Nursing Diagnosis

Updated:   Published

This will probably be a crazy question, because I am assuming we are actually meant to be taught these things. I am in my first semester just finished fundamentals and starting med surg, We did not go over care plans at all! Every now and then instructor would bring up a nursing diagnosis, I kept waiting for that "unit". I bought care plans made incredibly easy and read this book prior to starting class so I have a rough idea. Well now we are expected to write a care plan on a patient and I feel clueless I don't think I have the time to start from the beginning and learn all of this stuff in between whatever else we are doing. I got my care plan book out but I feel very lost.

Anyway my question is a simple one, am I writing this diagnosis right?

My patient is day one post op, she is doing very well but experiencing pain so I figure my first priority dx should be acute pain. I wrote it like this please let me know if I am doing it wrong and how I can fix it.

My outline says I have to have 3 dx 2 actual one risk this is one of my actuals, and it says we need all 3 parts, problem statement, etiology (r/t) and signs and symptoms.

dx 1:

Nursing diagnosis number one. Acute pain r/t tissue trauma associated with surgery, evidenced by a patient rating of 7 on a 0-10 pain scale.

I think my next dx will be Impaired physical mobility r/t pain and muscle atrophy

1
Up Vote Up Vote ×

I am also in a simillar situation with you. I think I have nursing Diagnoses down, now I don't know interventions. I am almost positive that your dx are great though.

1
Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

Am I writing this diagnosis right? acute pain r/t tissue trauma associated with surgery, evidenced by a patient rating of 7 on a 0-10 pain scale.

Yes, this is written correctly. however, unless your instructors want acute pain of a surgery sequenced as a priority, see page 83 in your book, nursing care planning made incredibly easy. pain, to my way of thinking, is a comfort issue and is in last place on the list of physiologic needs.

Dear heart, if this patient had surgery, does she have an incision somewhere? if so, then she has impaired tissue integrity.

You have a very good care plan book. take a few moments to look at the table of contents page. part i is organized by, surprise! the steps of the nursing process:

  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)

When I answer care plan questions here on allnurses that is the sequence i keep telling students to follow. Those who are having problems are not following this sequence of activity. I can tell in seconds from just reading what they post. The biggest problem students have is assessment. The reason for this is just because you are all inexperienced at it. Some abnormal data could be waving and yelling out at you and you will still miss it because it just doesn't seem abnormal at first. This is why you also have to read about the signs and symptoms of the diseases and conditions that patients have in order to help you learn this information. And, as time goes on and with clinical experience you will also pick up on more about assessment.

The other area of problems is nursing diagnosis. Many students skip through assessment and go right to diagnosis without realizing the role assessment data plays in determining nursing diagnoses, goals and nursing interventions. Probably 90% of the questions on the forums asks what nursing diagnosis to use for a patient with some medical disease. It doesn't work that way. A medical diagnosis is different from a nursing diagnosis.

If you are going to use impaired physical mobility r/t pain and muscle atrophy then you must have the defining characteristics (patient symptoms) which you found during your assessment as the items following the aeb part of the diagnostic statement as evidence supporting the existence of this problem.

My outline says I have to have 3 dx 2 actual one risk this is one of my actuals, and it says we need all 3 parts, problem statement, etiology (r/t) and signs and symptoms.

See page 63 in the book, Nursing Care Planning Made incredibly Easy, which explains what these three parts are. the very first pages of nursing diagnosis handbook: a guide to planning care by Betty J. Ackley and Gail B. Ladwig does a really good job of explaining the construction of the 3-part diagnostic statements.

P - E - S
Problem - Etiology(ies) - Symptoms

P = problem
E = etiology
S = symptoms

These are, in NANDA language...

nursing diagnosis - related factor(s) - defining characteristic(s)

In a care plan they look like this:

problem [related to] etiology(ies) [as evidenced by] symptom(s)

or

nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

The related factor is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. To help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. To help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?" remember this important rule: you cannot list any medical diagnosis as a related factor. You have to state a medical condition in some other scientific terms. As an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". They essentially mean the same thing--the difference is in the phrasing of the words.

The defining characteristics are always the signs and symptoms that the patient has. These will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.

For your at risk diagnoses, or potential problems, look at the potential complications this patient is in danger of getting. This is a surgical patient, right? What are the potential complications of the specific surgical procedure she had done? Is she likely to be at risk for any of them? You may be able to find that information on this website by looking up the procedure (surgery) she had:

Also, the complications of general anesthetic are:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

And, the complications of epidural anesthesia are:

  • hypotension
  • rash around the epidural injection site
  • nausea and vomiting from the opiates administered
  • pruritis of the face and neck caused by some epidural narcotics
  • respiratory depression up to 24 hours after the epidural
  • cerebrospinal fluid leakage and spinal headache from accidental dural puncture
  • sensory problems in the lower extremities

Is your patient likely to be at risk for any of those problems (depending on the type on anesthesia she had)? I gave you the lists of anesthetic complications to illustrate how important assessment and critical thinking are as a part of the nursing process in care planning. That first step of the nursing process (assessment) is a doozy, I keep telling students this, but I don't think you all believe me. You can never know too much. You have to be like a detective and always be on the alert for data. You never know what is going to break the case. And, believe me, patients from time to time do drop bombs of shocking information that make all the difference in the world in their care.

