Need Help Coming up with a Nursing Diagnosis Please :)

Daytonite, BSN, RN · Feb 8, 2009

there is information there for several nursing diagnoses. the problem is in how the information is worded. some more information may be needed. do you have a nursing diagnosis reference?

hard time hearing people over the phone is a hearing loss. is this because of the tumor, the radiation therapy or aging? i had radiation therapy to the right side of my face and my ear was in the radiation field. i am nearly deaf in that ear as a result. radiation can destroy the little hairs that conduct the sound waves. did she describe the type of visual changes she is having and the reason for her contact lenses? refractive errors: myopia (nearsightedness)? hyperopia (farsightedness)? astigmatism? vision is also a sensory perception these two are disturbed sensory perception, auditory and visual r/t [cause of the hearing loss] and altered sensory reception aeb difficulty hearing and difficulty with vision.
rosacea can be described. do you have a medical dictionary where you can look this condition up, even if you don't know how to spell it? there aren't many words similar to it. rosacea either appears as redness or a kind of pimples. just describe what you see and if the patient tells you they have any pain or itching. ask what they do for it and if anything makes it better or worse. the cause of rosacea is unknown. this rosacea is impaired skin integrity r/t unknown cause aeb [objective description].
the hemorrhoids are caused by either hard stools (due to not enough fiber) or ingesting too much rough fibrous foods such as nuts, coconut, peanut butter or cornmeal that irritate the hemorrhoids during defecation. people who have them know what aggravates them and if they don't pay attention to what they are eating, their hemorrhoids will bleed. depending on which is going on, the diagnosis could be constipation or ineffective health maintenance.
for the beginning stages of osteoporosis, acute pain r/t inflammation of joints aeb [description of pain]
unless the patient is on a blood thinner, bleeding gums is usually a sign of gum disease because of poor oral hygiene. this website lists the defining characteristics for this diagnosis: impaired oral mucous membrane this is impaired oral mucus membrane r/t [refer to your assessment] aeb bleeding gums
for her diet, if you feel she would be open to improvement, go for readiness for enhanced nutrition r/t desire to improve aeb consumes adequate diet but expresses willingness to enhance nutrition. don't get hung up on the amount of fluid she is drinking. fluid is contained in the food she eats as well.

the gums or hemorrhoids would be the top 2 diagnoses because the mouth is involved with eating and the hemorrhoids are part of elimination. fluid and eating diagnoses come before elimination ones. readiness for enhanced nutrition is a wellness diagnosis and has to do with self-actualization, a high level need that is low on the totem pole of priorities.

Nursey103, ADN, RN · Feb 8, 2009

We had to do something similar at my school also ...we called it our gero paper. We couldn't do ours on someone healthy though - we had to interview a patient in the hospital and it needed to be someone who was ill (obviously that's why they're in the hospital). Maybe you can find someone with issues that are currently affecting their life...?! :twocents:

Sl1011 · Feb 8, 2009

my comments are in red below :)

there is information there for several nursing diagnoses. the problem is in how the information is worded. some more information may be needed. do you have a nursing diagnosis reference?
hard time hearing people over the phone is a hearing loss. is this because of the tumor, the radiation therapy or aging? she said the doctor told her it was probably from the radiation since the hearing loss is mostly on her left side (where the radiation was done), but aging could also be a possibility.i had radiation therapy to the right side of my face and my ear was in the radiation field. i am nearly deaf in that ear as a result. radiation can destroy the little hairs that conduct the sound waves. did she describe the type of visual changes she is having and the reason for her contact lenses? she told me she has myopia, and that her "eyes" were how she discovered she had a tumor. she said she was in the grocery store and all of a sudden her vision went a bit blurry and her depth perception was gone. this lasted about 3 minutes, and after that she went to the doctor. that's when they did tests and saw the tumor. refractive errors: myopia (nearsightedness)? hyperopia (farsightedness)? astigmatism? vision is also a sensory perception these two are disturbed sensory perception, auditory and visual r/t [cause of the hearing loss] and altered sensory reception aeb difficulty hearing and difficulty with vision.
rosacea can be described. do you have a medical dictionary where you can look this condition up, even if you don't know how to spell it? there aren't many words similar to it. rosacea either appears as redness or a kind of pimples. just describe what you see and if the patient tells you they have any pain or itching. ask what they do for it and if anything makes it better or worse. the cause of rosacea is unknown. this rosacea is impaired skin integrity r/t unknown cause aeb [objective description]. i will have to ask her more questions about this, but yes, i do have a medical dictionary :)
the hemorrhoids are caused by either hard stools (due to not enough fiber) or ingesting too much rough fibrous foods such as nuts, coconut, peanut butter or cornmeal that irritate the hemorrhoids during defecation. people who have them know what aggravates them and if they don't pay attention to what they are eating, their hemorrhoids will bleed. depending on which is going on, the diagnosis could be constipation or ineffective health maintenance. i will have to ask her what foods aggravates it, and by what she was telling me about her diet... she doesn't eat enough fiber. but i'll double check on that too.
for the beginning stages of osteoporosis, acute pain r/t inflammation of joints aeb [description of pain] she told me she was in no pain, but i could probably dig a bit deeper on this.
unless the patient is on a blood thinner, bleeding gums is usually a sign of gum disease because of poor oral hygiene. this website lists the defining characteristics for this diagnosis: impaired oral mucous membrane this is impaired oral mucus membrane r/t [refer to your assessment] aeb bleeding gums she's not on blood thinner.
for her diet, if you feel she would be open to improvement, go for readiness for enhanced nutrition r/t desire to improve aeb consumes adequate diet but expresses willingness to enhance nutrition. don't get hung up on the amount of fluid she is drinking. fluid is contained in the food she eats as well. so i shouldn't mention low fluid intake? just that she wants to improve her diet?
the gums or hemorrhoids would be the top 2 diagnoses because the mouth is involved with eating and the hemorrhoids are part of elimination. fluid and eating diagnoses come before elimination ones. readiness for enhanced nutrition is a wellness diagnosis and has to do with self-actualization, a high level need that is low on the totem pole of priorities.

