Need to formulate a 2 nursing diagnosis and goals/expected outcomes

Bringonthenight · Sep 26, 2013

Hi, It's my first time here and I'm a first year nursing student from Australia. In 3 weeks time my comprehensive NCP is due and I need someone help urgently to formulate my nursing diagnosis and goals/expected outcomes. My patient suffered from degenerative neuromuscular disease(MS) for 20 years and I'm thinking to focus on 2 nursing diagnosis (1 actual and 1 potential) This are the assessment: I WANTED TO FOCUS ON 2 NURSING DIAGNOSIS: RISK FOR IMPAIRED SKIN INTEGRITY R/T.. IMBALANCE NUTRITION...R/T SWALLOWING DIFFICULTIES IMPAIRED PHYSICAL MOBILITY R/T.. and I need to come up with 1 goal and 2 expected outcomes for every nursing diagnosis. O/E: Musculoskeleltal:impaired mobility, paraparesis, ataxia and spasticity. Tremors of both upper limbs interferes with abilityto perform activities of daily living (ADLs) Sensory: diminished temperature perception, decreased touch sensation, parasthesia. Blurred vision. Slurred speech. Urinary/Bowel: occasional incontinence of urine, constipation. Skin:skin integrity maintained Nutritional: some swallowing problems Respiratory: normal resps, no obvious congestion. Emotional: occasional depressive episodes, first time experiencing respite care and separation from primary carer and family I need help with this to start my NCP. Thanks in advance

This forum can't help with homework.

nursebk · Sep 26, 2013

Hi,

I'm new to this site and hopefully someone will help me formulate my nursing diagnosis to start my comprehensive NCP. I'm a first year nursing student from Australia and in 2 weeks time my NCP is due, I'm freaking out at the moment.

My patient was diagnosed with degenerative neuromuscular disease and this is all the important data:

O/E: Musculoskeleltal:impaired mobility, paraparesis, ataxia and spasticity.

Tremors of both upper limbs interferes with ability to perform activities of daily living (ADLs)

Sensory: diminished temperature perception, decreased touch sensation,parasthesia. Blurred vision. Slurred speech.

Urinary/Bowel: occasional incontinence of urine, constipation.

Skin:skin integrity maintained

Nutritional: some swallowing problems

Respiratory: normal resps, no obvious congestion.

Emotional: occasional depressive episodes, first time experiencing respite care and separation from primary carer and family

I wanted to focus on Impaired physical mobility r/t..

Risk for nutritional imbalance r/t..

Risk for impaired skin integrity r/t..

and I need goals/expected outcomes for every nursing diagnosis

Hopefully some nurses/student nurses will help me with this..

Thank you in advance..

Cheers,

nursebk

Esme12, ASN, BSN, RN · Sep 26, 2013

Welcome to An! The largest online nursing community!

Do you uses NANDA I? http://www.nanda.org/ What ND book do you use?

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/care map: ADPIE. From our beloved Daytonite....RIP

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/care map is nothing more than the written documentation of the nursing process you use to solve one or more of a patients 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. Tune 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.

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 will have to be a detective and always be on the alert and lookout for clues.......at all times. 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 the 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.

#2. 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.

#3. 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 the next step of the process which is

#4. Determining your patients problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

#5. How are all your interventions changing/helping this patient.

You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.

For example: As a contributor to AN....Daytonite said best.

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it..............a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated.

What you have just done is.......

Step #1 of the nursing process--performed an assessment. You determine that you have a flat tire.

Step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do i do?" You are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. .......Good thing you took that class in how to do simple maintenance and repairs on a car!

Step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work.

Step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive....... Good....... Everything seems fine. The spare tire seems to be ok and off you go and on your way.

Step #5 of the nursing process--evaluation (determined if your goal was met).

Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

critical thinking involves knowing:

the proper sequence of steps in the nursing process
the normal anatomy and physiology of the human body
how the normal anatomy and physiology are changed by the medical and disease process that are going on
the normal medical treatment that the doctor(s) are likely to order to treat the medical and disease process going on
the nursing interventions that you have learned for the things that support the medical and disease process that is going on
making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are

So I am sure this is now clear as mud.......questions?

Esme12, ASN, BSN, RN · Sep 26, 2013

This forum can't help with homework.

That is not true.....you are mistaken this is the nursing student assistance forum and I help students ALL THE TIME!

Esme12, ASN, BSN, RN · Sep 26, 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.

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.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the patient?

nurseprnRN, BSN, RN · Oct 1, 2013

We don't DO homework. We HELP with homework. We do that all the time, sometimes to the detriment of our other life responsibilities. :)

You are responsible for delivering some components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

You don't have to make up nursing diagnoses-- they are all there for you. What you do is see which ones apply based on your assessment. As to goals, surely you can guess what a good outcome would be for a "risk for impaired skin integrity" might be, hmmm? Or "Risk for imbalanced nutrition: More than /less than body requirements"? Or any others? What do you think a good outcome might be for any diagnosis, given the definition of nursing diagnosis includes that it looks at human response to injury or illness?

MendedHeart · Oct 1, 2013

What is a bigger potential problem with impaired swallowing(dysphagia)? It would trump you current -risk for-diagnosis.

What is the difference between a goal and an expected outcome?

What ideas have you come up with?