Pl, need help with nursing diagnosis

Published

Specializes in med-surg.

so far i had one class in "patient assessment" and i'm really not sure how to go about with an assignment she gave us. the case is simple, but being my first i am unsure of how to word it, confused about using the pes in diagnosis.

i would really appreciate if someone can help me get a clear picture and any tips or sources, so that i can tackle my next one more confidentally. i wish our instructor had gone thru atleast one example in the class!

here it is:

mrs.martha jones is a 70yr old female who tripped at home 2 weeks ago and suffered a sprain in her right ankle. her initial treatment included an ace bandage wrap, ice and non-steroidal inflammatory drug for discomfort. she was instructed to elevate the extremity for 3 days and to increase weight-bearing activity gradually. she is being seen in a follow-up visit and reports that her ankle is feeling much better, but she has abdominal discomfort. when questioned about the problem, she stated, "my stomach has been kind of achy and it really started a couple of days ago". she denied having a problem with bowel elimination in the past and stated, "''usually i go once a day and it is soft, but essentially i just been sitting around becasue i am afraid to put too much weight on my ankle. i have been eating as usual, but i have not been drinking so much becasue i hate to have to get up to use the bathroom".

a pysical examination was conducted and the following were found:

bowel sounds were present in all quadrants; percussion revealed dullness in the left lower quadrant, the abdomen was softly distended and non tender, and there were dry feces in the rectum.

i don't know if i am right or way off but i wanted to try and this is what wrote(bold attempt, please don't laugh:bugeyes:);

diagnosis: hard bowel movement

not enough mobility

goal: to have soft bowel elimination

increase mobility

implementation: intake of fluids, atleast 6 to 8 cups of water.

to assist her in walking and putting weight on her ankle.

evaluation: i don't know how to write this.

thanks a lot for the help!

Up Vote Up Vote ×

I am a newbie too (one month into Fundamentals), but one thing I know for sure is that it is a violation of HIPAA to use names and if that is not her real name you should state it. There is bound to be someone out there with that name that is constipated :idea:.

I think you are on the right track though with your diagnosis but in the back of your Tabers cyclopedic medical dictionary you will find a extensive if not complete index of NANDA diagnoses. It will give you the proper wording for your thoughts which sound great to me. I love this tool, if you don't have one, you must GET ONE!!!! I lean on this thing hard when concept mapping and/or care planning. That and the Davis drug guide get me through clinicals.

Anyway, just remember HIPAA :nuke:. It is there to protect our patients and even as students we are bound by it and can incur fees and penalties if we are caught not abiding by it. Be careful!!!:uhoh3:

Up Vote Up Vote ×
Specializes in med-surg.

Nurse2Bhomeschoolmom, thanks a lot for the help. However, I just wanted to clarify that I gave the details of the case just as the instructor gave us. It is not from a clinical(I haven't started yet). But I will remember what you told me, about not using any names.

Up Vote Up Vote ×
Nurse2Bhomeschoolmom, thanks a lot for the help. However, I just wanted to clarify that I gave the details of the case just as the instructor gave us. It is not from a clinical(I haven't started yet). But I will remember what you told me, about not using any names.

The thing is, this isn't a HIPAA violation, because this isn't a real patient - I'm gathering this is a case study created by your instructor. So since it's not a real person, you haven't violated anyone's privacy.

If you had used my real name, and I was the patient - THAT'S a HIPAA violation. This, however, isn't - because it's neither a real patient nor a real situation involving this person.

Up Vote Up Vote ×

PES- problem ,etiology, symptoms or x r/t(related to) as evidenced by

make a list of her symptom- mark 'subjective' ( what she is telling you) and 'objective' (what is found in assessment)

from those symptoms you can figure your NANDA dx - mosby has a great book that is really desscriptive...that will be a good start I hope- there are a ton of great post on here- Daytonite is a super helpful and knowlegeable member- be ure to see her reponses..hth!

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

you are definitely on the right track with this. you just need a nursing diagnosis book to get the nursing diagnosis label correct.

in writing a care plan you must follow the steps of the nursing process in the sequence in which they occur:

  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)

so, the first thing you needed to do was pull out all the abnormal data from this case study which it seems you did. so you can go onto step #2 of the nursing process and make a list of your patient's symptoms in order to start determining her problems and looking for nursing diagnoses:

  • abdominal discomfort
  • "my stomach has been kind of achy and it really started a couple of days ago"
  • ''usually i go once a day and it is soft"
  • "i've just been sitting around because i am afraid to put too much weight on my ankle."
  • "i have not been drinking so much because i hate to have to get up to use the bathroom."
  • dullness to percussion in the left lower quadrant
  • the abdomen was softly distended
  • there were dry feces in the rectum

when i look at this list of symptoms it screams "constipation" which is an actual nursing diagnosis whose definition is: decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool. (page 44, nanda-i nursing diagnoses: definitions & classification 2007-2008)

now, what needs to be done is to put the diagnosis into a 3-part diagnostic statement. you are being asked to use the form of pes.

the 3-part nursing diagnosis statement has this structural format:

p - e - s

p= problem

e= etiology

s = symptoms

or

problem - etiology(ies) - 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". 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 come from that list you created from your assessment activities. 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.