thank you for explaining everything in detail!!! this really helps me :) i'm going to set up a time to meet with her again today to get some more questions answered.

sakura_RN · Feb 9, 2009

I am a recent graduate nurse and although I see that all physical aspects have been given diagnosis -where's the psychosocial??? there are lots of those issues here - for example with the hearing loss - you have to imagine that this affects her body image (disturbed body image) or risk for ineffective coping or ineffective health maintenance r/t perceptual impairment. R/f injury is a BIG one - if they have hearing loss there is a major risk for that or r/f injury r/t osteoporosis - they can break bones a lot easier! How about powerlessness??? spiritual distress?

These may be a little harder to assess but there's bound to be ONE of them!!!

Remember - nursing encompasses all aspects of the human being - it's a holistic science! and if your school is anything like mine -trust me - they will ding you for not having though of the psychosocial, socioeconomics areas.

Best of luck!

Sl1011 · Feb 15, 2009

these are 5 nursing diagnoses that i came up with. do you all think these are worded properly? i appreciate your help :)

- constipation r/t insufficient intake of fiber and fluid, amb straining and pain during defecation and hard, dry stools

- acute pain r/t constipation secondary to hemorrhoids, amb verbal report of pain and bleeding during defecation

- risk for falls r/t risk factors: age over 65, osteoporosis, hearing loss, cataracts, myopia, and impaired memory.

- disturbed sensory perception, visual and auditory r/t altered sensory reception and proton beam radiation, secondary to brain tumor, amb difficutly with vision and difficulty with hearing in left ear.

- impaired skin integrity r/t unknown cause of rosacea, amb redness on epidermis, burning, raised bumps, and itching

would acute pain be the most important? i know risk for falls generally isn't a priority.. or perhaps disturbed sensory perception?

silvia

Daytonite, BSN, RN · Feb 15, 2009

constipation r/t insufficient intake of fiber and fluid, amb straining and pain during defecation and hard, dry stools (physiological need for elimination)

acute pain r/t constipation secondary to hemorrhoids, amb verbal report of pain and bleeding during defecation (physiological need for comfort)

when you say "constipation secondary to hemorrhoids" you are introducing a medical diagnosis as the cause of a symptom/condition you are citing as the underlying etiology of your nursing problem. what you are trying to say here is that hemorrhoids are the cause of this person's constipation. that can't be right. hemorrhoids are the result of constipation.

your ambs are the evidence (proof) that the problem (pain) exists. "bleeding during defecation" is not proof of pain. you already have pain during defecation and that is covered with the diagnosis of

constipation

.

correct: acute pain r/t irritation and inflammation of anorectal veins amb verbal report of pain during defecation

see:

http://www.merck.com/mmpe/sec02/ch020/ch020f.html

disturbed sensory perception, visual and auditory r/t altered sensory reception and proton beam radiation, secondary to brain tumor, amb difficulty with vision and difficulty with hearing in left ear. (safety need - physiological and psychological threat)

the way this is worded makes it sound like proton beam radiation is causing her problem. wording is important.

can you be more specific with the description of vision and hearing difficulties? below, you mention she has myopia and cataracts. what are her symptoms of those? they can be your amb evidence that you list here. for example, since my radiation therapy, i can no longer put the receiver of the phone to my left ear and hear anything (

), i deliberately sit so people are on my right side because i can hear better and i often keep the close caption on the tv so i don't have to turn the volume up too high. without my glasses i have to squint to see distances clearly. those are symptoms--patient

responses

to the medical treatment or medical conditions.

better:

disturbed sensory perception, visual and auditory r/t altered sensory reception secondary to effects of radiation therapy for a brain tumor amb difficulty with vision and difficulty with hearing in left ear.

impaired skin integrity r/t unknown cause of rosacea, amb redness on epidermis, burning, raised bumps, and itching (safety need -protection)

we can't use medical diagnoses in nursing diagnostic statements except in very sly ways. this way won't work.

just say:

impaired skin integrity r/t unknown cause amb redness on epidermis, burning, raised bumps, and itching

risk for falls r/t risk factors: age over 65, osteoporosis, hearing loss, cataracts, myopia, and impaired memory. (anticipated need for safety - protection)

unless this is how your instructors want you to word "risk for" diagnoses, it is unnecessary to say "risk factors:" in the statement. everything that comes after the "r/t" is a risk factor in these diagnoses. i wouldn't capitalize all of them either. technically, osteoporosis, cataracts and myopia are medical diagnoses and shouldn't be used. they should be converted into a more acceptable nursing language.

better: risk for falls r/t age over 65, progressive reduction of bone mass, hearing loss, impaired vision and impaired memory.

would acute pain be the most important? i know risk for falls generally isn't a priority.. or perhaps disturbed sensory perception?

acute pain according to maslow's hierarchy of needs would be a comfort need. some instructors want it sequenced first in post-op patients. if pain medication were an important issue with a patient it might be sequenced first, but i don't think it is necessary here. i sequenced the diagnoses according to maslow. sensory perception and impaired skin are both safety needs. i felt the sensory perception was a little more important here. "risk for", or anticipated problems, are usually sequenced last because they are non-existing. one of the few exceptions would be

risk for suicide

.

see

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

- maslow's hierarchy of needs