Nursing Diagnosis....Please Help!!!!!

Nurse Kyles, BSN, RN · Feb 22, 2011

I always use my nursing dx book "Nursing Diagnosis Handbook, an Evidence-Based Guide" by Ackley The book is set up in two sections. The first section has medical dx alphabetically with appropriate nursing dx listed under each medical dx. The second section is all of the nursing dx alphabetically. First I look up my patient's medical dx(s) in the front section of the book. All of the applicable nursing dx will be listed there. I use the other data that I know about my patient to decide which of all of these nursing dx is most appropriate. Then I look up the nursing dx in the back of the book. In that section goals, interventions, and teaching points are listed.

Hope this helps! Good Luck! :coollook:

DayDreamin ER CRNP · Feb 22, 2011

A good place to start is Maslow, Maslow, Maslow, then ABCs.

OB-nurse2013, BSN, RN · Feb 23, 2011

Thank you for the replies!!! I am hoping to get better at it, I'm going to try to find a copy of taht book because that seems liek it would be very helpful :)

AggieNurse99, BSN, RN · Feb 25, 2011

The first part of formulating your nursing diagnoses/care plan is to assess your patient.

1. What problems does your patient have?

2. Are any of these going to kill your patient today?

3. What can you reasonably do in a shift or two?

Create your diagnoses backwards: AEB is stuff you found to be the problem in the assessment. R/T causes the problem.

95 yo little old lady with hx COPD, DM, dementia presents from the nursing home with pneumonia. MBS reveals she aspirates.

Impaired gas exchange r/t aspiration AEB sats 85% and cough with drinking thin liquids.

For the dementia patients I always liked Self-care deficit as opposed to Altered thought process because I can, as a nurse, independently do things to help with the self care defict but I have to give meds for the altered thought process. If that makes sense at this point. Care plans never made sense until after nursing school for me :)