nursing diagnosis need help

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my instructor told me to revise my ncp. my pt's chief complaint is productive cough and his impression is pneumonia. I already made a potential problem and that is Loss of appetite and my diagnosis is

risk for imbalanced nutrition; less than body requirments related to increased amount of mucus secretions. I know my nusing diagnosis is inappropriate but I really need your help guys on how to correct this diagnosis. This is my first time and I'm out of idea....thank you. :cry:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

a nursing care plan is a written documentation of your problem solving process of the patient's nursing problems. since it is a process that means that there is a method we employ to accomplish this task. it's the nursing process, has 5 steps and the first 3 are crucial to the writing of a care plan. to determine a patient's nursing problems (nursing diagnoses) the initial assessment is crucial.

  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)
  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)

every nursing diagnosis has a set of signs and symptoms that nanda calls defining characteristics. the process of diagnosing includes evaluating and investigating the patient first. from what you find, you focus on what was abnormal and use that information to determine what nursing diagnoses you have. this is no different from what a police detective or car mechanic does. a police detective doesn't go to the scene of a murder and just put the cuffs on the first person that he "thinks" looks guilty. he examines the corpse, looks at the scene, questions witnesses, examines objects and gathers as much evidence as he can. then, he makes an educated and informed decision. you tell a car mechanic what is wrong with your car and then he tinkers around and looks under the hood to figure out what the problem is before making the repair. this is exactly what critical thinking and care planning are! your investigation process is to do a thorough assessment of the patient that includes

  • 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.

and your evidence that will support the nursing diagnoses is the abnormal data that shakes out at the end of these activities.

a pneumonia patient coughing up a lot of sputum is not unusual. ineffective airway clearance r/t infectious process in the lungs aeb excessive sputum production would be a possible diagnosis. this is an actual problem the patient would be having because in all likelihood they are having difficulty maintaining a clear airway if they are coughing all the time.

also see

since this patient has pneumonia you need to look up information about this medical disease, it's signs and symptoms. with a respiratory disease, your respiratory assessment should be very thorough. does this patient have any other symptoms beside the excessive mucous and productive cough? do you understand from your reading why the mucous is so excessive? you need to be able to explain the pathophysiology of inflammation in order to determine the "related to" parts of some of the nursing diagnostic statements you will have (https://allnurses.com/forums/f50/histamine-effect-244836.html) and for pneumonia, as well (https://allnurses.com/forums/f205/pulmonary-tuberculosis-pneumonia-pathophysio-273191.html) were any abgs done? were they abnormal? is the patient on oxygen? why? is the patient getting an antibiotic? any fever? what were the lung sounds like? how about the breathing--any shortness of breath? was the patient able to ambulate without getting short of breath?

when diagnosing it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

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we were taught that our related to needs to be on the cellular level; what is causing the secretions and the associated with is the medical diagnosis, medication etc. If the medical diagnosis is pneumonia look up its patho. as to what it causes and why and use it for you related to.

nursing diagnosis r/t patho of disease a/w medical diagnosis,surgery,medication etc.

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thanks a lot people.......

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Specializes in med/surg, telemetry, IV therapy, mgmt.
thanks a lot people.......

OK, that sounds very vague. Are you still lost out in the woods? Are you even more confused? Do you still need help with this? I was trying to light a fire and get you moving in the right direction without handing you the answers, but if you need more help or have more questions please ask. There are generally a whole handful of nursing diagnoses that we can come up with for a pneumonia patient with a cough.

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hmmmp i got no problem with the potential problem related t pneumonia . I was required to make 4 ncps 2 actual and 2 potential...what confused me most is the potential problem because my instructor keeps on discarding my potential problems. my first diagnosis is risk for infection: spread but our c.i told me to find another potential problem. Pt is not on IV, in good general condition, may go home anytime but still with occassional productive cough.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Use Risk for Deficient Fluid Volume. Patients who are ill often don't drink enough fluids and are losing fluid through imperceptible losses through the lung and skin because of increased metabolism (increased respirations and sweating because of fevers). You should also have Ineffective Airway Clearance for the coughing and either Ineffective Breathing Pattern or Activity Intolerance for your actual problems for this patient depending on the symptoms your patient has. Always assess your patient's ability to perform their daily activities. There are 4 Self-Care diagnoses that can always be used for those.

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You need a good med-surge care planning book to use as a reference. I have Medical-Surgical Care Planning 4th edition by Nancy M. Holloway, RN, MSN. I haven't used it yet to make a careplan/map, but my friend who graduated ahead of me said that all her classmates were coveting this book of hers, because it just spells out the different possible nursing diagnoses for many illnesses/condition. We could sit here all day and give you the answers but you need to get your hands on some good reference material and get the answers yourself :wink2:.

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ok thank you thank you. I dont know if you know this but mine is textbook of medical surgical nursing 11th edition by brunner and suddarth's. author is suzanne c smeltzer et al. I;ll try to find the book you told me about...

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REgarding "risk for" problems. these problems do not have related to. righ?

Problem: Loss of appetite

Diagnosis: Risk for imbalanced nutrition: less than body requirments

is this correctly stated? or should i add something? or should i write Risk for imbalanced nutrition only?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

"risk for" diagnostic statements also have r/t's. these r/ts are risk factors. what follows the "r/t" part of a diagnostic statement is always the underlying cause of the problem (nursing diagnosis).

the r/t factors here will be the underlying cause of why the patient would have a loss of appetite. this would be found in reading about the disease or medical conditions the patient has. often looking at the nanda taxonomy for the diagnosis will also point you in the right direction as well. the problem is that risk for imbalanced nutrition: less than body requirements is not an official nanda diagnosis. i'll give you some good rationale for that. potentially, the first thing to happen with a loss of appetite is that the patient will stop taking in fluids and food. then they become dehydrated. we can live without food for a while, but not water. we will dehydrate and die before we starve to death. so, ingestion of water (fluids) takes priority over food. this is also why you are not seeing a nursing diagnosis for risk for imbalanced nutrition: less than body requirements. the fluid is more important than the food. fix the fluid first--always.

people who don't eat enough are anorexic and over time lose weight. those are defining characteristics of the nursing diagnosis of adult failure to thrive. unless this is an elderly person with documented weight decrease, a physical decline and self-care deficits as well, this is not the nursing diagnosis to be using for your patient.

if your patient has a loss of appetite, that is an actual problem. the nursing diagnosis for this would be imbalanced nutrition: less than body requirements r/t loss of appetite.

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problem: potential loss of body fluid

diagnosis: risk for deficient fluid volume r/t inability to drink enough fluids accompanied by excessive fluid losses through sweating and the respiratory track

see this post on how to care plan anticipated/potential nursing diagnoses/problems: https://allnurses.com/forums/2751313-post8.html

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1)thank you. but why is it that in NANDA books there is Imbalanced nutrition:risk for more than body requirments but there is no Imbalanced nutrition:risk for less than body requirments..sorry if i keep on asking questions. I just want to make things clear. I appreciate you help a lot....

2) BAck to my patient, he may go home anytime, he still have ocassional cough ,not afebrile , not dyspneic in fact he looks healthier than me. My problem is that I still have to make 1 potential problem (i already done with the risk for fluid volume deficit) . Isnt it hard to find a potential problem for that kind of patient? HOw about RISK FOR IMPAIRED GAS exchange? his impression is pneumonia but it doest show a positive result.

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