Help in writing a diagnosis ASAP

Double-Helix, BSN, RN · Apr 7, 2012

How do you know that she is ready for enhanced communication? Is she requesting new methods of communication? Participating actively in speech therapy? What assessment data do you have that tells you this is an appropriate diagnosis. Your assessment data that supports the diagnosis is what you use as your r/t.

Don't get caught in the trap that a lot of new nursing students fall into- choosing the nursing diagnosis based on the medical diagnosis rather than your assessment. You'll find it very difficult to support your diagnosis that way. For example, two patients could both have aphasia, but depending on the assessment, your diagnoses are different.

One patient might be depressed, refusing to go to speech therapy, and refusing to use communication devices. That patient is not ready for enhanced communication, as they are still in the denial phase of their diagnosis grief. Another patient might be enjoying speech therapy and exploring alternative methods of communication. Readiness for enhanced communication could be appropriate for this patient.

So make sure you are doing your full assessment first, then choosing your nursing diagnosis, not just choosing the nursing diagnosis based on the medical diagnosis.

skang969 · Apr 7, 2012

My assessment data does indicate that the client wants to improve her communication skills. In addition, the family is very support of her doing so. My assignment is to write an teaching plan, impliment it and give an oral presentation. My top three diagnoses are 1. Activity intolerance. 2. Sedentary lifestyle. 3. Readiness for enhanced communication. The client understands to balance rest with her ADLs. However, she perfers activites like watching TV and going to musice performances. She is lacking motivation and encouragement to perform ROM/PROM or to go to exercise groups offered by the facility. I am doing my teaching plan with my 2nd diagnosis, Sedentary lifestyle. Part of my assignment is to present my top three diagnoses with one of them being psycho-social. I was considering Impaired verbal communication; however, the assessment data indicates she is ready for enhanced communication. I just do not know what to write for the r/t because all the diagnosis books and care plan books I have say to be developed. Her aphasia is secondary to a CVA five years ago. She has lived at the facility sense then.

Double-Helix, BSN, RN · Apr 7, 2012

I just do not know what to write for the r/t because all the diagnosis books and care plan books I have say to be developed

I don't know what you mean by developed. Do you mean specific? You stated that your assessment data indicates she is ready for enhanced communication. However, no information in your post relates to enhanced communication. What assessment data indicates that she has readiness for enhanced communication rather than impaired verbal communication? When you can find that assessment data, you will have your r/t section.

Esme12, ASN, BSN, RN · Apr 7, 2012

what year student are you? what is the nanda definition of readiness for enhanced communication? are you in the us? how do you determine she is ready for enhanced communication if she is aphasia? her families desires are little to no impact on the patient's ability. is her lifestyle sedentary or is she sedentary because of impaired mobility. have you considered her "lack of motivation" might be possibly relateds to depression? what care plan book are you using?

for example. nanda describes impaired verbal communication as..........nanda-i definition: decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols

common related factors arebrain injury (cva) or tumor that adversely affects the transmission, reception, or interpretation of language or other forms of communication

structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws)

cultural difference (e.g., speaks different language)

dyspnea

fatigue

sensory challenge involving hearing or vision

with defining characteristics asinability to find, recognize, or understand words

difficulty vocalizing words

inability to recall familiar words, phrases, or names of known persons, objects, and places

unable to speak dominant language

problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding

with a common expected outcome of......

patient uses a form of communication to get needs met and to relate effectively with persons and his or her environment

the biggest thing about a care plan is the assessment. 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.

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:

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)

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.html you can also use the search on this site to lead you to care plans.

care plan basics:

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.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

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.

this may help....http://www.pterrywave.com/nursing/care%20plans/1.aspx

skang969 · Apr 8, 2012

what year student are you? what is the nanda definition of readiness for enhanced communication? are you in the us? how do you determine she is ready for enhanced communication if she is aphasia? her families desires are little to no impact on the patient's ability. is her lifestyle sedentary or is she sedentary because of impaired mobility. have you considered her "lack of motivation" might be possibly relateds to depression? what care plan book are you using?
for example. nanda describes impaired verbal communication as..........nanda-i definition: decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols
common related factors arebrain injury (cva) or tumor that adversely affects the transmission, reception, or interpretation of language or other forms of communication
structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws)
cultural difference (e.g., speaks different language)
dyspnea
fatigue
sensory challenge involving hearing or vision
with defining characteristics asinability to find, recognize, or understand words
difficulty vocalizing words
inability to recall familiar words, phrases, or names of known persons, objects, and places
unable to speak dominant language
problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding
with a common expected outcome of......
patient uses a form of communication to get needs met and to relate effectively with persons and his or her environment
the biggest thing about a care plan is the assessment. 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.
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:
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)
a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.
there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.html you can also use the search on this site to lead you to care plans.
care plan basics:
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.
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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.
care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

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.
this may help....http://www.pterrywave.com/nursing/care plans/1.aspx

thanks, i am in minnesota.i am in the first year; well i almost finished the first year last spring but had to withdraw r/t family stuff. i am using davis's nurses's paocket guide and mosby nursing diagnosis. i know the nursing process. i just have a clinical instructor who really pushs me and wants more out of because i dd almost finish the semmest last spring. i had a really good idea that my r/t factor for readiness for enhanced communication was alteration of central nervous system secondary to cva. i just had to know for sure before i did my project on tue. i did ask a rn at my work who also went through the same program i am and she told me the same thing you did. i really understand what you were saying about the process. to do it in practice is easy. it's proving that i know it to instructors who are more focused on judging then teaching thats hard. school is going to be different next year. a lot of the instructiors are retiring.

Esme12, ASN, BSN, RN · Apr 8, 2012

Don't get wrapped up in the medical diagnosis. Look at your patient....what is she telling or showing you. I use Gulanick: Nursing Care Plans, 7th Edition .....I don't have readiness for enhanced communication I have readiness for enhanced immunization. Did you look at the care plan link for examples? I thought you were from out of the US because of the way you spelled and worded some things in your post. attention to detail is important in nursing and spelling as well......one spelling is one med and another spelling is completely another med.

Look to you patient for your clues not the medical diagnosis. I gave you plenty for you care plan to work off of and develop a good plan. Good Luck!

nurseprnRN, BSN, RN · Apr 9, 2012

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis. i might be missing something but i don't see anything that tells me she is ready for enhanced communication. if you want to use that as a diagnosis, you have to say why you think so.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.