nursing diagnoses

  1. hi am new to this site am i am a first year nursing student and i am having difficultuty with this scenario.

    Mr. T.H is 68 years of age and was admitted to a geriatric care facility two days ago and complains of feeling weak, difficulty swallowing and feeding self. He has severe right sided weakness from a stroke (Cerebral Vascular Accident - CVA), and cannot mobilize independently. He is disoriented and attempts to get out of bed. He has a reddened area at the sacrum and his right elbow and has had no bowel actions since entering the facility.

    Can someone please help me with two actual diagnoses and one risk diagnoses and also the nursing care plan and two priority needs. thanks can a get some assist tonite plz
    Last edit by gette on Mar 17, '12
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    About gette

    Joined: Mar '12; Posts: 2


  3. by   Esme12
    Quote from gette
    hi am new to this site am i am a first year nursing student and i am having difficulty with this scenario.

    mr. t.h is 68 years of age and was admitted to a geriatric care facility two days ago and complains of feeling weak, difficulty swallowing and feeding self. he has severe right sided weakness from a stroke (cerebral vascular accident - cva), and cannot mobilize independently. he is disoriented and attempts to get out of bed. he has a reddened area at the sacrum and his right elbow and has had no bowel actions since entering the facility.

    can someone please help me with two actual diagnoses and one risk diagnoses and also the nursing care plan and two priority needs. thanks can a get some assist tonite plz
    we will help you but we won't give you "two actual diagnosis, one risk diagnosis and also the care plan and two priority needs".

    what information can you get from this information as i think this is a book scenario and not an actual patient assessment. if someone is weak are they at risk for injury? if they are confused and weak does that make it worse? how would they be injured? nursing care is like being a are given clues and you need to use your knowledge and skill to get to the bottom of the mystery to help the patient and ward off any trouble.

    if they can't swallow properly what can happen to them as a consequence of not getting enough food or asparating it into their lungs....what risk does that pose to them, nutritionally and infection wise?

    if they can't get around or "mobilize independently" what risk does that expose them to....can they wash themselves? dress themselves? do they have a deficit in their daily activities? what effect does the cva have on the affected side? what risk is there to that extremity? know your disease process and pathophysiology.

    is his skin at risk from being unable to reposition himself or by injuring himself trying to get around without help.......does this show in his already has a reddened bottom and elbow?

    has his lack of proper nutrition affected his bodily functions? or could it be his immobility from the cva that has altered his bowel function.

    what do you have so far? you need a care plan book as you will be using it all through school.

    first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. there are many threads about this and a great nurse and an contributor daytonite (rip) is one of the greats. i use her information and advice all the time.

    since i sense you are already concerned about this care plan writing business, i would urge you to read about the nursing process. a care plan follows the 5 steps of the nursing process. if you have a care plan book, or you can often find one or two in a library, you want to pay particular attention to the beginning chapter(s) which usually have a discussion about the nursing process. they are often only a few pages long. however, this is important information that pretty much sums up what you are supposed to know and understand at the end of your nursing course. care mapping is nothing more than a different physical format of presenting a care plan. the underlying concept of the nursing process, however, is still very much at the very heart of each and every care map. so, you have got to know what it is and what is involved in every step.

    all nurses has two "sticky" threads in two different nursing student forums on care plans where you can also find information. there isn't a lot of information on care maps there, but my experience has been that students who are taught how to care map have a much better understanding of the nursing process and how all the pieces of assessment, outcomes and interventions all fit together. also, there are two links you can access that are attached to the bottom of every one of my posts. they are forms that all members of all nurses are free to download, print and use if you think they will be a help to you as you are learning to assess patients and write care plans.

    for help with writing care plans see:
    "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.

    here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:
    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) "
    Questions about writing good care plans.

    i hope this you have any questions?
    Last edit by Esme12 on Mar 19, '12
  4. by   nurseprnRN
    please, all students, realize that nursing diagnoses do not come from medical diagnoses, with the implication that nursing diagnoses are somehow derivative, secondary, or subordinate. nothing could be farther from the truth.

    medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

    nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.
    medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

    in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

    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.

    many nursing students think there is a big list somewhere where column a is the medical diagnosis and column b is the nursing diagnosis. this is wrong-headed for several reasons. one is that nursing diagnoses are made by nurses using the nursing process (which i know you don't have a good handle on yet but we're trying to help), not dependent on a medical diagnostic process. nursing diagnosis is in no way subservient to or inferior to medical diagnosis.

    i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.
  5. by   Qtip
    You have a lot info to work off of, 3 dx should not be a problem what do you have so far?
  6. by   chihuahuaman
    I agree with Esme12; Get a care plan book. Once I got one of those, doing my care plans became so much easier. The book I bought was Nursing Diagnosis Handbook by Ackley and Ladwig. It had all the NANDA classifications and plentiful interventions with rationales. It was really easy to use. I had the sixth ed. I'm sure there are newer out there.

  7. by   gette

    the diagnoses i have come up with are: injury risk for perpiopertative positioning in relation to reddened area at the sacrum and right elbow.
    the second one is: less than body requirement in balanced related to inflammation as evidence by patient inability to feed him self and difficulty swallowing.
    The risk diagnoses is risk for mobility impaired bed related to patient weakness from stroke and cannot mobilize independently
    Last edit by sirI on Mar 18, '12
  8. by   nurseprnRN
    "perioperative positioning" refers to the period when the patient is on the or table and immediately thereafter, and if he already has reddened area it's not a risk for, it's an actual. what you have said is, "he might develop an injury due to the way he was positioned in the or, and i know this because he has reddened areas over bony prominences on the sacrum and r elbow. " is that really what you meant, and concluded from your data? if not, let's think of a better way to say it. try this format to help you organize your thoughts:
    my nursing diagnosis is ......... . my patient has that because he has ..... . i know this is true because i can see this, this, and this when i examine him/read it in the chart/etc.

    i'm guessing you meant the second one to be related to nutrition; i'm not sure what you're saying when you say that he can't feed himself or swallow because of inflammation. could you clarify that?

    you're closest with the third: if he is already impaired for bed mobility, there is no "risk for," it's already happening. impaired mobility related to cva, as evidenced by (what? paralysis? weakness? specify.)

    "i know my patient has impaired mobility caused by his cva. i know this because he is paralyzed on the right side and cannot move in bed without assistance."

    see how that works?
  9. by   NightNurseRN13
    one thing that screams at me from this scenario is "
    [color=#333333]he is disoriented and attempts to get out of bed " along with everything else... safety! safety! safety!

    he has muscle weakness due to the cva, disoriented x ?, he attempts to wander?

    actuals: impaired skin integrity, self-care deficit, constipation (maybe depending on baseline), acute confusion

    risks: infection, falls, injury, aspiration, etc.
  10. by   nurseprnRN
    gold star to osteward for a good list.