Nursing Diagnosis Help

[Destinyx13]

i have a question! i haven't done a 3 part nursing diagnosis since the beginning of lpn school and now that i'm doing a transition program we have to do one again and i'm really having an issue with it! we have yet to do an assesment on our "fake" patient so i am a little confused on how we are suposed to do a diagnosis, but we were given a scenario:

transition i, simulation, scenario #2

mrs. hannah hurricane is a 72 year old female who was admitted to your unit from the er with a diagnosis of syncope. the patient's husband found the patient lying in the bathroom floor, unconscious and apparently had fallen off the toilet. the husband called 911, with the patient being alert and oriented to person, time, and place when the paramedics arrived. the patient doesn't recall losing consciousness and stated, "the last thing i remember was trying to have a bowel movement and i woke up on the floor a few minutes later". the patient has an iv of d5 ½ ns with 20 meq of kco at 125cc/hr. her admission vital signs were: temp 98.8 f, b/p 104/58, pulse 62, resp. 20. o2 saturation was 92%. the patient was placed on o2 via nasal cannula at 2l per min. the patient is on a soft diet, on bedrest with bsc, and i&o. the patient is on telemetry monitoring with normal sinus rhythm noted.

perform a head-to-toe assessment

physician's orders:

admit as an inpatient to the medical floor

dx: syncope

condition: fair

allergies: none known

vital signs every 4 hours

diet: soft

telemetry monitoring

o2 at 2l nasal cannula

activity: bedrest with bedside commode

iv: d51/2ns with 20meq kcl at 125cc/hr

chem profile in am

strict i&o

foley cath

meclizine 25 mg po bid r.b.v.o. "dr know-it-all"/c. courtney rn

we're suposed to make a 3 part nursing diagnosis based on this. .

i can come up with 2 part ones, but i'm realy having an issue with the aeb. . .we haven't even done an assesment how do we have any evidence?

[Daytonite, BSN, RN]

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

p - e - s

p

= problem

e

= etiology

s

= symptoms

problem related to etiology as evidenced by symptoms

read through the scenario. there are symptoms listed there:

• 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.

[Destinyx13]

Wow!! Thank you so much!! You really explained that a lot better than my Instructors in LPN school and in the transition program!! I really think I understand it now!! I appreciate your help soooooooooo much!!

[Daytonite, BSN, RN]

: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

[Destinyx13]

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

[Destinyx13]

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.

Printed it!! Thank you soooooo much!!

[Daytonite, BSN, RN]

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.

[Destinyx13]

yay!! I 've finally got it!!

[student86]

[color=#333333]cues and problems, three 3 part nursing diagnosis and 3 correct outcome statements and more if available.?

please need some good feedback on this :

72 year old woman was admitted following a motor vehicle accident. in the emergency department and x ray revealed that the head of the left femur was fractured. she is scheduled for an open reduction and internal fixation later today. at present, she rates the pain at 8 on a 0 to 10 scale. the son mentioned during the assessment that his mother is forgetful sometimes.

vital signs include the following: bp 168/92 mm hg, temperature 98 degrees fahrenheit/ 36.7 degrees celsius, pulse 102 beats/min and irregular respiration's, 26 breaths/min. breath sounds are clear bilaterally, respiration's even and unlabored, and peripheral pulses present and palpable at 2+ except the left foot, and pedal pulse is weak and barely palpable, and capillary refill time is 5 seconds. the patient is alert and oriented, is able to move all extremities except the left leg, and verbalizes appropriate responses to all questioning. she reports allergies to sufia and ampicillin.

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. significant medical history included high blood pressure controlled with medication.

my input is this but would like to have a detailed input: please help:cry:

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 patient 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

thanks...!!

[Daytonite, BSN, RN]

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

your turn

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

etiology: "hip fracture along with accompanying inflammatory process".

"hip fracture" is technically a medical diagnosis, so you have to state this a different way. this is one reason why english is a required pre-requisite. it takes a while for the edema of the inflammatory process of trauma to get a foot hold on a fracture and the scenario mentioned nothing about swelling in the hip or leg. it doesn't matter for this diagnosis anyway because broken bones and the inflammatory process are

not

what cause pain when someone has a hip fracture. when the bone breaks, the muscles around the break go into spasm and that is what causes the pain. the ends of the bones can also cut into surrounding tissues setting off the pain receptors as well. where in the scenario did it say the patient was grimacing? the patient can't move their leg because the hip is broken and the muscles are in spasm.

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

etiology: "bone fracture and surgery".

"fracture" is technically a medical diagnosis, so you have to state this a different way. notice i called it a "skeletal interruption". it can also be called a "skeletal impairment". how does surgery cause the patient to limit the purposeful movement of one or more extremities of their body (the definition of this diagnosis)? especially since surgery is going to restore mobility? the related factors for this diagnosis are things that

cause

these limitations. a fracture certainly does that. and, surgery hasn't even occurred yet.

nursing interventions are aimed at the symptom (inability to move the leg) or the reason for the problem (the broken bone). while watching for pressure sores, turning the patient q2h, preventing constipation and pneumonia and emphasizing turning, coughing and deep breathing are good things, they don't fit in with this diagnosis and have nothing to do with getting the patient to begin moving that left leg again. other diagnoses are needed for them.

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

the definition of the diagnosis of anxiety says "a vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. anxiety is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat" (

anxiety

). so, the etiologies (causes) for that must clearly make sense that there is impending danger. "hospital admission, diagnosis, surgery" isn't quite the ticket. it goes deeper than that. it's the fact that something is going to seriously change with regard to the diagnosis and surgery. the nanda guideline lists it as a change in health status. situational crisis could also be used as the related factor. in either case, each satisfies the definition of the diagnosis and the circumstances of the scenario. i think the hint here was that the son mentions she is forgetful along with the anxiety. there is no medical diagnosis stated, but the subtle hint in the scenario is that something is not working 100% upstairs in her brain, i believe. anxiety is typical when the mind is going in the elderly. her elevated vital signs are also symptoms of the anxiety.

[Sehille4774]

Someone said that the fainting was due to hypoxia..

however..i think the key phrase here would "while trying to have a bowle movement".

This to me would indicate that the client fainted due to a vasovagal response (aka low heart rate).

So i guess the decreased cardiac output would be correct.

[Daytonite, BSN, RN]

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.