Nursing Diagnosis---how to make one and when?

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Hi I was needing some help on nursing diagnosis....how do you make one and when....what is the rationale for a nursing diagnosis when a medical one is the one that matters?

Goal of care-Is this the 'planning' part of the nursing process and what is an example of one? Goal for nurse or patient's goals?

Planned strategies (nursing interventions)-Is this the same as nursing implementation or 'plan in action'?

HELP PLEASE....have clinicals tuesday and things I thought I was sure about....Im not.

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I got a test on this on Tuesday so let's see if I can help while reinforcing what I learned.

A nursing diagnosis attempts to explain symptoms manifested by the Pt. while the medical diagnosis explains the pathology of the illness that pt. has. So COPD is the medical diagnosis and ineffective airway clearance is the nursing diagnosis. Also the medical diagnosis ONLY takes into account the pathology of the illness and not the pt as a whole.

So the pt that I worked with for clinicals this week was admitted for hypotension but the pt. had a history of COPD, was incontinent and didn't speak English. The nursing diagnosis' that I've been messing with are much different than the medical diagnosis (hypotension).

"Goal of care" - I'm not familiar with this term. Where does it fit in within ADPIE (assessing, diagnosis, planning, implementation and evaluation)?

Nursing interventions are the actual steps that the nurse does to treat the nursing diagnosis.

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Specializes in Emergency/Cath Lab.

Goal of care is the SPECIFIC goal you want to happen in a certain timeframe or by a certain point

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Specializes in alternative healing.

here are a few of the websites i copied from the website section as well. good luck.

care plan database

[color=#164c97]http://www.satelephone.com/~ghost/cp.htm

careplans.com, a gathering place for healthcare professionals and students.

[color=#164c97]http://www.careplans.com/pro/pages/problemlist.asp

rn central - care plans

[color=#164c97]http://www.rncentral.com/

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