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Discussion

nursing diagnosis

I need help with coming up with nursing diagnosis for the common diagnosis. Such as muscle spasms, UTI, diabetic, pylenephritis, CHF, hip fractures, the more common you see more often. I am having problems with coming up with nursing diagnosis. I need help, I just need some education. Please help me.:banghead:

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I recommend this book, it's the one that our school uses: http://www.amazon.com/Nursing-Diagnosis-Handbook-Evidence-Based-Planning/dp/0323048269/ref=sr_1_2?ie=UTF8&s=books&qid=1252085729&sr=8-2

and here is the NANDA site for a complete list of nursing diagnoses:

http://www.nanda.org/

I suggest talking to your instructor about how to come up with a nursing diagnosis--it's not hard, but it's not something you can really explain well in a forum post. It's better with case examples and a list of possible diagnoses in front of you, and someone saying, "Yes, but have you thought of this? And this?"

Two things.

Learn the disease process and expected problems.

Second, think about what you as the Nurse are going to do to prevent, correct, or otherwise intervene in that problem. Then I would figure out what the Dx would be.

For example, someone has Sx on their hip. Well we know they have Sx wounds so we will want to keep those clean and prevent infection. Dx right there. They will have pain so what will you do to ensure they have a tolerable level of pain? Dx right there. They will need help with their ADLs, Dx right there. They will need help to prevent skin breakdown, Dx right there.

I like to work backwards. Instead of looking at the Dx and trying to find out which ones fit I like to imagine the patient and think about what I am going to need to do for them and then find the Dx that fits my course of action. I know this violates ADPIE but it seems to work better for some.

A huge nursing diagnosis for these would be risk for infection especially diabetes.

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the most common question in relation to care planning that gets asked on this forum is how to determine nursing diagnoses and i address it all the time. i was just talking to a physician friend of mine about the process of diagnosing last evening because doctors do it all the time. before diagnosing a medical condition docs do a workup. in much the same way we nurse do as well, but our workup is different. we call it an assessment. it is step #1 of the nursing process and it can be elaborate or simple. i print this guideline of what needs to be done for assessment before making a nursing diagnosis all the time:

  • a health history (review of systems)
  • performing a physical exam
  • assessing adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

so, when you are asking what the nursing diagnoses are for medical conditions of muscle spasms, uti, diabetic, pyelonephritis, chf, and hip fractures, one of the first things you need to do is break these things down into their signs and symptoms and find out what their pathophysiology is. are they a complication of another medical problem and do they have complications themselves? that is the minimal work that you must do.

all nursing diagnoses are based upon evidence that exists. in a patient, we assess and look for the evidence (signs and symptoms) of these problems and then give a name to them when we spot a familiar grouping (nursing diagnosis). the best tool we have for diagnosing is the nursing process. i demonstrate how to use it over and over in posts all the time. see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. i use my copy of nanda international nursing diagnoses: definitions and classifications 2009-2011 which contains the taxonomy (definitions, related factors, defining characteristics) for all 206 diagnoses so much that it is falling apart. this taxonomy is also printed in the appendix of recent additions of taber's cyclopedic medical dictionary. also in the appendix of taber's you will find nursing diagnoses grouped by diseases/disorders which is a nursing diagnosis to medical disease crossover reference.

circejane. . .the nanda website does not provide a free list of the nursing diagnoses on their website. people must pay for the list. it is proprietary and wholly owned by nanda. here is the 2007-2008 list, but there have been more diagnoses added since and the 2009-2011 list must be purchased from nanda:

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