I don't think I have the time to start from the beginning and learn all of this stuff in between whatever else we are doing. I got my care plan book out but I feel very lost.

Use the index in the back of nursing care planning made incredibly easy to find subjects as you need them. This is a very easy to read book and I use the index to find things in it. However, the first part of it is organized according to the steps of the nursing process. As long as you are following the steps in sequence, you should be able to find your way through this book. It will become easier as you get more experience writing care plans.

If you are still having trouble, ask for help.

1
Up Vote Up Vote ×

Thank you very much daytonight!

I am trying to realy use my book (care plan's made incredibly easy), I am also using mosby's guide to Nursing Diagnosis, that is where I got the labeling for my care plan it was listed under hipreplacement.

As far as following the nursing process, from reading the book I have been trying to do that, we have not had any instruction on the nursing process, my course is so jumbled frankly worried I will even be prepared to be a nurse, but it's all i have to work with. This project we were told last week to find a patient we could do this project on and glean as much info from the chart as we could, it was meant to be over a 2 day span but our instructor is a bit overwhelmed and unprepared and didn't know how to organize this. My pt was one day post op, she really was recovering well, she did have a blood transfusion 2 units, however her only real complaint was the pain. I am sure I probably did not assess as well as I should have, had I the experience, so now I am stuck only with what I do have which isn't much. I tried to leave there with my 3 nursing diagnosises, I guess I was probably assessing to formulate them instead of assessing to really find any issues, it was my first time ever with a patient on my own. I thought pain was the most important factor as she was having a great deal and was very anxious about it, her wound/dressing looked good. My other two dx I came up with are .

Nursing diagnosis number 2 (Actual): Impaired physical mobility r/t musculoskeletal impairment from surgery.

Nursing diagnosis number 3 (Potential): risk for ineffective tissue perfusion r/t prolonged immobility.

I then have to come up with the intervention's and rationale.

I am confused as to how to come up with these things, do I use a special nanada book? NIC? or do we make them up on our own while looking for rationale using other materials?

As far as asking for help not an option in our class, our instructor is not assessable at all, if you write or call she will not return your email or phone calls I have tried several times, then if you go to see her in person the office will say she is unavailable. I am very frustrated by the whole process and trying very hard to pick up extra reading material and get through this on my own. I think I am on the right track then I get overwhelmed and feel like I am messig it all up. I am trying very hard to take this care plan one step at a time.

thanks again for all your help, I have several posts from you saved that I often refer too and you have helped me more times then I can count without ever even directly corosponding.

1
Up Vote Up Vote ×

This was a very helpful thread!

I always ask myself, what will kill my patient first? Pain is actually the last priority, pain wont kill a patient. It is a priority but injury and infection should come way before that. ?

1
Up Vote Up Vote ×

For any hip fx, or abdominal surgery our clinical instructor taught us that Risk for DVT is always the #1.

I have the book Nursing Diagonisis Handbook: An evidence-based guide to planning care.

Its by Betty Ackley and its the fifth edition. In a nursing student, and it has SERIOUSLY saved my life this semester. We have to do careplans every hopsital clinical week. It really helps I PROMISE.

1
Up Vote Up Vote ×
Specializes in LPN presently trying to pass the nclex.

I am having problems with mu foundamental of nursing 5th Edition

I study, I read and than my teacher put questions that relates to the chapter but it is turn around in a way that I don't understand is there a easy method you can help me with please!!!!!!!!

1
Up Vote Up Vote ×

Well the book I reccomended was for nursing dx, and fundamentals is different.

Nursing school, and nursing, is not black and white, its gray. For every mulitple choice question there is usalluy four right answers. For fundamentals, I have an ATI fundamantals book. Which I love. It summarises everything. The way I got through that class is teaching. I would sit at home, and teach my boyfriend, friend, mom, sister, dad, everything and anything about a subject untill they understood exactly what I was saying. I would have them ask me questions, and I'd ans them.

It'll all critical thinking. It's just practice. Also, flash cards really helped, and I always ans the objectives at the begining of the chapters, and also I Did key terms, ans the questions at the end of each chapter, took advantage of online resources, and did the cd companion with each book.

Good luck!

1
Up Vote Up Vote ×

Hey there,

You may know this by now, however don't let someone no matter how great their info totally mislead you. In nursing pain is considered the '6th' vital sign. While pain itself is not all important your vital sign readings will be off because of pain. A pt. in pain cannot be taught correctly etc. so always keep that in mind. My clinical instructor a nurse practitioner agrees with this, in fact pain if it is a concern, is always priority one.

1
Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
krystal reeves said:
Hey there,

You may know this by now, however don't let someone no matter how great their info totally mislead you. In nursing pain is considered the '6th' vital sign. While pain itself is not all important your vital sign readings will be off because of pain. A pt. in pain cannot be taught correctly etc. so always keep that in mind. My clinical instructor a nurse practitioner agrees with this, in fact pain if it is a concern, is always priority one.

Thanks Krystal Reeves.......this was a thread from 2008 and contains valuable information that remains pertinent and important assessment. ?

1
Up Vote Up Vote ×
+ Join the Discussion