Please help with nursing diagnosis

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I am completely confused, and flustered as to what to chose as my nursing diagnosis for my paper.

I for some reason chose to my assessment on the abdominal region of my patient;

a 69 yr. old woman with depression, hypertension, anxiety, sleep apnea, chronic obstructive pulmonary disease, type II, diverticulitis resulted in patient having a colostomy, acute renal failure, and VRE. She also has a bruit in her left arm.

The paper has to be related to their RFA; which in her case is ARF, and Diverticulitis, and are also required to find an abnormality within that region.

If anyone can please help it would be greatly appreciated!

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i don' t know if this will help but she also has hypoactive bowel sounds, bowel movements once only 2 -3 days, doesn't really eat much, and has abdominal tenderness in all quadrants...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi, poopsiez, and welcome to allnurses! :welcome:

you cannot choose any nursing diagnoses without collecting together this patient's abnormal assessment data. nursing diagnoses are not based upon medical diagnoses. you must follow the steps of the nursing process in the sequence they occur in order to complete this paper. please read the information on this thread as well as the other information on the links listed there. if you still have questions after reading this information, post them here:

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Ok this is what I have thus far;

patient has food intolerance to dairy; resulting in bloating and flatulence

bowel movements are once every 2-3 days; good amount, dark-medium brown colour and soft, administered laxatives by RN as needed

past history of diverticulitis, operation to place colostomy,

nutritional assessment could not be completed for 24 hr. period as patient is unable to recall meals, current day; only consumed a bowl of bran cereal with milk, and refused to eat remainer of breakfast. patient is on a renal diet

patient does eat alone most often; as she is in isolation due to VRE status

patient has a 6 inch scar on midline of abdominal wall 2 inches superior to umbillicus

demeanor of patient changed while repositioning due to fatigue; facial grimace, and sleepy look

hypoactive bowl sounds, low pitch infrequent noise heard through stethoscope

I was not able to perform examination on vascular sounds as patient was fatigued and requested to rest (although I am told she has a bruit in left arm) and required assistance in repositioning and lifting of legs to assume supine position.

I was also not able to perform deep palpation to any area as a result of discomfort to the patient

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Specializes in med/surg, telemetry, IV therapy, mgmt.

so, you feel you have completed step #1 of the nursing process? did you look up information about depression, hypertension, anxiety, sleep apnea, chronic obstructive pulmonary disease, type ii ??, diverticulitis, acute renal failure, and vre? did you miss any of the signs and symptoms of these conditions in this patient. is that type ii, type ii diabetes? is her renal failure a complication of this? acute renal failure is supposed to be reversible; what's going on that she went into acute renal failure and why does she have a bruit in her left arm? does she have a fistula in order to have dialysis? you need to be asking why, why, why and trying to find some of those answers.

  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)

once you have completed gathering all the assessment information (you can never know too much) you need to know the pathophysiology of this patient's medical conditions. why? to determine the related factors (etiologies) for the physiologic nursing diagnostic statements you will be choosing. then, you can move on to step #2 of the nursing process.

first, go back through all this data you have collected and make a list of everything that is abnormal. this becomes your list of the patient's symptoms. it will contain some of the same kinds of symptoms that medical diseases have, but may also consist of problems accomplishing adls or statements by the patient of their negativity or doubts about their health status. these are also considered symptoms to us nurses for the purpose of diagnosing their nursing problems so it is important to pick up on them during your assessment activities.

next, is the actual picking of nursing diagnoses. every nursing diagnosis has a set of signs and symptoms (nanda calls them defining characteristics) and your patient must have at least one or more to be able to assign any specific nursing diagnosis to them. a doctor wouldn't diagnose you with pneumonia unless you had some of the signs and symptoms of the condition. and, he would only determine this after doing a thorough assessment (their assessment activities involve other modalities than what we nurses do). we nurses follow the same similar process to get to assigning nursing diagnoses (my oncologist pointed out to me, when i was discussing this with him, that physicians do physical examinations and we nurses do physical assessments and they are not the same thing. i wanted to kick him in the nuts. we also do adl and other functional assessments which doctors don't normally do as part of their h&p).

it is helpful to have some kind of nursing diagnosis reference to help you out when you are new to doing this, how else are you going to become familiar with the nursing diagnoses? the information doesn't just osmose into our brains overnight. the more you work with certain diagnoses, the more familiar you get with their symptoms. doesn't that make a lot of horse sense? there are a number of ways to acquire this information.

  1. your instructors might have given it to you.
  2. you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  3. many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  4. there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

    http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

the nursing diagnosis information provided by nanda is:

  • a definition (actually, this is a more descriptive statement of the nursing problem)
  • defining characteristics (actually, these are merely the signs and symptoms that support the problem)
  • related factors (the etiology, or underlying cause, of the problem) - often you need to understand the pathophysiology of the disease process going on to choose the correct related factor connected with a physiological nursing diagnosis
  • risk factors - these are etiologies that are only listed with the anticipated, or potential, (have yet to occur) nursing problems. these are the nursing diagnoses that begin with the words "risk for" and are used when the patient is vulnerable to possibly developing a problem.

all of that information is going to help you compose your 3-part nursing diagnosis statements for your care plan. but you need information from your assessment to make it happen.

once you have chosen your nursing diagnoses, that's the end of your nursing diagnosis anxiety. you move on to step #3 of the nursing process. now, here's the beauty of the nursing process in case you haven't figured this out yet. . .the whole thing depends on what you did back in step #1. in step #3 you will develop nursing interventions for the signs and symptoms (defining characteristics) that you used to prove the existence of the various nursing problems (nursing diagnoses). and, the goals/outcomes are, in actuality, the results you predict will occur because of those nursing interventions having been done. how much more logical and reasonable can you get?

now, if you had read the threadlisted above as well as the other threads i posted on the site you would have already read this same information because i type it sometimes two times a day for students. however, it is getting physically harder for me to type these days as a result of a side effect of recent chemotherapyi had to have. i used to be able to type 100 wpm. now, i have to type with two fingers so i am sorry if you feel you aren't getting enough personal attention. i'm, trying to give you as much guidance as i can without overtaxing myself.

what does rfa mean?

make a list of what you now believe this patient's symptoms are. if you are braver try to diagnose some of them and post what you think she's got.

