Identifying actual/potential health problems and prioritising nursing diagnoses

phuretrotr · Aug 11, 2013

Infection could be health problem, but it is not the priority nursing diagnosis for this patient. What do your ABC's tell you? That would be your #1.

What would be manifestations you would see with ABC problems? Do you see any problems with her vital signs besides temperature? You noted her O2 sats. Why is it low if she is on oxygen?

Esme12, ASN, BSN, RN · Aug 11, 2013

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? TELL ME ABOUT YOUR PATIENT...:)

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.

Esme12, ASN, BSN, RN · Aug 11, 2013

My patient (75y.o F with Hx HT and DMII) presented following a fall where she sustained fractured ribs and a left haemothorax (has insertion of ICC and UWSD). Her O2 stats are 90% on NP at 6LPM, but she keeps removing them (GCS is 13/15) seems to be getting a bit agressive and confused.

Pulse is 116bpm, BP 145/85, Temp 100.94F, IDC insitu - draining cloudy, straw colored urine with a pungent odour with 250mls present. She also has 120mls/hr of N/S (bag is getting low) and is NBM awaiting review of the Cardio-thoracic team. Her BSL is fine (last 5.8). Her RR is 22 with sligh crackles in lungs and air noted in L) lung with slight breath sounds.
She fainted this morning following severe pain, which is now controlled and obs stable with CT scan showing nothing abnormal. She's started to get a bit confused.

Wht about this story would make you concerned if this were your Mom. I had to figure out some of the things.... insertion of ICC and UWSD...is this a chest tube to water seal? IDC insitu....is an in dwelling cath...yes? I can't figure out NBM. BSL is fine (last 5.8)how exactly is that expressed so we can convert it to a US value. I would say you are from Australia? Yes?

ok.....I have highlighted what I feel is important.

Here is what my nurse brain sees....you have a 75 year old patient that fell and suffered a traumatic hemothorax, has a chest tube with an O2 sat of only 90% with increasing agitation and confusion that is hypoxic, tachnepic, tachycardic, hypertensive, with a temp. She continues to have severe pain which caused a vagal response that once again proves that safety is a concern for this patient. She has a foley with foul smelling, concentrated, urine which MIGHT mean she is at RISK for an infection.

Tell me....What would concern you first? Then we will go from there.

nurseprnRN, BSN, RN · Aug 11, 2013

NBM: nothing by mouth?

Esme12, ASN, BSN, RN · Aug 11, 2013

There ya go! NBM nothing by mouth...duh.... :down: