Nursing Diagnosis

there is a systematic way nursing diagnoses are determined. we use the nursing process to help us do that. nanda, the north american nursing diagnosis association, has put together the nursing diagnosis taxonomy which currently consists of 188 nursing diagnoses. for each there is a definition, related factors and a set of defining characteristics (symptoms) if it is an actual problem. just as doctors examine a patient and analyze the data before making a medical diagnosis, we do something very similar utilizing the steps of the nursing process in the sequence as they occur. you need to look up the signs and symptoms of anencephaly, microcephaly, encephalocele, meningitis, pvl and apnea. then, use those signs and symptoms to determine the appropriate nursing diagnoses that would apply since they are the evidence that will support the nursing problems (nursing diagnoses). there is information on how to write care plans on the student forums: https://allnurses.com/forums/f50/help-care-plans-286986.html. i will help you determine nursing diagnoses, but only if you post the abnormal assessment data.

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)
   • 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.
     
   • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

[*]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)

• it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  
• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)