Need help on Nursing Diagnoses (NANDA Format)

[misscherie]

Hi guys,

This is the first time I am putting together nursing diagnoses for the 11 Functional Health Patterns and could really use your wisdom on a few of these I have put together below (I have no idea what I am doing)!

- Bathing/Hygiene Self-Care Deficit related to impaired physical mobility evidenced by inability to bathe and groom self independently(Im not sure how to word this one. Basically, my patient is in his late 80's, he can stand and walk but only with assistance but does not have the strength to shower, or to stand for very long or to dress himself. He requires assistance with all of this).

- Constipation related to inactivity/immobility evidenced by frequent but nonproductive desire to defecate and straining at stools(My patient often tells me he feels he 'needs to go' but on many attempts, tells me he can't "produce anything" and finds it uncomfortable).

- Chronic Pain related to long-standing scoliosis evidenced by verbalised pain and management of chronic pain by fentanyl patches (Im not sure what to put for "evidenced by" since it's kinda obvious he's in pain..? This is managed by fentanyl patches insitu every 72 hours)

- Anxiety related to change in environment and routines evidenced by restlessness and confusion upon admission. (My patient was admitted to the rest home hospital wing as a result of an injury and initally was very anxious about being in a rest home and change of environment as he liked his routine and now has had to adjust to life in a rest home, causing anxiety).

- Impaired Verbal Communication related to dementia evidenced by cognitive impairment, and difficulty verbalising. (He takes a very long time to respond and has problems word-finding due to dementia).

Under some of the other FHP headings (such as "sexuality-reproductive", "sleep-rest", and "value-belief", my patient does not seem to have any problems or risks there so I am guessing we leave these headings blank rather than creating a nursing diagnoses for wellness? Hope this makes sense

Thank you SO much for your help, really appreciated :redbeathe

[misscherie]

Or could I also put for impaired verbal communication: "Impaired Verbal Communication related to dementia evidenced by decreased ability to send or receive messages (ie, has difficulty exchanging thoughts, ideas, or desires)."... ? Not sure which is best.

[One Flew Over]

I think for the pain one you could probably just write 'Chronic pain related to diagnosis of Scoliosis' because I think 'long-standing' might be a bit redundant since it's assumed that chronic pain alludes that he's had the condition a while :)

Also, for pain, did he give you a number out of 10? Or did you use any kind of pain scale? I would probably use that as your evidence or any non verbal signs that you witnessed such as 'pt wincing upon repositioning' or 'pt guarding (painful area)' can be used as your evidence

Also just as an aside, for the anxiety one, I think if there is a statement that the patient made that indicated that he was anxious, that would be stronger evidence?

I hope I helped a little :)

[AgentBeast, MSN, RN]

Your first two have two Nursing diagnosis. Nursing diagnoses R/T Nursing Diagnosis. With those two you should focus on fixing the impaired mobility and the other problems should resolve themselves. Provided the constipation isn't caused by medications and/or diet. In your third and fifth ones the R/T is a medical diagnosis. The R/T is always something a NURSE can do something about. I posted the same diagnosis in another thread but it will work here. Chronic Pain R/T Ineffective pain management AEB Patient report of pain 7/10 (and any other subjective or objetive data data you have to support this. If you feel you must use a Medical diagnosis you put that as your S/T. So using the example above and combining it with your diagnosis. Chronic pain R/T ineffective pain management S/T Scoliosis AEB patient report of pain 7/10.

Your 5th diagnosis the AEB Cognitive impairment isn't evidence of impaired verbal communication rather impaired verbal communication is evidence of cognitive impairment. I would just leave cognitive impairment out.

Your 4th diagnosis isn't terrible, but your evidence could be better. What was the HR? BP? RR? Anxiety usually comes along with physical signs too. Confusion doesn't really go with anxiety either. Rather the confusion is likely the cause of the anxiety.