nursing diagnosis trouble

[RNKel, ASN, RN]

I'm having trouble coming up with 2 nursing diagnoses for my patient. We must have at least 10 pieces of supporting data for each, and this is where I run into trouble. I know this comes from my assessment, but honestly there just wasn't much to work with. (at least to my eye, which happens to be so tired right now that perhaps I'm missing what is right in front of me) Background: pt was 11 days post-op; she had come to the ED with severe abd pain, N/V... found she had a femoral hernia and a small bowel obstruction, went to surgery and had the hernia repaired and a small bowel resection. I'm not sure exactly what happened that kept her in the hospital so long - except I read in her chart that she was on a vent for 4 days and she had HTN due to some meds given to her during SX, but that was corrected. She was completely off the vent but was on O2 2L nc. She has an NG tube, she's getting TPN, she had an IV of NS with 20 KCl, and she has a Foley. SCD's bilat. VS all WNL. BS was running high and she is on sliding scale insulin. She ambulated very well and a long distance w/ a walker. Had her up in chair all shift. She slept a lot. I see plenty of "risk for's", but there's no way I can come up with enough data to use those. And I can't see enough data to get 2 really good nursing diagnoses, either. I have Nanda book here, but again, none of her assessment info gives me enough to have 2 good ND. What am I missing? Can someone help give me a push in the right direction? Thanks so much.

[Daytonite, BSN, RN]

if you look at a nursing diagnosis reference book you will find defining characteristics listed for each nursing diagnosis. so, when you decide upon the two nursing diagnoses you want to use, and you have plenty of information there to choose two, simply look at a reference and see what else you might add. keep in mind that data can also be subjective as well as objective, so statements that have made by the patient count just as much as your objective ones. i, personally, for an assignment like this wouldn't be above making stuff up to meet the 10 data quota, but that's just me.

[RNKel, ASN, RN]

if you look at a nursing diagnosis reference book you will find defining characteristics listed for each nursing diagnosis. so, when you decide upon the two nursing diagnoses you want to use, and you have plenty of information there to choose two, simply look at a reference and see what else you might add. keep in mind that data can also be subjective as well as objective, so statements that have made by the patient count just as much as your objective ones. i, personally, for an assignment like this wouldn't be above making stuff up to meet the 10 data quota, but that's just me.

i jotted down several that i felt might work, then looked through my reference book and there was not one that had enough data to back me up, that's my whole problem. i never considered fudging it, lol, but i have no idea what else to do. lol i'll talk to my instructor today and see if she can at least point me in some direction. my patient made very few statements, in fact the only time she was awake was when i got her up to ambulate her (didn't say a word that whole time other than she was fine), and when i helped her bathe. and all she said then was how good it felt to have her back washed. the whole rest of the time she slept.

[carolinapooh, BSN, RN]

You need this book:

Ackley, B, and Ladwig, G. (2004). Nursing diagnosis handbook: a guide to planning care. Missouri: Mosby.

Get your hands on a copy - it is the ONLY book I ever used for care plan references and interventions/rationales. I got upper 90's on every single careplan. It doesn't do the work for you - it just lists every single NANDA dx and oodles of interventions with the rationales (many referenced with specific research). LOVED this book and couldn't have done a careplan without it.

You still have to read the interventions and pick the ones specific to your patient - but this book is PHENOMENAL and worth its weight in gold, IMHO.