Nursing Diagnosis Help

the structure of the 3-part nursing diagnostic statement is put together as follows:

• syncope (transient loss of consciousness)
  
• lying on the bathroom floor, unconscious
  
• apparently had fallen off the toilet
  
• doesn't recall losing consciousness
  
• "the last thing i remember was trying to have a bowel movement and i woke up on the floor a few minutes later"
  
• o2 saturation was 92%
  
• has a foley catheter

the steps of the nursing process (which is a problem solving method) as it relates to care planning involves the following:

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.
     
   • 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 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)
    
  • 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)

part of your assessment involves looking up information about syncope, its signs and symptoms, possible causes, likely medical treatment and potential complications. i would want to know if this lady hit her head when she fell. syncope is often due to momentary impaired blood supply to the brain as a result of tias, hypoxemia, hypotension or an arrhythmia. look up the drug meclizine and why it is given to give you an idea of what the doctor is thinking and what symptom he is treating that isn't listed in the scenario.

nursing diagnoses are based upon the symptoms (abnormal assessment data) that shakes out of the assessment. you've already been given most of them, so i'll just repeat them again:

• syncope (transient loss of consciousness)
  
• lying on the bathroom floor, unconscious
  
• apparently had fallen off the toilet
  
• doesn't recall losing consciousness
  
• "the last thing i remember was trying to have a bowel movement and i woke up on the floor a few minutes later"
  
• o2 saturation was 92%
  
• has a foley catheter

these are all potential aebs (evidence) that will support nursing diagnoses. for example, one diagnosis might be

• ineffective tissue perfusion: cerebral r/t interrupted flow of blood aeb syncope, found lying unconscious on the bathroom floor, and patient's statement that "the last thing i remember was trying to have a bowel movement and i woke up on the floor a few minutes later".
  
• and, risk for falls r/t age over 65, observed on floor of bathroom and statement by patient that she awoke and found herself on the floor of the bathroom. [these are all risks of potential why she could fall again, not symptoms. because this is not an actual problem, but an anticipated problem, there are not being considered for this diagnosis as actual symptoms.] see https://allnurses.com/forums/2751313-post8.html for how "risk for" diagnoses (anticipated problems) are treated differently from actual problems.

:wink2: i've been answering these kinds of questions for a couple of years now. i can tell when students are lost in the woods. i've tried to figure out the best ways of explaining it so we can get you back on the path. usually after doing a couple of case studies or care plans it all falls in place. you might want to print out the critical thinking flow sheet for nursing students at the bottom of all my posts to help you put all the elements together as well. it might also help you in studying specific diseases for exams.

there is also care plan information on this sticky: https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

Okay, I'm on a role so far I think!! Getting past the 3 part diagnosis was amazing, lol! Now that I understand that everything else is falling into place! I have come up with some unmet needs (we need 1 for each category) Would these be correct because they are all things that might need to be addressed in the future?

Safety: Pt wanted to get up out of bed to walk down the halls. But with this incident it puts her a risk for injurying herself.

Oxygen: Pt needs to keep her nasal canula connected to the o2 on the wall or oxygen tank because if her o2 falls lower than 92% that she came in with it could cause another syncopal episode.

Nutrition: Since patient needed soft diet, she may be lacking the proper nutritional components

Sounds OK. She needs oxygen because her syncope was most likely due to hypoxia.

you are problem solving here, basically writing a care plan, so follow the nursing process as i described it above.

step #1 - assess - look up information about your patient's medical diseases

• fractured head of the left femur - you need to look up the pathophysiology of a fracture in order to understand what goes on physiologically
  
• history of high blood pressure controlled with medication
  
• scheduled for an open reduction and internal fixation later today - this lady has just become a surgical patient; surgery is a treatment for a medical problem

step #2/part 1 - determine the patient's problem - make a list of the abnormal assessment data - notice how i went through the scenario, pulled out and made a list of the abnormal data

• rates the pain at 8 on a 0 to 10 scale
  
• sometimes forgetful
  
• bp 168/92 mm hg
  
• pulse 102 beats/min and irregular
  
• 26 breaths/minute
  
• left foot pedal pulse is weak and barely palpable
  
• cannot move left leg
  
• during assessment the patient is very anxious and states that she has never been in the hospital before; she did confide that she had spent a lot of time at the hospital when her husband died from cancer last year

step #2/part 2 - determine the patient's problem - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - i used all the data in the list above as evidence to support nursing diagnoses; if you use a nanda reference you will find each of these are defining characteristics for those particular diagnoses.

1. decreased cardiac output r/t altered heart rate and contractility aeb elevated bp of 168/92 mm hg, irregular pulse of 102 beats/minute and elevated respirations of 26 breaths/minute
   
2. ineffective tissue perfusion, peripheral r/t interrupted blood flow aeb weak and barely palpable pedal pulse in left foot
   
3. impaired physical mobility r/t skeletal interruption aeb inability to move left leg
   
4. acute pain r/t muscle spasm aeb pain of 8 on a 0 to 10 scale, elevated bp of 168/92 mm hg, elevated pulse of 102 beats/minute, and elevated respirations of 26 breaths/minute
   
5. anxiety r/t situational crisis aeb anxiousness during assessment, elevated bp of 168/92 mm hg, elevated pulse of 102 beats/minute, and elevated respirations of 26 breaths/minute
   
6. deficient knowledge, surgical procedure r/t cognitive limitation aeb a history of forgetfulness and statement that she has never been in the hospital before

step #3/part 1 - planning - write measurable goals/outcomes - each outcome corresponds to a nursing diagnosis and is based on nursing interventions that would be performed for that diagnosis. it was hard to write these without actually writing the interventions as well.

1. within a day the patient's heart rate will improve to a normal parameter of 60-100, blood pressure between 100 - 139/60 - 89, and respirations to 12 - 20 breaths per minute
   
2. within a day the circulation to the left lower leg will remain stable as evidenced by the pulse in the left foot continuing to be palpable though weak.
   
3. within an hour following recovery from surgery the patient will be able to begin moving the left leg.
   
4. the patient will report improved pain immediately following positioning designed to help relieve discomfort.
   
5. by discharge the patient will use relaxation techniques she will be taught to control her anxiety.
   
6. before going to surgery patient will state the importance of deep breathing and coughing and demonstrate the use of a bedside incentive spirometer.

step #3/part 1 - planning - write nursing interventions

acute pain r/t hip fracture along with accompanying inflammatory process aeb patient stating pain 8/10, grimmacing and not moving l leg.

impaired physical mobility r/t bone fracture and surgery, aeb atient unable to move l leg.

watch 4 pressure sores, turn q 2

constipation (big issue in nursing)

pnemonia

emphasize turn cough deep breath

anxiety r/t hospital admission, diagnosis, surgery aeb by asking questions, stating she feels nervous/anxious

The problem with using Decreased Cardiac Output

• fainting or a change in LOC is not a defining characteristic (symptom) of this diagnosis

All my references say that any time it is known that hypoxia is affecting brain cells to diagnose Ineffective Tissue Perfusion: Cerebral or Ineffective Tissue Perfusion: Cerebrovascular. This makes sense because the fainting is caused by changes occurring in the brain, not the heart. Hypoxia to the heart results in an MI.