Nursing diagnosis

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First, I apologise if I am in the wrong place. I am a bit computer illiterate, and am not sure how to navigate yet.

I have a student question.

I have a final exam due tomorrow. I am first quarter. For my exam, I had to do an assessment, and list two nursing diagnosis. I do not know how to write the diagnosis.

my patient presented with loss of balance, disturbed vision, severe head pain.

He had already been diagnosed with diabetic neuropathy, and COPD.

He has never had any hospitalizations or surgery.

He is independent, his house is tidy and neat. His stress reduction technique is to take a long drive. However....

He drinks at least 12 beers per day, has no appetite, forces himself to eat at least one meal per day, usually dinner that he prepares himself.

He now needs a walker for balance, has fallen several times. He was just recently diagnosed with 2 brain tumors on the cerebellum secondary to lung and liver cancer.

I know that he is at risk for falls, due to the loss of balance and drinking.

I have no clue how to write a diagnosis... can you help me please to put it in perspective. ??

Thank you...

Will do...

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Specializes in Postpartum.

Great suggestions you have had. I just wanted to add that this is the way I was taught to a nursing diagnosis.

Pick a diagnosis that applies to patient from NANDA approved list (found here http://wps.prenhall.com/wps/media/objects/745/763096/kozier_nanda.pdf )

Related to (R/T) why do they have this problem? (no medical diagnosis here, that is doctor stuff you are a nurse)

As Evidenced By (A/E/B) What do you see that lead you to that diagnosis? (if it is a "Risk For" diagnosis, this section can be left off.)

I hope that makes sense. Let me give you some examples.

Impaired walking R/T poor balance A/E/B pt states "if I don't use my walker I will fall"

"Risk for" example

Risk for falls R/T poor balance.

Hope this helps.

Dina

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I just completed my RN program and I found that the thing that helped the most for diagnosis was NANDA you use the diagnosis and elaborate

Like: Pt at risk for uncontrolled pain due to inability to take meds due to vision and dexterity changes with disease progression

Website for nanda http://www.efn.org/~nurses/nanda.html

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Well I'd have 2 questions, first what brought him to the hospital (if he's a hospital pt, you didn't say), and second, how badly does his COPD affect his ADLs? But absent that info (viewing it as a test question or something), I guess I'd go with "Risk for falls related to impaired sense of balance" and "Ineffective breathing pattern related to decreased lung expansion."

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That is very very helpful, thank you.

In answering the questions:

His COPD was not a big issue for him, although he is on a disk inhaler he was very active and it did not affect ADL.

He has diabetic neuropathy and is suffering from severe pain from that, prior to going to the hospital.

What brought him to the hospital was, within the last month, he had noticed some dizziness and loss of balance. It has progressed to the point of being debilitating.

He "feels he is having seizures because he wakes up on the floor some mornings and has been covered in blood because he had a gash on his head" He did not remember falling out of bed. This has happened often.

He lost his vision temporarily in his right eye for about 2 hrs. Vision did return, but peripheal vision he says "appears that things are moving away from me". He turns his head toward an object to completely view it.

His balance is Wide based and unsteady. Without his walker or cane, he walks with his hands in front of him holding on to the wall or whatever he can.

He said his "final straw was waking up one morning and could not stand up at all and the room was rushing around him" He could not stand to use the restroom, or even make it to the restroom.

while in the hospital, they diagnosed him with 2 brain tumors on the cerebellum "walnut sized" as well as lung and liver cancer.

He also has nutritional habits that are harmful. He is diabetic and drinks a non-light beer, as well he eats "what he wants to regardless of the sugar" not to mention the drinking and taking medicines.

We are only allowed two diagnosis, and we have to pick the most important one for this assessment. I think they are all pretty significant. This is the hard part about nursing for me, the prioritizing.

So as long as I don't use the dr. diagnosis, I can say that he is at risk for fall, because of the alcohol consumption? Or is that a DR. Diagnosis?

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Specializes in floor to ICU.

Poor coping mechanisms (alcohol)

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Specializes in Postpartum.

Alcohol intake is not a Dr diagnosis. You can use it. I wouldn't call that the most important problem though. I would call the impaired walking or risk for falls most important followed by visual distrubances. JMHO though

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You'll have to ask your instructors. We were permitted to use medical Dx's that the doctors came up with if they were in the chart, with this format:

Nursing Dx 2° Medical Dx

Ex. "Risk for falls 2° cerebellar mets."

2° = "secondary to". You can type the degree sign by holding down the ALT key on your computer and typing in the number 248, then letting go of the ALT key.

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First, I apologise if I am in the wrong place. I am a bit computer illiterate, and am not sure how to navigate yet.

I have a student question.

I have a final exam due tomorrow. I am first quarter. For my exam, I had to do an assessment, and list two nursing diagnosis. I do not know how to write the diagnosis.

my patient presented with loss of balance, disturbed vision, severe head pain.

He had already been diagnosed with diabetic neuropathy, and COPD.

He has never had any hospitalizations or surgery.

He is independent, his house is tidy and neat. His stress reduction technique is to take a long drive. However....

He drinks at least 12 beers per day, has no appetite, forces himself to eat at least one meal per day, usually dinner that he prepares himself.

He now needs a walker for balance, has fallen several times. He was just recently diagnosed with 2 brain tumors on the cerebellum secondary to lung and liver cancer.

I know that he is at risk for falls, due to the loss of balance and drinking.

I have no clue how to write a diagnosis... can you help me please to put it in perspective. ??

Thank you...

