Nursing Diagnosis Help!!

[sarah1515]

Hi all,

I am working on a project for the practical nursing program I am in. I am to come up with 4 nursing diagnoses, including a psychosocial diagnosis. I am having difficulty coming up with 4 solid nursing diagnoses. I think I am reading too into this. Any help would greatly be appreciated!! The information I have is as follows:

On admission you find a frail, elderly woman who is short of breath and repeatedly pointing to her abdomen and grimacing. She appears anxious and is unable to answer most of your questions due to the language barrier. She appears to be in considerable physical and emotional distress. Her vital signs are: T - 38.6 P - 102 BP - 186/98 R - 24 O2 sat 88 % on room air. When you ask her to rate her abdominal pain on a scale of 1-10 she tells you that it's 7. She is coughing up small amounts of thick, beige sputum. She has been incontinent of a large amount of foul smelling urine. Mrs. Smith's daughter tells you that her mother hasn't had a BM for 5 days and that the last one was small, hard and black. She also tells you that her mother ambulates with a cane, is "quite with it!" and used to work in a toy factory. She still likes to spend time making toys for impoverished children and volunteers at an East Asian day care center reading to children. She wears glasses to read and still has excellent hearing. She has a grade 12 education.

I should also mention that she is diabetic and speaks English as a second language (hence why she is not able to answer questions). However, her daughter acts as her translator. I should also mention that the medical diagnosis for this patient is: exacerbation of COPD (chronic obstructive pulmonary disease) and possible small bowel obstruction. She is also being assessed for MRSA and is on contact precautions.

[AmericanChai]

There are some good nursing dx books that have medical dx, and then they list and suggest possible nursing dx based on those dx. The two books I have list emotiona/social nursing dx as well as physical ones.

When dealing with pain and difficulty breathing, anxiety is a common dx to have. The language barrier could suggest another nursing diagnosis. The fact that she can't engage in her social activities anymore because of her health issues at hand would lead to another nursing dx.

I don't have my book in front of me, but there's some hints for you look something up. :) Good luck! Those care plans can be quite PAINstaking!

[sarah1515]

Ok awesome! Those are good suggestions. Thank you!

[jennilynn]

That scenario is full of potential dx.

What are some that you can come up with off the top of your head?

More people may be willing to help if you show that you already have a foundation. I haven't been around this board long, but long enough to know that people aren't going to do your work for you. :)

[Whispera, MSN, RN]

Go through what you wrote and find the 4 main problems she is experiencing. Then, with a list of nursing diagnoses in front of you (if you don't have a book, you can find lists online if you do a web search), go through them until you find ones that fit.

I'm thinking breathing, constipation, pain, anxiety right off the top of my head. There are diagnoses that fit those. It's up to you to write them so they give a more detailed impression of the specific patient....

[sarah1515]

I was leaning towards constipation, shortness of breath, and the emotional stress/anxiety she's experiencing prior to posting this, but wasn't sure if I was on the right track. I've JUST learned the nursing process and have limited knowledge about different conditions, so I was was unsure about my abilities to be able to complete this.

Does anyone know what being incontinent of foul smelling urine would indicate? Or would more information be needed to make a nursing dx?

Thank you everyone for ensuring I'm on the right track.

[Whispera, MSN, RN]

You don't have to know what is causing (medical diagnosis-wise) the incontinence of foul-smelling urine to write a NURSING diagnosis. Go through the lists of nursing diagnoses and find one that fits your patient. You know the patient better than we do.

I've found that most nursing textbooks have spots in them that pair nursing diagnoses with conditions. Try flipping to the chapter on kidneys/bladder/ureters/urethra and see if there's anything there.

It's confusing to do nursing diagnoses at first but it does get easier. You'll get the hang of it!

[sarah1515]

Thanks for the input, everyone. Here's to hoping that this nursing diagnosis bit gets a little easier. :)

[casi, ASN, RN]

the nursing diagnosis bit does get easier. Go to your nursing diagnosis book and just start going through your textbook and look at various diagnosis that you think might fit.

When clustering data to support diagnosis look at everything. 7/10 pain obviously supports acute pain, but what about vital signs, facial cues, and what not.