Nursing diagnoses

KrCmommy522, BSN, RN · Nov 8, 2017

You include the signs or symptoms that your patient has that are "evidence" of the diagnosis you have chosen. So, when you assessed your patient and cared for your patient, what signs and symptoms did the patient exhibit that lead you to the diagnosis of risk for injury r/t invasive procedure?

Do you have a care plan book? I felt that care plans were really easy, more time consuming than anything. But, I think it all depends on having a good care planning book!!

Did your patient have an appendectomy? I'm assuming so, since you chose a diagnosis related to an invasive procedure unless the patient had some other kind of invasive procedure done.

However, there are other higher priority diagnoses that you should be focusing on - did your patient have excessive nausea or vomiting where he/she was showing signs of dehydration? If so, the higher priority diagnosis would be deficient fluid volume related to nausea and vomiting as evidenced by patient c/o nausea, pt vomiting 3x, ....etc. If the patient had nausea and vomiting but wasn't showing signs of dehydration, there was a risk of it..so risk of fluid volume deficit related to nausea and vomiting as evidenced by... If the fluid volume is only a risk, then that would no longer be the highest priority.

Did your patient complain of pain? - If so, you would want a nursing diagnosis for acute pain.

Your patient is also at risk for infection due to possible perforation of the appendix - if the patient hasn't had the appendectomy - or due to the surgical procedure - if the patient had the appendectomy.

At my school, we had to come up with at least 4 nursing diagnoses. 2 of them HAD to be actual nursing diagnosis, and 2 could be a health promotion or a risk diagnosis. However, we always had to prioritize them.

I don't know where you are in school or what your instructor requires. But, it's a good idea to get in the habit of choosing the diagnosis based on the highest priority - what is most life threatening to your patient right now? Use ABCs and Maslow's Hierarchy when prioritizing and choosing your diagnoses.

I hope this helps some!