help

So are you supposed to diagnose the medical condition? I thought the MD's did that.

lol so did I. What do you think about Ms J and her manifestations?

Think about the effects of prolonged hyperglycemia and acid/base balance.

To be honest with you I would simply call it CKD. Renal failure and ESRD fall under CKD. There is not enough information to positively identify what stage the patient is at. Both HTN and DM cause renal failure but without a GFR (glomerular filtration rate) it hard to tell how advanced the CKD is.

FIRST you need to move away from the medical diagnoses. Place yourself as the NURSE and look at the patent; what objective and subjective information do you see??? What are your NURSING PROBLEMS???

That is where you develop you clinical manifestations.

Another way to help discern important information in order to guide your nursing plan of care is using the nursing process:

Assessment: objective and subjective information;

Diagnoses: what NURSING diagnoses do you see with your pt? NOT MEDICAL do you have a care plan book? What have you learned about this in your Med Surg book that suggests what nursing diagnoses are suitable for your pt? Do the correlate for your pt?

Goals: what MEASURABLE goals do you see with this pt?

Interventions: HOW are you going to manage your pts current diagnoses?

Evaluate: Assess the end result of said interventions? Are there other interventions needed?

An the cycle will continue util the goals are met.

If you THINK like a nurse; you guide yourself to the information by finding out what is presented, what your pt is experiencing and what you are observing.

Now, review what you see as objective and subjective information; look at the past medical history and determine what issues from the PMH that could be a part of the nursing pictures and how they play a big part in the assessment presented. That should be your clinical manefestations, and lead you to your nursing diagnoses.

This could be ESRD, or quite possible right sided heart failure A/E/B peripheral edema in lower extremeties.

Ladies, gents: It is inappropriate for you to make medical diagnoses. Right-sided heart failure and ESRD (which it isn't anyway, if there is still urine being made) are medical diagnoses --and before you jump down my throat because you think they're obvious, let me tell you that there are other things that could make this patient have edematous legs, you have no renal labs, and you have only a vague statement about urine production. So stop with that. You really do not know enough to make a medical diagnosis, literally and conceptually. And even if your scenario gave you medical diagnoses, you still can't say, "My patient has X and Y, what are his nursing diagnoses?" There is no such possibility, no matter what you think.

Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, caregiver role strain, dysfunctional family coping, sexual dysfunction, or risk for falls, too. These are all things you often see in diabetics who come in with complications (and there are many, many more, and many that an individual patient might have independent of his medical diagnosis). They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

This is a nursing care assignment. It requires a nursing assessment. I am not really sure what the purpose of this assignment is, because the OP doesn't say. Is it to make a nursing plan of care? No nursing assessment appears. Is it to do something else? Let's hear it, and let's hear the OP's ideas first , because we do not do your homework for you.