nursing diagnosis

CT Pixie, BSN, RN · Dec 11, 2012

Did you do a system assessment on her? What else did you assess on her? How is she communicating? Pain? What do her labs look like? Prognosis? How are her I&O's? Any cough (productive?), thick secretions? What does she know about how to care for the trach when she is home? Any nausea or vomiting, what is her bowel regimine? Need a little more info other than ca dx w/trach.

Off the top of my head w/the limited info, I can come up with several priority nursing diagnosis regarding airway, firstly being the trach and its complications (aspiration, airway clearance etc). There are several possible dx's for this lady depending on what the asessment showed.

You have to get your nursing dx from how the pt is presenting not build it around her diagnosis.

Esme12, ASN, BSN, RN · Dec 11, 2012

Welcome to AN! The largest online nursing community!

We love to help with homework.....but need your thoughts first. What I see here are medical diagnosis.....What is the PATIENT ASSESSMENT. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? Again........TELL ME ABOUT YOUR PATIENT...:).

What care plan book do you use?

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis. Right.......?...ADPIE......

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, 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)

So what would a young patient with laryngeal cancer have to be concerned about after a disfiguring surgery? How will this affect his life? How would it affect you....how would you feel? What complications could arise with tube feedings and a trache? what does hte patient complain about? what about their job and family?

What do you think and we'll go from there....

hello111 · Dec 12, 2012

the patient is doing fine, she is breathing from room air(no O2 therapy), blood results are normal, the cough is non productive, no pain. she understands anything you ask, but she can't talk of course, so she writes on a white board, or on her phone and shows it to us what she needs.

Ashen · Dec 12, 2012

Nurses don't diagnose. Tell ur instructor that lol.

Try assessing his emotional status and impact on the family. Hope this helps

Esme12, ASN, BSN, RN · Dec 12, 2012

Then......what does she ask for? Again.....what does she need? does she need teaching about the trach and how to take care for it at home?(Deficient Knowledge (specify)) What would a patient with a radical Neck need? What would they be as risk for? Qualify fine.....did you talk with her? Ask her anything? How would you be if this were you....what would you be feeling? would you be afraid? would you be upset? How would you view yourself in mirror? One week after a radical neck? Do they have any pain? Any trouble sleeping? How is their family coping? Did you ask?

my patient who is 36 years old was diagnosed with laryngeal cancer, and had a left neck dissection a week ago. He has a tracheostomy, and is getting fed by a NG tube
His vital signs are WNL, is voiding freely, but need some assistance with his ADLs

the patient is doing fine, she is breathing from room air(no O2 therapy), blood results are normal, the cough is non productive, no pain. she understands anything you ask, but she can't talk of course, so she writes on a white board, or on her phone and shows it to us what she needs.

What does she ask for????

Here is a list of things this patent may have or is at risk for without ever looking at the patient.

Anxiety

Risk for Aspiration

Impaired Comfort

Impaired verbal Communication

Disturbed Body image

Risk for compromised Human Dignity

Disturbed Energy field

Fear

Grieving

Imbalanced Nutrition: less than body requirements

Acute Pain

Bathing Self-Care deficit

Risk for Falls

Risk for Infection

nurseprnRN, BSN, RN · Dec 12, 2012

Nurses don't diagnose. Tell ur instructor that lol.
Try assessing his emotional status and impact on the family. Hope this helps

Wrong wrong, wrong-o. Nurses absolutely do diagnose. We investigate and assess for the signs that lead us to our nursing diagnoses, the same way that physicians investigate and assess for the signs that them them to medical diagnoses. Tell your instructor that nurses don't diagnose and you are in for a world of hurt.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.

Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

TheSquire, DNP, APRN, NP · Dec 13, 2012

Disturbed Energy Field is always a good one to round out a list of Nursing Dxs when you need just one more to meet your requirements...but use it wisely, 'cos you're only going to get away with it once a class.

psu_213, BSN, RN · Dec 13, 2012

Wrong wrong, wrong-o. Nurses absolutely do diagnose. We investigate and assess for the signs that lead us to our nursing diagnoses, the same way that physicians investigate and assess for the signs that them them to medical diagnoses. Tell your instructor that nurses don't diagnose and you are in for a world of hurt.

You beat me to it! I almost aspirated my soda when I read the whole "tell you instructor that nurses don't diagnose" bit.

NTessier13 · Dec 15, 2012

WOW!!!!! Nurses don't diagnose??? There goes ADPIE .... look in NANDA for NDx that would fit. Off the top of my head first thought would be integument impairment. But I just finished my Fundamental clinicals in a Rehab hospital with an advanced wound care clinic, so that's fresh in my mind. She's vented and on GT so Henderson and Maslow's 1st few basic needs are met.

stefanyjoy · Dec 15, 2012

I'd probably go with a risk dx here since it looks like he's well underway with his care. Risk for Ineffective Airway Clearance would be my best guess, unless you're allowed to make a dx from the initial admission then it would be Ineffective Airway Clearance. Remember your ABC's...

blueyesue · Dec 16, 2012

If he is stable, impaired verbal communication is a safe bet. :)