Nursing Diagnosis, correct and in order?

TLynn89 · Nov 3, 2014

I can't comment on the accuracy (not my patient), but the rest of it looks good. Our professors make us do the PES (problem, etiology, signs/symptoms), so the order looks right. As far as the nursing diagnoses, my professors require that we use only the NANDA nursing diagnoses, and all of yours are there, so I think that's it :)

PaulBaxter · Nov 3, 2014

I know that one issue is that risk diagnoses do not have related factors, they have risk factors instead. I don't know how those should be written out though. Probably you should ask your prof.

My experience is limited to writing care plans at our clinicals. I just use our nursing diagnosis book to identify the defining characteristics and related factors (as well as suggested outcomes and interventions). If your "aeb" statement isn't listed as one of the defining characteristics then that would be something to look at more closely, either for rewording or for looking for a different diagnosis.

HouTx, BSN, MSN, EdD · Nov 3, 2014

Yes ^^^^^^^ this ^^^^^^

Don't try to figure what 'ought' to be used. ALWAYS start with your assessment data - this should synch with the 'defining characteristics' of your NDx.

Esme12, ASN, BSN, RN · Nov 4, 2014

I can't tell you what is appropriate without your assessment. Care plans are all about the assessment....of the patient.

What is this patient hospitalized for? Why are they seeking care?

Esme12, ASN, BSN, RN · Nov 4, 2014

I always have trouble putting it in order. Also I just want to make sure they are accurate. This is for a health history. All the information gathered was subjective.
Thanks
Diagnosis:
Imbalanced nutrition less than body requirements r/t insufficient intake aeb reporting food intake is less than recommended daily allowance
Fatigue (p229) r/t occupation aeb reports feeling tired
Sedentary lifestyle r/t lack of motivation aeb reports choosing a daily routine lacking physical exercise
Chronic pain r/t gymnastic injury aeb reporting pain. (479)
Risk for injury r/t insufficient seatbelt use

If they are taking gymnastics then they don't have a sedentary lifestyle.

Each NANDA has it's own statement/definition and isn't it activity intolerance R/T fatigue? For example....Imbalanced nutrition : Intake of nutrients insufficient to meet metabolic needs

Defining Characteristics: (AEB) Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication:

Related Factors (r/t): Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors.

How does your patient fit into these definitions?

Tell me your assessment and we can start from there.

messymissy · Nov 4, 2014

Esme12,

I'm glad to see your back! I hope you are feeling better and all is well with you and your family.

I'm mostly a lurker, but I truly enjoy your posts.

Messymissy

Esme12, ASN, BSN, RN · Nov 4, 2014

Thanks.....I'm getting there....I had emergency surgery and spent a few days in ICU for SBO/ischemic bowel. I have a 14 inch incision but well on my way back to normal....((HUGS)) thanks.

messymissy · Nov 4, 2014

Oh my goodness! I'm glad to hear you are feeling better. (HUGS) I've had GI issues before, SBO was a big worry of mine. Had some not so fun other issues (GI) but we don't want to go there......