Nursing Diagnosis

prettyparade_3 · Jul 15, 2008

thank you if anyone else can contribute to this it would be greatly appreciated

Daytonite, BSN, RN · Jul 15, 2008

Hi! I looked at everything you posted. We do have information on how to write care plans on this sticky thread in the general nursing student discussion forum:

Some of what I'm going to tell you is posted there.

A care plan book is great--if it has a care plan for someone who attempted suicide. If it doesn't, you really need to know how to use the nursing process to help you out here. The steps of the nursing process as they pertain to care planning are as follows:

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

You have to follow these steps in the sequence they occur and do the work that is required within each step. You can't even get into choosing your 5 nursing diagnoses until you go through and organize your assessment data.

Assessment (step #1) 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.

Much of this you would have done on site at the facility where you observed this patient. However, the last bullet suggests that you hit the books to look up information about this patient's diagnosed conditions. One of them is a suicide attempt. The other is a bipolar disorder with depression. There are signs and symptoms of bipolar disorder, depression and suicidal tendencies that you need to look up and list. You need to double-check you own observations to see if you missed any of these signs or symptoms in this patient. What else was is her chart? Just because she exhibited no manic symptoms when you saw her doesn't mean she doesn't get them. You are perfectly allowed to use the objective data collected by another healthcare provider, particularly a doctor, and especially if it is documented in the patient's record. That is all valid assessment data that you can use in determining what this patient's nursing problems are. It is unreasonable to believe that your plan of care for the caregivers under your supervision has to be based solely upon only what you observed.

You mentioned that this patient "Seemed perfectly fine" when you observed her. That may be true, but she would not be an inpatient if there were not a reason for 24-hour observation.

Step #2 of the nursing process here has you making a list of all the patient's abnormal assessment data. This is important because all diagnoses are based upon abnormal signs and symptoms. Because you could not specify what these are is why you are having trouble coming up with nursing diagnoses. Every nursing diagnosis has a set of defining characteristics, nanda's term for "Signs and symptoms". You have to have them to prove that the nursing problem exists to begin with. The nursing diagnosis is merely a shorthand label that is a tag for the nursing problem.

The precipitating event--the suicide attempt--pretty much puts this patient at a risk for suicide. It's true that one of the risk factors that nanda lists for this diagnosis is previous suicide attempts, but I'm interested in also knowing what medications she used and if there was any preplanning and saving up of these medications at all which would indicate that there is more going on here than the grandmother's death. And what were these drugs, anyway? I thought it interesting that you didn't include grief over the death of the grandmother as a risk factor for this diagnosis either although it is perfectly legitimate to use with this diagnosis whose definition is "At risk for self-inflicted, life-threatening injury" (pages 213-4, nanda-I nursing diagnoses: definitions & classification 2007-2008). She probably needs assessment for grief. You mentioned that this patient had impulsive behavior when you described the cause of her being at risk for violence. So, is this an assessment item that you picked up from the chart? It is also a risk factor for suicide. I would diagnose this as risk for suicide r/t grief over the death of grandmother, impulsiveness, and history of prior suicide attempt.

You mentioned some very interesting things in the diagnostic statement: disturbed sensory perception overload r/t anxiety or anxiousness aeb patient mood/interaction with peers.

This is no such nursing diagnosis that I know of unless this is something that your instructors have given you to use. if that is the case, what are the signs and symptoms? the related factors?
Anxiety is a nursing diagnosis all on its own with a whole set of related factors (causes) and defining characteristics (signs and symptoms)
"Psychological conflicts" cannot be a related factor of this nursing diagnosis. it sounds very much like a medical diagnosis to me. however, "situational crisis" (the death of her grandmother) would certainly be a valid related factor. see the long list of defining characteristics that go with the diagnosis of anxiety.
The related factors of disturbed sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) cannot be another nursing diagnosis or medical disease.
The definition of this diagnosis is "change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli" (page 195, nanda-I nursing diagnoses: definitions & classification 2007-2008). so entitling this as an "overload" is incorrect.
"Patient mood with peers" and "patient interaction with peers" would be your evidence to support this sensory perception overload. what exactly was the patient's mood that proved she was in a perceptual overload? what exactly were the specific interactions she had that proved she was in a perceptual overload? you have to provide specific examples or I think your instructor is going to ding you. not only that, but your goals and nursing interventions are aimed at and based upon that evidence.

Before using risk for self-directed violence r/t impulsive behavior or risk for other-directed violence r/t impulsive behavior you need good cause. What makes you think this patient might harm another person? Nothing in your post indicated that she was like that. has she made any statements since admission that she would try to kill herself again if the opportunity presented itself?

This is the encyclopedia article on bipolar disorder on medline plus: https://medlineplus.gov/ency/article/000926.htm. It lists these symptoms during the depressive phase of the disorder:

Persistent sadness fatigue or listlessness sleep disturbances excessive sleepiness inability to sleep eating disturbances () loss of appetite and weight loss overeating and weight gain loss of self-esteem (situational low self-esteem) feelings of worthlessness, hopelessness and/or guilt (hopelessness) difficulty concentrating, remembering, or making decisions (disturbed thought processes) withdrawal from friends (social isolation, or risk for loneliness) withdrawal from activities that were once enjoyed persistent thoughts of death (risk for suicide)

You can always turn any nursing diagnosis into a "Risk for" or potential problem if it is not a real problem. I am referring to the fact that the patient is not manic at this time or having sleep or eating problems. Look up suicide and why people do it. Not all bipolar patients attempt suicide so it is not a symptom of the bipolar disorder. Something else is wrong in this person's life.