NANDA nanda

Published

hi i just want to make sure im doing this right, patient c/o generalized weakness,nausea and vomiting 2 to 3 x a day

Admitting diagnosis Anemia./ potassium is very low

Past medical history: DM2,HTN,GI bleeding,Renal failure,Prostate ca

1. Deficient fluid volume related to inability to eat and drink due to vomiting.

2.Activity intolerance related to generalized weakness(do i have to know more about generalized weakness?)

3. disturbed energy field related to decreased of potassium intake

Thanks for any help!

Up Vote Up Vote ×

Disturbed energy field?:confused:

The very low K+ is the most serious problem your pt has. Very dangerous.

Up Vote Up Vote ×
Specializes in Finally an RN!.

You're missing your "as evidenced by" part for all of these. You need to identify exactly how this patient is presenting for this part.

"Disturbed energy field" r/t decreased K+? This nursing dx is used for emotional disturbance, from my understanding. There are much better dx for hypokalemia--keep trying!

I know these nursing diagnosis can drive you crazy, but you'll get it--it just takes practice (and lots of it!).

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

please post in the nursing student assistance forum (https://allnurses.com/forums/f205/) where i can find your questions much faster. you will also get help from other students there.

when care planning you should follow the nursing process:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  • your instructors might have given it to you.
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

utilizing the nursing process, you have. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - patient has renal failure, type ii diabetes, htn, anemia, low potassium, a history of gi bleeding and a history of prostate ca. this patient has diabetes, htn, anemia and hypokalemia which are all related with the renal failure. the only symptoms of all this that you observed were nausea and weakness? you need to read about these medical conditions and their signs and symptoms to learn what other signs and symptoms they might have or that you might have missed seeing and observing in this patient. the symptoms were probably there; you most likely missed seeing them.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - the only data you provided was

  • generalized weakness - needs more description
  • nausea and vomiting 2 to 3 x a day
  • inability to eat and drink - needs more description

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - from those symptoms the only diagnoses i can come up with are

  • imbalanced nutrition: less than body requirements related to inability to eat and accumulation of metabolic toxins as evidenced by nausea and vomiting 2 to 3 x a day
  • fatigue related to chronic renal disease as evidenced by weakness

the nanda taxonomy provides you with direction in your choices of the related factors you can use along with your nursing diagnoses. see this thread on how the nursing diagnostic statement is constructed: https://allnurses.com/forums/f50/diaper-dermatitis-337580.html

Up Vote Up Vote ×
+ Join the Discussion