I NEED HELP PLEASE

BeachsideRN, ASN · Oct 21, 2015

I have a patient that has a medical diagnosis of hyperlipidemia. I need to pick out an actual, risk or potential, and a psychosocial or knowledge deficit for it. Please someone help me! I've been searching through books. I'm doing this to prepare to do a care plan

You can't "pick" a nursing diagnosis based on a medical one. You MAKE a nursing diagnosis based on assessment. As far as books go, you need a copy of NANDAI and a care planning resource.

Trauma Columnist · Oct 21, 2015

Moved to Nursing Student Assistance

Apples&Oranges · Oct 22, 2015

Based on his history, (hyperlipidemia,) what is his biggest problem? This is pretty clear, what do you have to worry about when you have vessels occluded with crap? I'm certain that he has other ACTUAL issues going on, or else he would not be in treatment. What are his ACTUAL problems? WHY is he in the hospital? Holy cow! You have at least two nursing diagnoses right there! Not making fun of you, OP ;-), this was sooo hard for me in school, too. I agonized over nursing diagnoses and care plans. Now it seems so obvious. WHY is your patient here? That's at least 1 right there.WHAT are they at risk for (the original problem AND what puts them at risk just by being here? Think VTE, skin, etc.) Boom, 4 no problem. Don't forget your ABCs. If he is in with a cardiac issue, is he oxygenating well? what's his breathing like? How about perfusion? Are ALL of his cells getting the O2 they need? How would you tell? Once you start thinking about secondary systems (like kidneys - how do you tell if they are working?) and the liver (hmmm, how to check on that?) you will have a TON of info to come up with some really great dx. Don't forget psychosocial - everyone skips over that one till they get into psych - how would you or your mom FEEL if y'all were in the hospital and couldn't wipe your own bums? Think that's an issue? It would be for me!

Really, once you start looking at care plans from a systemic point of view, you will have WAY more dx then you could ever use in one care plan... pick the best couple actual and throw in a risk or two for good measure - just be sure you have reasons (rationales) for each, document them correctly, and you are golden!

Honestly, it's not nearly as hard as we make it :-)