nursing diagnoses

please, all students, realize that nursing diagnoses do not come from medical diagnoses, with the implication that nursing diagnoses are somehow derivative, secondary, or subordinate. nothing could be farther from the truth.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications.

they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

many nursing students think there is a big list somewhere where column a is the medical diagnosis and column b is the nursing diagnosis. this is wrong-headed for several reasons. one is that nursing diagnoses are made by nurses using the nursing process (which i know you don't have a good handle on yet but we're trying to help), not dependent on a medical diagnostic process. nursing diagnosis is in no way subservient to or inferior to medical diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

https://allnurses.com/nursing-student-assistance/nursing-diagnoses-655625.html

You have a lot info to work off of, 3 dx should not be a problem what do you have so far?

I agree with Esme12; Get a care plan book. Once I got one of those, doing my care plans became so much easier. The book I bought was Nursing Diagnosis Handbook by Ackley and Ladwig. It had all the NANDA classifications and plentiful interventions with rationales. It was really easy to use. I had the sixth ed. I'm sure there are newer out there.

Erik

the diagnoses i have come up with are: injury risk for perpiopertative positioning in relation to reddened area at the sacrum and right elbow.

the second one is: less than body requirement in balanced related to inflammation as evidence by patient inability to feed him self and difficulty swallowing.

The risk diagnoses is risk for mobility impaired bed related to patient weakness from stroke and cannot mobilize independently

"perioperative positioning" refers to the period when the patient is on the or table and immediately thereafter, and if he already has reddened area it's not a risk for, it's an actual. what you have said is, "he might develop an injury due to the way he was positioned in the or, and i know this because he has reddened areas over bony prominences on the sacrum and r elbow. " is that really what you meant, and concluded from your data? if not, let's think of a better way to say it. try this format to help you organize your thoughts:

my nursing diagnosis is ......... . my patient has that because he has ..... . i know this is true because i can see this, this, and this when i examine him/read it in the chart/etc.

i'm guessing you meant the second one to be related to nutrition; i'm not sure what you're saying when you say that he can't feed himself or swallow because of inflammation. could you clarify that?

you're closest with the third: if he is already impaired for bed mobility, there is no "risk for," it's already happening. impaired mobility related to cva, as evidenced by (what? paralysis? weakness? specify.)

"i know my patient has impaired mobility caused by his cva. i know this because he is paralyzed on the right side and cannot move in bed without assistance."

see how that works?

one thing that screams at me from this scenario is "

gold star to osteward for a good list.