.pdf

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Esme12, ASN, BSN, RN · Oct 11, 2012

So what is your assessment? What are your thoughts? What do you think?