Just a few for you to ponder:

1. Impaired mobility r/t disease process as evidenced by loss of balance

2. Acute pain r/t disease process as evidenced by client reported headache that measures a ?/10

3. Imbalanced Nutrition : less than body requirements r/t excessive alcohol consumption as evidenced by client report of drinking 12 beers per day and having no appetite

4. Risk for injury r/t disease process as evidenced by visual disturbance

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Specializes in med/surg, telemetry, IV therapy, mgmt.
i have a student question. . .i have a final exam due tomorrow. i am first quarter. for my exam, i had to do an assessment, and list two nursing diagnosis. i do not know how to write the diagnosis.
i am so sorry that i didn't see your post until today. obviously, your final exam is over. i wish you had posted this question in either:

because this is where i hang out. i answer a lot of questions about care plans and nursing diagnoses. i could tell from your post what it was that your instructors were looking for. there is a whole bunch of information on how to determine a proper nursing diagnosis as well as how to construct a nursing diagnostic statement on these two threads which happen to be in the two forums i've listed above:

the process of writing a care plan, which includes determining and writing the nursing diagnoses, follows the nursing process. the steps of the nursing process as they are applied to care planning are:

  1. assessment (collect data)
  2. formulate nursing diagnoses
  3. write measurable outcomes and interventions
  4. initiate the care plan
  5. determine if outcomes have been met

before you can choose and put together any nursing diagnoses for a patient, your instructors are expecting you to do an assessment of the patient. your assessment involves combing through the written record for abnormal assessment data (signs and symptoms) as well as performing a face-to-face interview and physical assessment. in the case of an assignment like this where this is not a real patient, you depend on the medical diagnoses and any other information about the patient's condition that the instructor has given you and you start making a list. for each medical diagnosis you would have looked up all the likely signs and symptoms of that disease or condition. now, here's the most important concept that i often find that students get very confused about: all those signs and symptoms become the defining characteristics (this is the nanda term for "symptoms") that are part of the various nursing diagnoses. each nursing diagnosis has a definition, a list of symptoms that help to define it and a list of etiologies, or causes for the symptoms. when you have completed the list of signs and symptoms for a patient you have, in effect, determined their problems. to turn those problems into nursing diagnoses, you need a reference of some sort that has information about each nursing diagnosis listed out for you.

now, nanda is the most popular system of nursing diagnoses used. it is because nanda has widely published and made available to the nursing community what the definition, defining characteristics and related factors are for each of the current 188 nursing diagnoses. the language is all there and ready for you to use. on the other hand, your nursing program might have given you another set of nursing diagnoses guidelines to use. in either case, the process of choosing and writing a nursing diagnosis is still going to be the same. you start to look for nursing diagnoses whose defining characteristics (symptoms) match with the symptoms on the list you put together from the assessment of your patient.

your instructor was very generous and gave you such a wide variety of information that there were buckets of problems that this patient could have. in another post you mention that you are to identify the two most important diagnoses. that is talking about priority. you didn't mention how you are to determine priority, so i'll default to maslow's hierarchy of needs. if you prioritize by maslow, then you have to look at the problems that affect the physiological needs first. absent any circulation or oxygen problems (abcs), the intake of food and water is next in importance. this patient has a drinking problem and diabetes that are affecting his intake of fluids and food. therefore, it would be appropriate to first list a nursing diagnosis such as this:

  • imbalanced nutrition: less than body requirements r/t inability to utilize glucose aeb inadequate food intake and ingestion of 12 beers per day

he also has problems with mobility. although they are definitely related to his brain tumor, we are nurses and concerned with his nursing problem which is how he is physically getting around. yes, he's falling, but a nursing diagnosis of "risk for falls" or "risk for injury" addresses potential problems and this patient has plenty of "real" problems that you must address first. so,

  • impaired physical mobility r/t dizziness (secondary to brain tumor) aeb loss of balance and patient statement that the room was rushing around him

now, i've kept these nursing diagnostic statement very simple, partly because i just don't have all the information that you do about the scenario and partly because i'm getting tired at the moment as it is 3am where i am right now.

one more point to make. . .the construction of a nursing diagnostic statement follows the formula of

p - e - s

where p is the patients problem, or nursing diagnosis; e is the etiology, or cause, of the symptoms; and s is the symptom(s) the patient is having. all three elements must be related to each other. your (s)ymptoms always are derived from your assessment of the patient. always. and, just to carry this through to the third step of the nursing and care planning process, all the nursing outcomes and nursing interventions that you will put into a care plan for this patient are solely based upon these symptoms. always. everything that you will write for one nursing diagnosis (the p-e-s, outcomes and nursing interventions) is related.

that should answer your initial question for you. the whole procedure of writing care plans and determining nursing diagnoses is probably the toughest thing all nurses have to learn in nursing school. it takes doing many, many exercises in this to really get a handle on the process. it's slow going at first, but as you work with some of the same nursing diagnoses over and over, you get used to what they mean and what their symptoms are and it gets easier.

please post any other questions you have on nursing diagnoses or care plans on the two student forums i listed above where i will be able to find them. i hope you did ok on your final exam.

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Thank you very much. My exams will be back by monday they said, and at that time, I will know how I did. I am stressed just from the wait. And I have no idea how I did... That is the bad part, usually, I walk away, knowing something, anything. But as it stands, I don't have the slightest clue what my grade is. Thank you all,, so very much for your help and advice. I realy appreciate itl

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This is slightly off topic, but do any of you actually use a nursing diganosis in your practice? How does it fit in? And why does it fit in? We all know the reason the patient is there, what is called the medical diagnosis, but is it true we all learn about disease process in school. I understand that nurses are not allowed to diagnose, but what is wrong with taking the medical diganosis and knowing the nursing roles related to that. Does anyone truely follow nursing careplans or is stuff made up by non practicing theorist that "think" up ways to "empower" nurses?

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