Help With A Nursing Diagnosis

[Hrickett]

Hi, I just started nursing school this semester and I'm doing my first set of clinicals, our instructor wanted us to come up with 2 nursing diagnosis for our pt one an actual and one @ risk.

my pt has unilateral edema in left leg, diabetes, hypertension, hypothyroidism, hyperlipemia , anxiety and depression, she also is high risk for falls, but I'm not allowed to use that one and I was also going to use at risk for impaired skin integrity r/ t incontinence but my partner snagged that one..

for the actual I picked Excess fluid volume r/t compromised regulatory mechanisms.. The one I'm having trouble with is the at risk

i was thinking of : at risk for infection r/t chronic disease or r/t deficient knowledge to avoid exposure to pathogens but not sure if that is the best choice and do I list the risk factors or just my expected outcomes and interventions??

[Rose_Queen, BSN, MSN, RN]

Welcome to AN! The most important detail about nursing care plans is that they are not dependent on the medical diagnosis; rather, they are dependent upon the nursing assessment of the patient. This is why two patients with the same medical diagnosis will not have an identical nursing care plan. You don't "pick" a nursing diagnosis; rather, you assess your patients and make a diagnosis.

Esme and GrnTea are posters here who have offered some awesome advice about nursing care plans. If you enter their names into the search bar in the upper right of the screen as well as nursing diagnosis or care plan, you will find a wealth of help.

[NurseGirl525, ASN, RN]

What does your assessment say? Your nursing dx is completely separate from a medical dx. What kind of nursing dx book do you have? Do you have the NANDA 2015-2107 book? You cannot make these dx up or the related to up. We need to know what your assessment says first.

[Hrickett]

Hi, thank you for responding. We just started learning physical assessment and we didn't actually do one on our pt yet, we just did basic hygiene and were allowed to look at their chart. In her chart we got the diagnoses (which I listed above) her past history which was just that she was admitted because of a fall and anxiety due to the fact that she was a hoarder. I also have a med list and we looked at her CBC which everything was normal and her chem 7 had an abnormally high glucose and A1C, and her chloride was slightly low. Upon meeting the pt I noticed that pitting edema was present in her left leg and the nurse had told me that her left lower lobe was barely audible. Also her vitals were normal except her BP was a little high but she has hypertension. That really is all the info I have to go on at the moment, I just think she wants us to start getting used to the process. We are using the Nursing diagnosis handbook, 10th edition with the NANDA nursing diagnosis. I wasn't making them up, I figured the excess fluid volume fit because under defining characteristics she has edema and altered electrolytes (chloride) my instructor actually already approved that one, just had to come up with expected outcomes and interventions, it was the risk one I was struggling with, I wasn't sure how to word it, what I have right now is : Risk for infection R/T compromised immune system secondary to diabetes... at first I had chronic disease but I changed it because I read that the medical diagnosis has to be secondary. Any tips based on what I have would be helpful, if I don't have enough I will just see what she thinks about what I have, thanks!!

[Alisonisayoshi, LVN]

She's not at risk for fluid volume excess, she has fluid volume excess. Now, think about the fluid and the barely audible lung sound, does anything click for you there? I know it's early on, but those things are your physical assessments, and the nursing dx should come from there. Her anxiety can also lead you, what kind of things can anxiety lead to in a pt? What kind of things can uncontrolled DM lead to in a pt?

[Alisonisayoshi, LVN]

Also search care plans on here, seriously, some of the advice here got me through nursing school, and I still use it at work, even though my computer system at is a bit more point and click then look up and research. It will really really help you.

[Hrickett]

Thanks for all the help! I appreciate it