nursing diagnosis

nurseprnRN, BSN, RN · Nov 12, 2011

oh, yes, she has ineffective tissue perfusion. she will end up having that hip disartic and then get worse, poor thing.

i'll bet she's also a bad diabetic, which is why she has had serial amputations for ischemia. if she isn't, why did she have the first amputation? but i'll bet she is.

look up dm, ischemia, and peripheral arterial disease, and see if that gets you some ideas. let us know what you find!

Always_Learning, BSN, RN · Nov 12, 2011

I have to break down all that "r/t" and "AEB" and put it in my own words. First things first: you have to pick a nursing diagnosis. So here's the process in my own words:

1) Nursing diagnosis ("What are my patient's issues? What complications could she have?") This is all very individualized; is she having pain? (Nursing diagnosis would be "Acute pain.")

2) R/T or "related to" ("What makes me think that this nursing diagnosis applies?") Well, if she is having pain, it's due to her surgery, right? So..."Acute pain r/t surgical procedure?" Yes. But you may have to be a little careful here...some instructors like you to stick to the "related to" options presented by NANDA. So review your care plan book, if they have provided you one, and make sure your "related to" applies to your patient.

3) AEB or "as evidenced by" ("What evidence do I have that the patient really has this problem?") Well, is she writhing around, guarding the incision area? Is her heart rate up? Is she crying? Perhaps she is stoic but rating her pain 9/10...again, this is all very individual. Let's say your patient is tearful and holding the incisional area. Now we have "Acute pain r/t surgical procedure AEB tearfulness and guarding of incisional area."

At this point, you can work on interventions...what do you, as a good nurse, want to do to help the patient with this particular problem. You say you will assess her pain? Good, but not specific enough. We need something measurable. "Assess pain hourly using the 0-10 pain scale?" Better.

You will give pain meds? Awesome, but again, not specific. What will you be giving? How often? How will you know if it works? That's the thought process.

Evaluation of outcome should also be very specific. Don't just say "Pain will be better." Find out from the patient what an acceptable pain rating is for them, and make that your goal.

NANDA diagnoses provide the framework, but you have to individualize them to your patient. Nothing irks instructors more than getting generic care plans. If your patient is jolly and joking, then an "anxiety" care plan isn't helping anyone.

Whew. That was long....hope this helped a little as far as how to break down the pieces of the nursing diagnosis.

yooperPN · Nov 12, 2011

Disturbed Body Image, Impaired Mobility....

possible activity intolerance.

All r/t Amputation.

gfoster6993 · Nov 12, 2011

No, this patient was not a diabetic, she told me that she kept having blood clots really, really bad so that was the reason for the amputation to begin with. Once the doctors did the first amputation, her tissues would not heal.

nurseprnRN, BSN, RN · Nov 13, 2011

aha, a zebra! (this is a reference to the classic "house of god," in which it is noted that upon hearing hoof beats outside the window, the medical student thinks of a zebra. the lesson is that you always think of the more common diagnosis first, and if that doesn't pan out, only then do you go for the less likely one.)

so, this lady has some sort of hypercoagulable state? or does she have something like atrial fibrillation, aortic or ventricular aneurysm where she's growing clot? or did she have some other sort of vascular injury? what is it? what other effects would that have?

whatever, she's at possible risk for more such incidents in other areas (depending on the cause); what happens when you get clots in your arteries?

Esme12, ASN, BSN, RN · Nov 13, 2011

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

how does a doctor diagnose? he/she does (hopefully) a thorough medical history and physical examination first. surprise! we do that too! it's part of step #1 of the nursing process. only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. each medical diagnosis has a defined list of symptoms that the patient's illness must match. another surprise! we do that too! we call it "critical thinking and it's part of step #2 of the nursing process. the nanda taxonomy lists the symptoms that go with each nursing diagnosis.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

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)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

some example care plans to help....

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

i would also check the patients chart and not go by what they say for the patients diagnosis and not by what they say......patients don't always understand or hear what they md is saying. you're looking at what any post op would face.

http://www.snjourney.com/clinicalinfo/careplans/careplann.htm