Just want to run my data and nsg dx's by you. Please critique!

Esme12, ASN, BSN, RN · Apr 13, 2014

There you go! Good! much better!

Probably the Bi-pap didn't apply if there was no breakdown from the bi-pap then, and you were just worried, that one would be a risk. Then inadequate nutrition would be another diagnosis.

Looking at the defining characteristics is what really helps you define for your patient.

That is all I do...I have never seen her. I am going strictly on what you say.

Esme12, ASN, BSN, RN · Apr 13, 2014

I love being bothered....take a look at these sheets to organize your thoughts. They were made by Daytonite a few years ago (RIP)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

lwandel · Apr 13, 2014

Is it right to address two different causes of the same issue? I remember my instructor throwing out a dx of Impaired Skin Integrity with risk for further breakdown r/t physical immobility, inadequate nutrition, and bipap dependency (I was worried about the bipap machine causing the skin on her face to breakdown, in addition to the stage 4 sacral pressure ulcer and and the non-blanchable patches of skin on her heels). She said that I was addressing 2 different causes of the same issue and they needed to be different nsg dxs. I don't want to do the same thing with the constipation being r/t two different causes... What do you think?

Never mind :) you just addressed it!

Esme12, ASN, BSN, RN · Apr 13, 2014

I went back and saw that ...LOLOLOL

lwandel · Apr 13, 2014

These are great!!!!! I'm going to share them with my classmates as well. I know we're all struggling with these care plans. :banghead:

Esme12, ASN, BSN, RN · Apr 13, 2014

Just mention where you got them and give credit to our friend who lost her battle with cancer. Tell your friends to come here! I love helping!

The biggest key is organizing your thought process to get the right information. The rest is easy. Sort of.... :nailbiting:

lwandel · Apr 13, 2014

She was prescribed morphine sulfate, tramodol and hydrocodone PRN, but was declining pain meds while I was there.

Still trying to find the 3rd nsg dx....

Adult failure to thrive won't work because the only r/t factor is depression. and without an actual medical dx or history of depression, my instructor won't accept it.

Can I use Risk for Electrolyte Imbalance if her labs already show that she has an electrolyte imbalance?

Looking at Deficient Fluid Volume, that won't work because her vitals were all within an acceptable range and her Hct levels were low.

I'll keep looking.....

lwandel · Apr 13, 2014

I certainly will let them know who made them. Thank you! And, just to give you and GrnTea a pat on the back, my instructor pulled me aside and asked me how I finally had my "AH-HA!" moment. I told her about you guys and this site and she had me share it with the rest of out clinical group during our post-conference time...I had already told them about it though. lol

Esme12, ASN, BSN, RN · Apr 13, 2014

She was prescribed morphine sulfate, tramodol and hydrocodone PRN, but was declining pain meds while I was there.
Still trying to find the 3rd nsg dx....
Adult failure to thrive won't work because the only r/t factor is depression. and without an actual medical dx or history of depression, my instructor won't accept it.
Can I use Risk for Electrolyte Imbalance if her labs already show that she has an electrolyte imbalance?
Looking at Deficient Fluid Volume, that won't work because her vitals were all within an acceptable range and her Hct levels were low.
I'll keep looking.....

Pain. She has pain. She made several comments about the pain, She has a spinal stimulator to help manage the pain. The narcotics may be what is aggravating her constipation.

Pain is your third.

or

Ineffective Health Maintenance

Activity Intolerance

Self-Care Deficit

Impaired Comfort

Risk for Falls

Esme12, ASN, BSN, RN · Apr 13, 2014

I still think you can use adult failure to thrive

NANDA Definition: Progressive functional deterioration of a physical and cognitive nature with remarkably diminished ability to live with multisystem diseases, cope with ensuing problems, and manage care

Defining Characteristics: Anorexia-does not eat meals when offered; states does not have an appetite, is not hungry, or "I don't want to eat"; inadequate nutritional intake-eating less than body requirements; consumption of minimal to no food at most meals (i.e., consumes less than 75% of normal requirements); weight loss (from baseline weight)-5% unintentional weight loss in 1 month or 10% unintentional weight loss in 6 months; physical decline (decline in bodily function) — evidence of fatigue, dehydration, incontinence of bowel and bladder; frequent exacerbations of chronic health problems (e.g. pneumonia, urinary tract infections); cognitive decline (decline in mental processing) as evidenced by problems with responding appropriately to environmental stimuli, demonstrated difficulty in reasoning, decision making, judgment, memory, and concentration; decreased perception; decreased social skills; social withdrawal-noticeable decrease from usual past behavior in attempts to form or participate in cooperative and interdependent relationships (e.g., decreased verbal communication with staff, family, friends); decreased participation in ADLs that the older person once enjoyed; self-care deficit-no longer looks after or takes charge of physical cleanliness or appearance; difficulty performing simple self-care tasks; neglect of home environment and/or financial responsibilities; apathy as evidenced by lack of observable feeling or emotion in terms of normal ADLs and environment; altered mood state-expresses feelings of sadness, being low in spirit; expresses loss of interest in pleasurable outlets such as food, sex, work, friends, family, hobbies, or entertainment; verbalizes desire for death

Related Factors: Depression; apathy; fatigue

nurseprnRN, BSN, RN · Apr 14, 2014

I certainly will let them know who made them. Thank you! And, just to give you and GrnTea a pat on the back, my instructor pulled me aside and asked me how I finally had my "AH-HA!" moment. I told her about you guys and this site and she had me share it with the rest of out clinical group during our post-conference time...I had already told them about it though. lol

Well, thanks. :thankya:

Do make sure to let them know that we don't do their homework for them, but we will definitely nudge them towards how to do it for themselves. And get the NANDA-I 2012-2014 book. It will make our conversations so much shorter.:)

Isis Phoenix · Apr 19, 2014

1.Risk for Pain related to recent surgery as evidenced by complaint of back pain with turning and positioning,as well as shoulder pain with activity.

2.Risk for skin breakdown due to impaired musculo-skeletal activity as evidenced by inability to turn and position self,as well as to activity intolerance.