Nsg Dx/Problem Statements?

[CaptScrubs13]

Hi everyone -

I am struggling with the new format of my clinical assessment tools given to us by the school. For each day we are on the floor, we are given a physical exam data sheet, organized by system. We fill out our findings (ie Neuro/Mental status; Cardiovascular Temp, pulse, BP, edema, IV access; GI diet, appetite, weight, bowel sounds etc) however new this semester is a Problem Statement for each system. Normally we just come up with pertinent Nursing Dx, prioritize and write separately.

My question is this -- what to do if there is no apparent "problem" for a given system?? For example, by patient has no history of urinary issues - no foley insertion, no symptoms/complaints related to urinary function, no incontinence, urinating without difficulty on her own ... What in the world would a problem statement be for this?! Also, Cardiovascular: Temp 97.7; Apical pulse 72; Blood pressure 149/87; + peripheral pulses, no edema, regular cardiac rhythm, not on tele, no murmurs or ectopic beats; no EKGs on this admission, IV access - line is patent, no redness/pain/swelling/tenderness at site. I'm at a complete loss for what to write -- any ideas??

[LadyinScrubs, ASN, RN]

hi everyone -

i am struggling with the new format of my clinical assessment tools given to us by the school. for each day we are on the floor, we are given a physical exam data sheet, organized by system. we fill out our findings (ie neuro/mental status; cardiovascular temp, pulse, bp, edema, iv access; gi diet, appetite, weight, bowel sounds etc) however new this semester is a problem statement for each system. normally we just come up with pertinent nursing dx, prioritize and write separately.

my question is this -- what to do if there is no apparent "problem" for a given system?? for example, by patient has no history of urinary issues - no foley insertion, no symptoms/complaints related to urinary function, no incontinence, urinating without difficulty on her own ...

what in the world would a problem statement be for this?! --why is the pt hospitalized? admit dx?

also, cardiovascular: temp 97.7; apical pulse 72; blood pressure 149/87; + peripheral pulses, no edema, regular cardiac rhythm, not on tele, no murmurs or ectopic beats; no ekgs on this admission, iv access [why--getting what?] - line is patent, no redness/pain/swelling/tenderness at site.

i'm at a complete loss for what to write -- any ideas??

if you picked this patient, get another. if it was assigned to you then you need to do it.

if everthing is a-ok, labs lytes, tests, neuro, etc...why is the pt in the hosital? sometimes a pt is admitted for 24 hrs for evaluation (aka observation). the case management guidelines allow for a 24-hour observation and the insurance carrier & medicaid/medicare will pay for that assessmentobservation.

if the pt has been in for more than 24 hrs, when was the pt admitted? what was the admitting dx? has the pt gotten better since admission (because of the treatment) and now ready for discharge?

i note an elevated b/p. iv access--what meds/iv(s) is the pt on--this could give you a clue. is there a cardiac irregularity? is the pt in pain? look at the patient--what do you see? this might give you a clue. does the pt have a severe pressure ulcer that requires hospital tx?