need help with Nsg diagnosis

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I have a new patient. He had a stroke in 2005 and has had convulsions since then. His right leg was amputated below the knee in 2006. I had trouble today assessing PERRLA because he doesn't open his eyes very much at all. He has tingling in his left foot and has lost those toes, I think due to his diabetes. He has edema in that foot. He also has diminished respirations. He spends all day in his room in bed. He stated that he wishes he could go back to doing what he used to do. He is only 55 years old. I need to make 4 diagnoses. I did poorly on my last paperwork for this, as it was my first time, and I want to do better this time, but I don't really know how to do that. Any suggestions? Some ideas I have are either altered mobility or risk for falls, risk for impaired peripheral tissue perfusion, adjustment problems due to loss of a limb, change in lifestyle, or losing independence.:o

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First of all what was he admitted for? Second, what S&S does he have? What did you assess? Third, when grouped what do these S&S point to for a ND? Look at the posts Daytonite does for care plan help, she explains it soooo well!:lol2:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, margaretofcastello, and welcome to allnurses! :welcome:

diagnoses, whether they are medical diagnoses or nursing diagnoses are based upon the symptoms that the person has. every diagnosis has a set of symptoms that the patient must meet in order to qualify to have that diagnosis. a doctor can't say that someone has the flu unless he does a history and physical exam and finds that the patient has a fever, cough, runny nose, red eyes, and perhaps a reddened throat. we nurses can't classify a patient with a nursing diagnosis unless the patient has one or more of the symptoms, or what nanda calls the defining characteristics, of that particular diagnosis. there are 188 official nanda nursing diagnoses. nanda has developed for each:

  • a definition
  • a set of defining characteristics, or symptoms (or risk factors for the "risk for" diagnoses)
  • related factors, or etiologies/causes, for most of the diagnoses

these can be found in nanda-i nursing diagnoses: definitions & classification 2007-2008 which is published by nanda. this information is also re-printed in many of the currently published care plan and nursing diagnosis books that are on the market today. you need one of these books as a reference to help you in choosing the correct nursing diagnoses to make sure you are picking them correctly. if you do not have one of these books there are two websites where you can access about 75 of the most commonly used nursing diagnoses on webpages that have the nanda information on them for free:

you determine your patient's symptoms from the assessment you do of the patient. this assessment is part of the nursing process that you should be engaged in. during assessment you should be:

  • doing a physical assessment of the patient
  • assessing that patient's ability to perform adls (activities of daily living)
  • going through the patient's medical record (chart) and collecting as much data about the patient that you can find, particularly from the doctor's notes
  • looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

as a student you learn a great deal by doing all of this preliminary work. in general, it takes a while to become proficient in assessing patient, so doing all the above will help you to pick up symptoms that you might have missed when you did your physical assessment of the patient. the whole idea here is that you need to make a list of all the patient's abnormal data, or symptoms, because that is what becomes the foundation of everything else you will do to develop a care plan. nursing diagnoses, goals and nursing interventions are all based upon the symptoms the patient has. the more data you are able to collect, the better position you are in to determine their nursing problems. and, that is exactly what the nursing process is--a problem solving method. a care plan is nothing more than the written documentation of your problem solving effort.

from what you posted, your patient has this abnormal data, or symptoms:

  • right leg was amputated below the knee in 2006
  • doesn't open his eyes very much at all
  • has tingling in his left foot
  • lost toes of left foot
  • edema in left foot
  • diminished respirations
  • spends all day in his room in bed
  • he wishes he could go back to doing what he used to do
  • history of convulsions

these things will be the defining characteristics of the nursing diagnoses (patient problems) for this patient. however, i think that if you go through your assessment data again, and specifically look at the signs and symptoms of stroke and diabetes you are probably going to find that you missed quite a few other things. i'm specifically seeing a lack of adl information. this patient has a right bka with circulation problems in his left foot and yet you have no information about how he walks, transfers or moves about in his bed. is he able to turn on his own, or does the staff have to turn him? how does he get bathed and his clothes changed? how does he eat? this man had a stroke and stroke patients often have many different types of deficits. what are his?

yes, impaired physical mobility is a possible nursing diagnosis. but what is the related factor (etiology) for this? this requires having done some reading of his chart and finding out more about his medical diagnoses and how they are affecting him. ineffective tissue perfusion, peripheral is also another possible nursing diagnosis because of the edema, lost toes and tingling in his left foot and it's related factor is because of compromised blood flow. it should appear on the care plan before impaired physical mobility because it involves oxygen supply to the tissues and this is a physiological priority over mobility. spending all day in his room (being alone) and keeping his eyes closed (no eye contact) are symptoms of the nursing diagnosis, social isolation. and with a history of convulsions he is at risk for injury r/t seizures.

now, these are 4 nursing diagnoses i can pick up from just what you posted about your patient. however, if i were your instructor i would be looking for at least one self-care deficit in connection with this patient because of his medical problems. stroke + diabetes + amputation = a debilitated patient. i suspect that there is a lot that the nursing staff has to do for this patient and a care plan needs to reflect that. forget the adjustment problems due to loss of a limb, change in lifestyle, or loss of independence. address the basic nursing care, adls and physiological needs on the care plan first. then, do one or two psychosocial needs, but do not make them a big focus.

hope that helps give you some direction. there is more information on writing care plans on this thread:

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