Nursing Diagnosis

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hello i'm in nursing school right now on my last rotation and i have to finish my last nursing care plan and i'm having trouble finding 5 nursing diagnosis for my psych patient. Here is a brief description of her: she is diagnosed with bipolar disorder with depression. we weren't allowed to assess the patients just observe them and she seemed perfectly fine. she didn't have any manic episodes while i was there. so i'm having major trouble coming up with diagnosis. Can you help me come up with 5? thank you.

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Specializes in MICU for 4 years, now PICU for 3 years!.

Do you have any diagnosis's yet? It's probably a better idea if you tell us what you have come up with, then we can help you figure out others, otherwise it appears as if you want us to do your homework... tell me what you've got and I'll be glad to help :)

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Specializes in ICU/Critical Care.
prettyparade_3 said:
hello I'm in nursing school right now on my last rotation and I have to finish my last nursing care plan and I'm having trouble finding 5 nursing diagnosis for my psych patient. Here is a brief description of her: she is diagnosed with bipolar disorder with depression. we weren't allowed to assess the patients just observe them and she seemed perfectly fine. she didn't have any manic episodes while I was there. so I'm having major trouble coming up with diagnosis. Can you help me come up with 5? thank you.

What diagnosis do you have so far? There are nursing care plan books that can help you with your homework. We have no problem helping you, but we will not being doing all of your homework for you. The greatest part of the learning process is researching on your own.

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prettyparade_3 said:
hello I'm in nursing school right now on my last rotation and I have to finish my last nursing care plan and I'm having trouble finding 5 nursing diagnosis for my psych patient. Here is a brief description of her: she is diagnosed with bipolar disorder with depression. we weren't allowed to assess the patients just observe them and she seemed perfectly fine. she didn't have any manic episodes while I was there. so I'm having major trouble coming up with diagnosis. Can you help me come up with 5? thank you.

did you post this in the student nsg forum?

daytonite will help you...she's the master in ncp's.

were you allowed to go through pt's chart to collect abnormal data, read med'l and social hx, labs?

I can think of a few dxs, but wouldn't randomly assign them to all pts w/bipolar.

how are her eating habits?

her thought process?

sleep patterns?

social interaction?

any risk factors?

good luck to you.

psych is difficult.

leslie

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Specializes in Education and oncology.

I teach nursing and you are resourceful to come to All Nurses. I agree with Earle 58's reply. How is she coping? Is she a care giver- think what would happen to take anyone out of their usual routine and pop them in a hospital. Is she over/under weight? Mobility ok? Compliant with treatment? Sleeping ok? Fearful? I would suggest looking at the laundry list of nsg diagnoses in your book and see if any apply or she would "be at risk for" or Potential complication:

Hope that helps! :typing

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yes i did come up with a few but none seem to apply to her here is what i came up with: risk for other/self directed violence r/t impulsive behavior, i could say risk for imbalanced nutrition: less than body requirements but she isn't underweight and i observed her eating habits and she has a healthy appetite, risk for insominia, disturbed sensory perception overload r/t anxiety or anxiousness AEB pt mood/interaction with peers, Risk for anxiety r/t psychological conflicts, and risk for suicide r/t prior suicide attempts. i'm not sure if these pertain.

i did look in her charts and her mental status assessment was perfectly normal and if you speak to her she is perfectly normal that is my dilemma i don't know where to go. hope this helps.

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Specializes in ICU/Critical Care.
prettyparade_3 said:
yes I did come up with a few but none seem to apply to her here is what I came up with: risk for other/self directed violence r/t impulsive behavior, I could say risk for imbalanced nutrition: less than body requirements but she isn't underweight and I observed her eating habits and she has a healthy appetite, risk for insominia, disturbed sensory perception overload r/t anxiety or anxiousness AEB pt mood/interaction with peers, Risk for anxiety r/t psychological conflicts, and risk for suicide r/t prior suicide attempts. I'm not sure if these pertain.

I did look in her charts and her mental status assessment was perfectly normal and if you speak to her she is perfectly normal that is my dilemma I don't know where to go. hope this helps.

Well, Risk for self harm/injury related to impulsive behavior is a good start. I would include that on the care plan. Risk for insomnia is a good one too.

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there has to be some abnormal data, if she's in the hospital...

is she compliant w/her meds? (therapeutic regimen)

does she know all about bipolar? (knowledge deficit)

how is her self care at home? (self care deficit)

what do the md notes say?

nsg notes?

social worker's notes?

all i'm trying to say is i don't know why she'd be in a psych hospital if everything was so 'normal'?

leslie

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Specializes in ICU/Critical Care.

I agree with leslie. One of the other diagnosis you mentioned was Risk for imbalanced nutrition. Risk for ineffective coping. There has to be some knowledge or self care deficit.

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Specializes in LTC/Rehab, Med Surg, Home Care.

She's obviously on a unit somewhere, which implies a need...I'd look at coping, and knowledge deficit either about her medication compliance or about a lack of knowledge of the condition itself.

prettyparade_3 said:
yes I did come up with a few but none seem to apply to her here is what I came up with: risk for other/self directed violence r/t impulsive behavior, I could say risk for imbalanced nutrition: less than body requirements but she isn't underweight and I observed her eating habits and she has a healthy appetite, risk for insominia, disturbed sensory perception overload r/t anxiety or anxiousness AEB pt mood/interaction with peers, Risk for anxiety r/t psychological conflicts, and risk for suicide r/t prior suicide attempts. I'm not sure if these pertain.

I did look in her charts and her mental status assessment was perfectly normal and if you speak to her she is perfectly normal that is my dilemma I don't know where to go. hope this helps.

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well the precipitating events were that she found out her grandmother was dying and she overdose on her meds in a suicide attempt. thats why she was admitted to the hospital

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Specializes in ICU/Critical Care.
prettyparade_3 said:
well the precipitating events were that she found out her grandmother was dying and she overdose on her meds in a suicide attempt. thats why she was admitted to the hospital

GOT IT. Ineffective coping! That's one of five. Risk for self harm/injury r/t suicide attempt, thats 2. You need 3 more. Maybe risk for ineffective coping, yeah she's got it but still at risk for it.

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