Nursing Diagnosis

londonflo · May 2, 2021

First you need to gather more information..how often is the patient awakened for : breathing treatments, RT just checking equipment, bathroom, lights in in station, feelings of SOB or low O2 high co2, dry mouth, plain bed discomfort, medications, frequent vital signs, EKG and pulse ox cords....You need to gather much more information to justify a diagnosis than hallucination etc. Remember, the etiologies will give you direction for interventions. Think about what makes it makes it hard for you to sleep...anxiety (low O2) worry etc. That is what is effecting this patient.

On 5/1/2021 at 3:22 AM, FaithVA said:

. I thought acute confusion would be a good starting point but having challenges with making my goals measurable.

You are having problems because you are trying to say her confusion is not letting the patient sleep. Take a paper and pencil and write down all that happens on the shift..including more than what you do. Then you can develop interventions that are realisitic and make you goal obtainable and measureable..

Hannahbanana, BSN, MSN · May 5, 2021

You are having a hard time in part because you haven’t learned about making a nursing diagnosis. You wouldn’t think much of a doc who, entering the exam room and seeing you for the first time, said, “You’re anemic. Let’s get you a transfusion, then we’ll draw some labs, and then I’ll do a physical exam and take a history.” Exactly backwards, right? Diagnosis first, then data collection? Nonsensical, huh?

So with nursing diagnosis, and for the exact same reason. You don’t know what you’re looking at, not thinking about your observations as data to help you make a nursing diagnosis. You can’t be expected to pull one out of the air, and you certainly can’t just pull one off a list because you think it sounds like it might work. The fact that you don’t have a clear plan of action demonstrates that, because if you knew why the patient has a diagnosis, you’d know what nursing treatment plan to apply.

In the medical example above, does this pt have anemia because she’s having blood loss? Is that acute or chronic? Bone marrow problem? Renal failure and lack of erythropoeitin? Anemia of chronic illness, like cancer? B12 deficiency? Poisoning? Malnutrition? The doc has to know why before developing a treatment plan to address it.

So your first step is data collection- the symptoms, situations, and behaviors you observe and glean from chart review. Then you need to know what those mean. Just as a low hematocrit is the definition of anemia, there are lots of ways to become anemic, and so your treatment must be aimed at the cause for THIS one.

How do you know? You go to the one, the only source for making (not choosing) a nursing diagnosis, the current NANDA-I (2021-2023). Then you thumb through it and identify some possible diagnostic choices, looking carefully at the defining factors and the causes for each. When you find that combination that matches your patient and your data findings, congratulations! You made a nursing diagnosis! AND because you know why it happened, you can make a plan to treat it with nursing (not medical) interventions aimed at the causative factors you identified. And bonus: when you see this combination of symptoms again, you’ll think about whether that means ... (nursing diagnosis).

See, nursing diagnosis isn’t subservient to medical diagnosis. It’s often hard for students to get the concept of thinking like a nurse because so many (like, all) “nursing diagnosis handbooks” are indexed by medical diagnosis. This cheats students out of their biggest tool: the mindset of doing a nursing assessment independently... which is why you are in nursing school, to learn to think like a nurse.

Do think about this and come back c questions when you think you’re on the right path.