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Thank you so much for all your time and patience, and hope you feel better soon! I have to admit, you have taught me more in these few postings than I have learned from my teacher this semester!!!

So, here is what I have in response to your last post...

The RFA is reason for admission...

Ok so I am slightly confused as to what is expected on this paper to start... the teacher is not very helpful, nor is she easy to talk to. However, moving on....

from what i gathered from the patients data, she had many hospitalizations, and been administered many antibiotics over those admissions. She developed diverticulitis and I think from that became septic and that is what caused the acute renal failure. she also has encountered the nosocomial infection VRE and as a result is in isolation. she has a bruit from the dialysis, and the av fistula again for dialysis that she is on 3 times a week. she has explained to me that she is tired often and has some abdominal pain. she also is diabetic and doesn't eat much and is on a renal diet... so i dont' think she is getting adequate nutrition from that terrible hospital food she hates so much. in addition to all of this she has copd, depression, anxiety....

Now, I was going to use the nursing diagnoses of activity intolerance due to the fact that she requires assistance with ADLs, requires the use of a walker, COPD, tires easily when being transfered and after sitting up for short periods of time...

and just now i found another diagnoses; social isolation. she stated to me that she eats alone almost all the time, is seemingly embarassed by her ostomy, she is depressed, and has anxiety, is croatian and has a slight langage barrier, and also due to her isolation status, and not being able to leave her room without the assistance of someone else, and risk for contamination of environment....

now i am not to sure which one is better to pick as i did my initial assessment on the abdomen... the more i think about this assignment the more I get confused...

So, if you could and are up to it.... please let me know if I'm totally off the rocker on this one...because i feel like i am running in circles here... :(

Thanks again for your time !!!

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I have used this site a LOT and I HTH

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/A-B.html

Oh and look in to using ineffective tissue perfusion (renal) or fluid electrolyte r/t renal failure, sepsis, etc aeb dialysis and look at her labs-BUN ratios to back up the kidney failure. If she has COPD use ineffective gas exchange.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you never did say what this lady's reason for admission was, so i can't help you there. that information would have been on the face sheet of the chart.

this is what i meant by asking you to make a list of the patient's symptoms:

  • doesn't really eat much
  • eats alone almost all the time
  • on a renal diet
  • has abdominal tenderness/pain in all quadrants
  • facial grimace
  • colostomy
  • embarrassed by her ostomy
  • in isolation due to vre
  • av fistula left arm
  • depressed
  • anxious
  • requires assistance with adls (needs to be more specific)
  • uses a walker
  • requires assistance in repositioning and lifting of legs
  • tires easily when being transferred and after sitting up for short periods of time
  • she is often tired
  • fatigue
  • is croatian and has a slight language barrier

the above are abnormal data from your assessment. i have a lot of questions about this information. do you have any weights on the patient or information from the nursing flow sheets on the percentage of food she is eating at meals? how do you know the patient is embarrassed about her colostomy? what did she say or do to make you make that judgment? you need that specific information to support any nursing diagnosis you use in relation to it. what are her symptoms of the vre? what are her symptoms of the depression, because depression is a medical diagnosis? what are her specific symptoms of anxiety? the defining characteristics (symptoms) of anxiety according to the nanda taxonomy are listed on this website just below the title: [color=#3366ff]anxiety. this is a possible nursing diagnosis you can use, but you really haven't listed any symptoms to support using it, so i'm suspecting you just missed noticing them. you need to be more specific about which adls she can and can't perform. there are 4 self-care (adl) diagnoses: bathing/hygiene, dressing/grooming, feeding, toileting. which ones and what actions, specifically, does she need assistance with? the tiredness and fatigue. . .i need to help you out here because i have more experience. her fatigue is related to her chronic renal failure and copd. it can be a related factor for her self-care deficits or you can use activity intolerance or fatigue. i would keep things simple and use the fatigue with self-care deficits because you really don't know the underlying pathophysiology causing it to use it with activity intolerance or fatigue diagnoses, do you?.

now, to choose the nursing diagnoses

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)

from the symptom list you start looking for nursing diagnoses that have some of those same defining characteristics (symptoms). remember i said previously, every nursing diagnosis has a set of signs and symptoms (nanda calls them defining characteristics) and your patient must have at least one or more to be able to assign any specific nursing diagnosis to them. i cannot complete all the information for many of these diagnoses because i don't have enough information about the patient. i want you to know that while i developed the diagnosis list below i was using my copy of nanda-i nursing diagnoses: definitions & classification 2007-2008 to verify related factors (where i could) and defining characteristics. however, i hope you will start to see how crucial your assessment information becomes as you get into the care plan.

  • imbalanced nutrition: less than body requirements r/t poor ingestion aeb not eating much at meals [this really needs to be stated in more specific terms]
  • acute pain r/t ??? aeb complaints of abdominal pain and facial grimacing
  • disturbed body image r/t colostomy aeb patient statements of embarrassment
  • anxiety r/t ??? aeb ???
  • () self-care deficit r/t fatigue, pain aeb ???
  • impaired physical mobility r/t ??? aeb requires assistance in repositioning and lifting of legs
  • impaired verbal communication r/t english as a second language aeb speaks croatian as primary language

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thanks so much for all your help with the paper!!!

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