Quote from mlauren
Thanks! I have a nurse's pocket guide. I definitely looked at all my data before just choosing diagnosis. When I assessed this patient she didn't seem to be in pain, but wasn't able to respond too much
. When I asked her if she was in pain when I palpated and at other times she said no, but then she would say yes when I asked her again. But by judging her facial expressions and body movements/posture, she didn't act like she was in pain. She did sleep all day though and her daughter said that she is normally more alert at home.
Her daughter also told me that she brought her to the hospital, because she hadn't been eating, felt warm, and said that her back hurt
after falling. Her CTs confirmed no fractures. Anyways, during my assessments her respirations were in the normal range, regular, not labored, and her O2 sat was above 94% every time. She would cough (weak) every hour or so, nonproductive. And also I heard crackles and wheezing when I auscultated. As far as the UTI symptoms, her urine was clear yellow and I didn't see anything abnormal.
She had been on antibiotics for 2 days when I was caring for her. I don't know what the new labs were as I wasn't there when they were verified.
There's much more, but some of my info was on the sbar papers that I had to shred I forgot to copy it down.
I think after looking at this some more that #1 should be the ineffective airway clearance and I thought that from the beginning. But I get myself confused about it when I start thinking that if I implemented interventions for the pain I could decrease the amount of time she is immobile, which is contributing to the ineffective airway clearance. I know what is most important when it comes down to what to treat first, but if the pain isn't fixed then the other diagnosis will get worse.
Am I making any sense here? This whole process is way harder than I expected it to be and especially since I am kind of an "overthinker" when it comes to...well everything. I just want to be good at this and not feel like I'm constantly struggling.
My patient this week was admitted with back pain
from a recent fall
, two old fractures, no new. She also had a mild temp
, O2 sat 88%
, and urinary retention/obstruction
when she arrived. (confirmed UTI
) They inserted a foley, ordered antibiotics, and O2. The patient had Alzheimer's, osteoporosis, arthritis, and hypertension. After a day at the hospital the patient's cough worsened and crackles/wheezes
were heard on auscultation
I have highlighted what I see as important information. Are you sure the back pain is from the fall? Can a "kidney infection" (pyelonephritis) cause back pain? Can fever cause lethargy in the elderly....especially the elderly with Alzheimer's? What meds is she on? What were her labs? Unfortunately, the information on your SBAR sheet is probably important.
It is necessary to have a good care plan book. I use Aclkey. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
What care plan book do you have?
Care plans are all about the assessment.....of the patient. The is not enough information here for us to help. Tell me about your patient, What is your assessment? What do they NEED? What is their main complaint? What are their co-morbidities? How old is this patient? What is their base line? What meds are they on?
YOU MUST have a good care plan book with the NANDA diagnosis and it defining characteristics.
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.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
Care plan reality:
- 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)
The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
THese sheet may help you out.....daytonite made them (rip)
critical thinking flow sheet for nursing students
student clinical report sheet for one patient
A nursing diagnosis standing by itself means nothing.
The meat of this care
plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.
What I would suggest you do is to work the nursing process from step #1
. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2
of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
Care plan reality:
What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.