Nursing Dx Help

[erint91DC]

Hello,

I'm a first semester student and I'm wondering if my NDx are correct. Sorry for the wall of text that follows!

I recently had an older adult (>80 y/o) as a patient who was being discharged. They were in rehab after sustaining right hip and wrist fractures due to a fall. I've had a hard time coming up with nursing dx for them because they seemed very healthy.

Right hip DHS (dynamic hip screw)

Right forearm cast

Concurrent health challenges: non-insulin dependent diabetes mellitus, hypertension, hypothyroidism, hepatitis C, and afib.

Used a 2 w/w with gutter.

Relatively mobile, ADL's without assistance

Daily meds include:

• Acetaminophen
  
• Amlodipine 10 mg PO
  
• Calcium carbonate
  
• Hydromorphone SR 3 mg PO TID
  
• Lactulose
  
• Metformin
  
• Levothyroxine
  
• Ramipril 10 mg PO
  
• Sennosides 24 mg PO
  
• Sotalol 80 mg PO BID
  
• Ursodiol 500 mg PO BID
  

PRNs administered while I was there: hydromorphone 1 mg

Strong social support network, daughter is an RN

Very positive, previously very active (walking) before their fall, pt stated they "cannot wait to cook proper food at home" (not overweight)

I've come up with three NDx, but I'm unsure.

1. Risk for falls related to impaired physical mobility, history of falls, use of mobility device (2w/w), and use of medications associated with falls.

Since they are >65 years old, would I include this? Do I have to put AEB for this dx? I am going to list the meds in the data/cues section.

Would it be "Risk for falls as evidenced by impaired physical mobility, use of mobility device and use of medications associated with falls; related to history of falls, right hip and wrist fractures, hypertension*, and pain."?

**Unsure of including hypertension as a R/T but they are receiving antihypertensives?

2. Impaired physical mobility related to pain and discomfort and restrictive therapy (cast) as evidenced by limited ROM, pain rating of 8/10, and decreased muscle strength.

3. Readiness for enhanced self-health management as evidenced by desire to improve, effective coping skills, and no acceleration of illness symptoms.

Do these seem correct? I'm more concerned about the Falls dx.

I used Doenges Nurse's Pocket Guide for Diagnoses, Prioritized Interventions, and Rationales + NANDA's Nursing Diagnoses: Definitions and Classification 2012-14 for this.

[akulahawkRN, ADN, RN, EMT-P]

Remember that "Risk for..." NDx is not an actual problem, rather an anticipated/potential problem, and therefore does not have any AEB because if there are any AEB's, you've got an actual problem. Since you're thinking about an AEB for "Risk for Falls" you might want to look at that information and see if there's something else that is an actual problem that may put him at risk for falls. Don't try to squeeze a patient into a NDx, let the data show you which ones fit the patient.

There could be problems with strength/conditioning, Range of Motion, pain, actual mobility problems compared to pre-fall/hospitalization, and so on. Remember that he fell and was injured before hospitalization and now he's post surgery and probably less strong and mobile than he was before the fall.

You're probably on the right track, but keep looking, I'm sure you'll be able to find something that matches the actual problems the patient has that need to be addressed.

[Esme12, ASN, BSN, RN]

Welcome!

Your nursing diagnosis is all about the patient and what they NEED. What semester are you?

Care plans are all about the patient and the patients problems. 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? TELL ME ABOUT YOUR PATIENT...:)

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.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

1. 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)
   
2. 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)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

Tell me your assessment...What does this patient need? Tell me about your patient

[nurseprnRN, BSN, RN]

1) A single person is never a "they" or "them." In this case, this patient is "she" or "her." Whenever I see a plural I look around and think to myself, "Who are those other people and what are they doing in here?"

You would say, "Risk for falls: (list the risk factors this patient has)." That's all. There is no "related to" or "as evidenced by" in a risk diagnosis.Don't forget to say, for example, what those meds associated c increased risk of falls are. When you do list all the risk factors, you'll find it easier to develop a plan of care that addresses decreasing risk from all of them.

Otherwise, I think those three sounds reasonable based on what you describe about her and her support system.

Now, see if you can move beyond those and look at some others in the family relationships, self-health management, and coping domains. Look for some of those "...and that can be strengthened" ones, because she is going home and will need help there, but as far as you can tell is on the right track.

[Esme12, ASN, BSN, RN]

GrnTea ‼ 1) A single person is never a "they" or "them." In this case, this patient is "she" or "her." Whenever I see a plural I look around and think to myself, "Who are those other people and what are they doing in here?"

I am just too lazy. I get really annoyed when I write he and someone inevitably corrects me and says she or they will come back with some smart response about beiung a nurse and not being able to identify gender....grrrrrrr....it's like nails on a chalkboard.....I am too lazy to type he/she in every post so I say they, them. It may not be grammatically correct but it saves me frustration.....LOL

[nurseprnRN, BSN, RN]

I am just too lazy. I get really annoyed when I write he and someone inevitably corrects me and says she or they will come back with some smart response about beiung a nurse and not being able to identify gender....grrrrrrr....it's like nails on a chalkboard.....I am too lazy to type he/she in every post so I say they, them. It may not be grammatically correct but it saves me frustration.....LOL

.... and increaseth the frustration of thy readers. If this patient has a preferred gender, use it. If you insist on using "them," then make your verbs plural as well. Easy-peasy.

Why would you not? Did somebody tell you it would be a HIPAA violation or something? I commend your attention to the very definite list of what is and what is not included in PHI, and remind your classmates that exchanging information in an academic setting for purposes of education is not a HIPAA violation as long as no unrelated private information is spread around. Giving your patient's age and gender in this context is not a violation.

[Esme12, ASN, BSN, RN]

.... and increaseth the frustration of thy readers. If this patient has a preferred gender, use it. If you insist on using "them," then make your verbs plural as well. Easy-peasy.

You want me to engage my brain???? Typing he/she will be easier....LOL