Help with Priority Nursing Dx's

Esme12, ASN, BSN, RN · Nov 21, 2012

Welcome to AN! The largest online nursing community!

We will help with homework but we will not do it for you.....what do you have so far other than the pateint info/labs.

There is not enough information here to make a good diagnosis really. I think you are falling into the pitfall that catches students......finding a diagnosis and fitting the patient into it. What is the assessment of the patient? What do they need?

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. What is YOUR scenario? Again........TELL ME ABOUT YOUR PATIENT...:) what care plan book do you use.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

I am willing to help ........So tell me about your patient...... What are the vitals? What is YOUR assessment of the patient? What do the complain of????

What is this patients story......TELL ME ABOUT YOUR PATIENT.

What care plan book do you use? Having a good cage plan book and/or a nursing diagnosis book is essential to do care plans. Here is a list of the NANDA diagnosis provided by VickyRN asst admin.

Nursing Diagnoses 2012 - 2014.pdf‎ (35.7 KB, 3833 views)

Here are some brain sheets made by another contributor Daytonite (RIP) for you next care plan.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

ViennaMarie · Nov 21, 2012

Hi, I am not looking for my hw to be done, we have to back everything up with at least 6 sources (BOOKS!)...We are not allowed to use nursing care plan books either :/...

Here was MY assessment of my patient.. Awake, Alert, Oriented x2. Disoriented to time. Responsive to pain, touch, verbal. Speech is normal. Moves all extremities, but lower extremities are weak. Heart rate, regular, S1,S2 Present. VS T 96.7, PULSE 76, RESP 16, B/P 155/69, PULSE OX 99% with O2 via nasal cannula running at 2LPM. Respirations unlabored, diminished, with crackles in the right base. No c/o of pain at rest or with activity. Abdomen is soft, non-distended with bowel sounds present in all 4 quadrants. She is incontinent. Her skin is warm, dry, jandice but intact. She has excoration under breasts, abdominal folds, and around lady partsl/rectal area. She is not hooked up to any tubes and has no drains.

Esme12, ASN, BSN, RN · Nov 21, 2012

I am just looking for some input so I know where to go how best to help you.....is this your first care plan/care map? What books are you allowed to use? How can you get your nursing diagnosis if you can't use the NANDA book?

Esme12, ASN, BSN, RN · Nov 21, 2012

So care maps.......Concept mapping is a technique that allows students to understand the relationships between ideas by creating a visual map of the connections. Concept maps allows the student to (1) see the connections between ideas they already have, (2) connect new ideas to knowledge that they already have, and (3) organize ideas in a logical but not rigid structure that allows future information or viewpoints to be included.

Nursing students face a great need to understand the larger questions and problems of their chosen field. Unless there is understanding, students may only commit unassimilated data to short-term memory and no meaningful learning will occur. Meaningful learning is most likely to occur when information is presented in a potentially meaningful way and the learner is encouraged to anchor new ideas with the establishment of links between old and new material (All & Havens, 1997). Concept mapping is an effective teaching method for promoting critical thinking and is an excellent way to evaluate students' critical thinking because it is a visual representation of a student's thinking.

I think you will find this web site helpful...what do you have so far.

Concept Mapping