in this patient's case, the related factor for her constipation is "insufficient physical activity" (this is a related factor that is actually listed in the nanda taxonomy for this nursing diagnosis, but if you want to change the wording to something like "physical immobility" that is ok). so, your 3-part nursing diagnosis for this should look something like this: constipation r/t insufficient physical activity aeb dry feces in the rectum, abdominal discomfort, dullness to percussion in the left lower quadrant, softly distended abdomen, and statements by the patient that "my stomach has been kind of achy and it really started a couple of days ago", ''usually i go once a day and it [the bowel movement] is soft", "i've just been sitting around because i am afraid to put too much weight on my ankle", and "i have not been drinking so much because i hate to have to get up to use the bathroom."

your nursing interventions are aimed at treating the patient's symptoms--those items that follow the "aeb" part of the diagnostic statement. goals reflect your anticipated results of those interventions. however, what you are calling "implementation" is really your nursing interventions and part of the planning stage of your care plan. implementation is actually putting the nursing interventions into action. that you can't really show on a written care plan because it is physical action. evaluation is reassessment of the patient, determining if they have made any progress with regard to the goals you set, revising the care plan as needed, and documenting this evaluation. in writing an evaluation statement you will use words such as continue, revise, discontinue, achieved and reinstate to refer to the nursing diagnoses, goals and nursing interventions.

Up Vote Up Vote ×
Specializes in med-surg.

I thank everyone for their input. Daytonite, I can't thank you enough for such a detailed explanation. I got a good picture now but will go thru it again to make sure I got it thoroughly. I think it will be helpful for me to keep writing more care plans as a practice. I just have a couple of questions:

1. I wanted to write "constipation" but thought it is medical diagnosis, but now realize it is mentioned in NANDA. In regards to that, please can you suggest a NANDA book? Someone said Mosby is good. If you have any other suggestions, I would appreciate it. Is this something you would recommend? -NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008).

2. The other thing is, our instructor mentioned PES and ADPIE. Which one do you follow? Or it doesn't matter as long as I am following the steps?

3. My instructor asked us to buy a stethoscope(for assessment labs, though I start my clinicals only in Aug) and at this point I am so ignorant that I have no idea what to look for. I browsed thru other posts and still stumped. Do you have any suggestions?

Sorry for barging you with questions but will appreciate if you could let me know. Thanks once again for everything.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.
can you suggest a nanda book? someone said mosby is good. if you have any other suggestions, i would appreciate it. is this something you would recommend? -nanda-i nursing diagnoses: definitions & classification 2007-2008).

most students like nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig. it is currently in its 8th edition, i believe. in addition to listing all the nanda nursing diagnoses, it also includes the nanda information (definition, related factors and defining characteristics) for each as well as some noc (outcome) and nic (nursing interventions). the front section of the book has a cross section index where it matches likely nursing diagnoses with medical disease and conditions to help save you time in searching for nursing diagnoses. the mosby handbook of nursing diagnoses is a shortened version of the ackley/ladwig book.

nanda-i nursing diagnoses: definitions & classification 2007-2008 is the bare bones taxonomy published by nanda international. all it has in it is the 188 nursing diagnoses alphabetized with their definitions, related factors and defining characteristics and nothing more. it costs $24.95 and you have to buy it directly from nanda. you get order information online from this site: http://www.nanda.org/html/nursing_diagnosis.html

our instructor mentioned pes and adpie. which one do you follow?

pes refers to the format of the 3-part nursing diagnostic statement:

problem - etiology(ies) - symptoms

adpie is a mnemonic for the 5 steps of the nursing process that you follow when problem solving, critical thinking or writing a care plan (which is also problem solving)

assessment - diagnosis - planning - implementation - evaluation

you follow adpie when solving patient problems and when writing a care plan. you follow pes when composing the 3-part nursing diagnostic statement that goes on your written care plans.

my instructor asked us to buy a stethoscope (for assessment labs, though i start my clinicals only in aug) and at this point i am so ignorant that i have no idea what to look for. i browsed thru other posts and still stumped. do you have any suggestions?
i am no expert on this. i never bought a stethoscope that cost more than $10. you can buy them in uniform stores. it worked just fine. and, i worked in a stepdown/telemetry unit where we listened to heart and lung sounds all the time.
Up Vote Up Vote ×
Specializes in med-surg.

Daytonite, thanks a lot for answering my questions. Things are a lot clearer now.

Up Vote Up Vote ×
Specializes in psych,and detox,and Ltc.

Very well put....and very helpful.

Up Vote Up Vote ×
Nurse2Bhomeschoolmom, thanks a lot for the help. However, I just wanted to clarify that I gave the details of the case just as the instructor gave us. It is not from a clinical(I haven't started yet). But I will remember what you told me, about not using any names.

OMG, I am so sorry!!! I did not understand that. I was not trying to accuse you at all. You are going to make a great nurse and you seem to understand and desire to understand more. You rock!!!:up:

Up Vote Up Vote ×
Specializes in ER,MED_SURG,REHAB,HOME HEALTH, OR,.

just a thought but some pain meds at times slows gi tract just thought id throw that in

Up Vote Up Vote ×
+ Join the Discussion