Nursing Diagnosis Label

i'm a relatively new student and dealing with writing the nursing dx.

i thought we only use the official nandas it just doesn't make sense to me how to set it up! i have my fundamentals nanda list, gulanick, ackley and online mosby that i'm trying to use for reference.

for example, my current patient is a 78 yr old female s/p cervical laminectomy and spinal fusion. a few of the problems i can help her with are:

--post op recovery making sure she is ok since she is

-pain

-infection, bleeding risk

-nutrition

the bottom three are more simple, but my priority concern is the neuro. i look at the nandas and i just don't see how to use a nanda for this patient that applies. i've read a lot of threads, but i'm still unclear. the nanda i see that have to do with surgical care are: delayed surgical recovery and my patient is not delayed...

deficient knowledge r/t postop? i'm assessing her neuro, it's not so much that she lacks knowledge.

when i use the online care plan constructor with "surgery, postop care" i get:

activity intolerance

anxiety

nausea

imbalanced nutrition

ineffective tissue perfusion

acute pain

delayed surgical recovery

urinary retention

risk for bleeding

risk for infection

my patient doesn't fit the defining characteristics (unless mentioned above, but i don't think they are my priority)

thanks in advance for any tips...i'm sure i can get this, just need some guidance!

welcome to an! the largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. you find your diagnosis and then try to retrofit them into the diagnosis. 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.

what is your assessment? what are the vitalk signs? what is the neuro assessmeny. is the the patient having pain? are they having difficulty with adls? what teaching do they need? what does the patient need? what is the most important to them now? what is important for them to knowin the future.

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.

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.

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.

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

1. 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)
   
2. 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)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. 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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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 (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis

definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities

(does this sound like your patient's problem?)

defining characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

related factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

i've just listed above all the nanda information on the diagnosis of activity intolerance from the taxonomy. only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.

one more thing . . . care plan reality: nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

a dear an contributor daytonite always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

now....about your patient.

OK....For example...."my current patient is a 78 yr old female s/p cervical laminectomy and spinal fusion".

What is your assessment? What are her vitals/labs? Does this patient have any co-morbidities? HTN? Diabeties? that may be compromised during the stress of illness and recovery? What are her complaints? Does she have pain? Is there any numbness or tingling? What does the surgical site look like?

Is there any redness/swelling/hematoma/brusing? How does the surgical drsg look? Does she have a fever? Has she voided? Has she ambulated? Does she need help with bathing/drsg/ambulating/toileting?

What is a laminectomy?

Laminectomy is the excision of a vertebral posterior arch and is commonly performed for injury to the spinal column or to relieve pressure/pain in the presence of a herniated disc. The procedure may be done with or without fusion of vertebrae. Minimally invasive procedures are taking precedence over laminectomy in many areas of the country. These include endoscopic lumbar and cervical discectomy and intradiscal electrothermal therapy (IDET) also known as thermal discoplasty. These procedures cause nodamage to muscles, no bone is removed, and no large incisions are made, so they can be performed in an outpatient setting.(Also, in the early stages of testing there is a genetically designed version of a natural body chemical called OP-1. This “gene putty” acts as a bone spackle that fuses diseased vertebrae

what do you need to do for this patient?

NURSING PRIORITIES

1.Maintain tissue perfusion/neurological function.

2.Promote comfort and healing.

3.Prevent/minimize complications.

4.Assist with return to normal mobility.

5.Provide information about condition/prognosis, treatment needs, and limitations.

DISCHARGE GOALS

1.Neurological function maintained/improved.

2.Complications prevented.

3.Limited mobility achieved with potential for increasing mobility.

4.Condition/prognosis, therapeutic regimen, and behavior/lifestyle changes are understood.

5.Plan in place to meet needs after discharge.

I think this site may help you immensely........

Nursing Care Plan for "Disc Surgery"

Post op teaching is a must.......all patients have deficient knowlege

http://www.tibss.org/docs/cervical_laminectomy_full.pdf

Discharge palnning....

http://medicine.missouri.edu/ortho/spine/docs/reinsel%20ACDF%20post%20op%20instructions%2012-10.pdf

The NANDA I see that have to do with surgical care are: delayed surgical recovery and my patient is not delayed...

Deficient knowledge r/t postop? I'm assessing her neuro, it's not so much that she lacks knowledge.

Sure she does.....Does she know her limitations and restrictions? Does she have a foley? Does she know about moving her LE to pprevent the formation of blood clots?

When I use the online care plan constructor with "surgery, postop care" I get:

Activity intolerance does she have any? Does she need help with ADL's?

anxiety

nausea

imbalanced nutrition

ineffective tissue perfusion is there any numbness or swelling?

acute pain

delayed surgical recovery She is only 24 hours post op are there any signs of complications? What are her co-morbidities?

urinary retention has she voided? Does she have a foley?

risk for bleeding How does the srugical site appear?

risk for infection Is there any redness/swelling/fever?

What was your assessment?

here are some useful care plan sited with examples to follow

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

I was pretty sure you did by the diagnosis that you had. I always ask to see what work the student has done but I didn't have to with you as it was clear you ahd already given this some thought and put work into it.

It is hard to judge how much information that a student has, as I have only what you post to go on. I am glad the links will help!

GoodLuck! Come back when you need help!

my friend esme has beaten me to the punch (i'm working too much lately, not keeping up my end of the bargain, sorry ).... i agree it's good that you have done your assessment enough to rule out some of the nanda-i diagnoses, and you're not trying to develop a nursing diagnosis because you have a medical one. common student error, btw. good start so far.

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:hug:......i wish i could join you. i got your back!!!!