need help with nursing dx!

i will give you direction and get you started on this. some information about care planning. . .it is a problem determination process where you strategize solutions. using the nursing process to help you organize your way through the care planning process helps immensely. carpenito is very knowledgeable, but i have always found her difficult to understand unless i read the introductory chapter(s) of her care planning books several times.

this is an analogy of the nursing process (the problem solving process) applied to a normal life situation.

something that should be very clear about the care planning process is how the assessment information that is collected becomes the foundation of everything that follows. abnormal data collected during assessment forms the basis that supports nursing diagnoses. they are what you treat with nursing interventions. they are what you expect to change as a result of performing those nursing interventions. goals are expressed as positive changes experienced by that abnormal data. the eventual evaluation that is made to determine if nursing interventions are working, or worked, test to see what the status of that abnormal data is. so, what is learned in initial assessment is extremely important and pretty much drives the problem solving process.

this can be likened to police detectives who are investigating a crime, lets say murder. they are looking to find a murderer, not much different than trying to find a nursing diagnosis. they spend most of their time hunting down clues which is pretty much the same as assessing data. the more they have, the more likely they are going to make the best decision. they are also trying to make connections between all the different pieces of data that they collect--fit the pieces of a puzzle together to make a logical picture. you are attempting to do the same when you start out to make a care plan. the more information and data you have to work with, the better your diagnostic decisions are going to be.

there are actual nursing problems and potential nursing problems. this patient has plenty of actual problems. the problem for you is to figure out is what they are and express them in nursing language (nursing diagnosis). the actual process of diagnosing, as every medical student can tell you, is the result of logical problem determination. you must systematically break down information you obtain from the patient's medical history, physical examination, and laboratory tests and reassemble it into patterns that fit well-defined groupings of symptoms that describe nursing diagnoses. you use your knowledge of the person's diseases and their treatment, the nursing process and a nursing diagnosis reference to help you.

this is the nursing process as it should be utilized to develop a care plan.

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.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]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:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

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

• goals/outcomes (https://allnurses.com/forums/2509305-post158.html) 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)

based on the information you provided:

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 - look up information about each of these conditions. what are the textbook signs and symptoms? did this patient have any of them? did you possibly miss seeing or observing any of the symptoms that the textbooks list? perhaps the patient is already being treated by the physician (meds, other therapies) for some of the symptoms so they are not as noticeable or have been altered (the goal of most interventions, including medical interventions is to improve, stabilize or support the deterioration of a condition). also, note the complications of the patient's diseases and conditions, particularly the alzheimer's disease and diabetes in this patient. why does this patient have contractures? what do you suppose is the underlying reason for the hypertension for someone who is comatose and primarily bed ridden? how is the patient being fed, bathed, moved?

• comatose - non-responsive and maintains a persistent vegetative state
  
• severe dementia r/t alzheimer's
  
• anemia
  
• type ii dm
  
• glaucoma
  
• hypertension
  
• contractures on her right upper and lower extremities
  
• generalized left-sided weakness

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i know there is more abnormal data than this. you just missed it. in the center of taber's cyclopedic medical dictionary is a 7 page nursing assessment form under the heading of nursing. use that as a guide to help you assess this patient.

• incontinent
  
• needs total assistance with adl's

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

• decreased cardiac output
  
• imbalanced nutrition: less than body requirements
  
• impaired physical mobility
  
• self-care deficit, specify type(s)
  
• disturbed sensory perception
  
• risk for impaired skin integrity r/t immobility and moisture (see https://allnurses.com/forums/2751313-post8.html)

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem - how to construct a goal statement: https://allnurses.com/forums/2509305-post158.html

Anticipated problems, diagnoses that begin with "At Risk for" or "Risk for", do not have AEB evidence because these problems do not yet exist so there can be no evidence of their existence. There is only risk that they could occur.