Nursing Diagnosis Help

jadelpn, LPN, EMT-B · Oct 18, 2014

Also look at: Alteration in health maintenance, and each patient--regardless needs both a skin and fall care plan, Also, many require a discharge care plan. Knowledge deficit is also a good one.

JustBeachyNurse, LPN · Oct 18, 2014

Your first AEB would indicate a fluid volume excess not deficit. Are you using the NANDA-I to have access to the acceptable r/ t factors and AEB? There are no exceptions to the standards when making a nursing diagnosis. Unsteady gait is not a nursing diagnosis

JustBeachyNurse, LPN · Oct 18, 2014

Hi everyone, i'm having trouble with nursing diagnoses, and I need 2 different dx for my pt.
Background: pt. is a lady partsl delivery & lost almost 2 times the normal amount of blood postpartum. I need to base my dx off of the blood loss/fluid imbalance afterward.
One of my dx is: fluid volume deficit r/t EBL AEB shift intake of 1,200mL and output of 130mL
My second one is: unsteady gait r/t EBL AEB pt. reporting dizziness upon standing
Are these ok? Pleaseee help me!

You don't mention vital signs or labs which are critical to these nursing deficits. There cannot be a change in sodium level to use this nursing dx.

Per NANDA-I: Fluid volume deficit can only be AEB change in mental status, decreased BP/pulse pressure/pulse volume/skin turgor/tongue turgor/urine output/venous filling, dry mucous membranes, dry skin, elevated HCT, increased temp/pulse/urine concentration, thirst, weakness

AEB is active fluid volume loss (double blood loss during delivery would qualify)

Fluid volume deficit refers to dehydration , "water" loss without change in sodium. It's decreases intra vascular, interstitial and or intercellular fluid. (Blood is an intravascular fluid )

There is no unsteady gait nursing diagnosis (that's a PT or medical diagnosis) but there is risk for falls. She doesn't meet the characteristics for impaired walking or impaired mobility and not yet for activity intolerance/risk for)

Possible risk factors: physiological anemia(if labs so indicate), difficulty with gait, impaired balance (dizziness indicates), ortho static hypotension ( you didn't list VS), post operative

What about acute pain?

Risk for disturbed maternal- fetal dyad (at risk for the disruption of the symbiotic maternal-fetal dyad as a result of comorbid or pregnancy related conditions) due to the risk factors complications of pregnancy (EBL at delivery), compromised O2 transport (anemia, hemorrhage)

Esme12, ASN, BSN, RN · Oct 18, 2014

Welcome!

Here is my standard beginning.

Care plans are all about the patient assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

assessment consists of gathering data about:

a health history (review of systems) - you've provided more than enough of that
performing a physical exam - you have none and this information is crucial to have
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what its side effects and potential complications are

Esme12, ASN, BSN, RN · Oct 18, 2014

A nursing diagnosis goes like this.... GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
Related to" means "caused by," not something else.

Look at your NANDA resource.

Each nursing diagnosis has a definition, defining characteristics (symptoms that you patient has), and related factors (what causes it).

All care plans are based off your assessment. Wht are your patients vital signs? Did you take orthostatic vitals? What is hr H/H? Did she have any tearing? Did she have an episiotomy?

Tell me about your patient.

SnowballDVM · Oct 19, 2014

Esme12, thank you! I found your posts very useful!

Jennx · Oct 19, 2014

I had a pt. who delivered lady partslly and had a high blood loss (double what is normal for a lady partsl delivery). She then had a shift intake of 1,000mL and output of 110mL. Also, she was dizzy upon standing and was unsteady with ambulation. BP in the morning was 80's/50's, everything else was normal.

My first diagnosis (based on what my instructor wanted): Fluid deficit r/t EBL AEB shift intake of 1,000mL and output of 110mL

Second diagnosis: Activity intolerance r/t EBL AEB pt.'s unstable gait, BP of 89/50, and pt.'s report of dizziness upon standing.

Are these ok?

missmollie, ADN, BSN, RN · Oct 19, 2014

Patient loses 1000 mL (1L) of fluid during delivery. Patient takes in 1000ml of fluid (I'm guessing IV) and only has an output of 110 mL. Why do you think that happened?

SopranoKris, MSN, RN, NP · Oct 19, 2014

Tell us your rationale for choosing these (other than your instructor said so). Why do you feel these are correct?

Everline · Oct 19, 2014

I need to understand your thinking on these. Please explain more.

missmollie, ADN, BSN, RN · Oct 19, 2014

Another thing to consider is Maslow's hierarchy. What's the most important/crucial thing you can do for your patient? What is going to cause the most problems that you can head off early.

What does the fetus do in the last few weeks before it's born? (hint: it steals from the mother to store this, because it can't make it). Also, what was the mother's heart rate, how would you rate her pulse, and why is it like that? Is 1000 mL enough for fluid replacement, and why wouldn't they use more? What's the mom's HBG and HCT?

I've been waiting to see your responses, and I hope you reply soon!