Published Apr 26, 2014
I have a patient that has a lot going on but I'm having a hard time trying to figure out which diagnosis is most priority.
She is 40 years old and just had her first baby (advanced for maternal age).
She lost her mother the week before she was admitted to the hospital for induction of labor.
She suffers from Anxiety. She smoked during pregnancy.
Her vital signs were stable up until the point where she received an epidural and her bp feel really low.
She was in some pain during the labor process, which is not uncommon.
She is also anemic.
I'm trying to find a diagnosis that kind of incorporates all of these or most of these finding but it's hard. If I chose one component out of all of these problems. I don't have a lot of supporting information that I can use for my care plan.
I hate nursing care plans so much! I've been doing so horrible thus far.
Ruas61, BSN, RN
Postpartum should start the list
Esme12, ASN, BSN, RN
thread moved for best response
Postpartum depression? But I thought that would be a medical diagnosis.
I thought about Anxiety related to threat to self-concept secondary to pregnancy, because there is a lot that i coudl work with.
AmyRN303, BSN, RN
I have a patient that has a lot going on but I'm having a hard time trying to figure out which diagnosis is most priority.She is 40 years old and just had her first baby (advanced for maternal age).She lost her mother the week before she was admitted to the hospital for induction of labor.She suffers from Anxiety. She smoked during pregnancy.Her vital signs were stable up until the point where she received an epidural and her bp feel really low.She was in some pain during the labor process, which is not uncommon.She is also anemic.I'm trying to find a diagnosis that kind of incorporates all of these or most of these finding but it's hard. If I chose one component out of all of these problems. I don't have a lot of supporting information that I can use for my care plan. I hate nursing care plans so much! I've been doing so horrible thus far.
There are a lot of great posts on here about how to formulate nursing diagnoses, so definitely do a search. Your diagnoses come straight from the assessment, so you want to be specific. What was her BP, what was her pain, what were her labs? Is she anemic because she couldn't take prenatals, because she lost blood during delivery, because maybe she received a lot of fluids and now she's diluted? You don't have just one diagnosis here, you have a problem list in which each individual problem for the patient leads to one diagnosis each....make sense? Then once you have your diagnoses (Use NANDA-I for this....do a search and you'll read why...Esme, I believe has written several relevant posts about it) you will quickly see which one is a priority and why.
Writing care plans can be daunting for students. I know starting out it was for me. Just make sure you're not making the patient fit the diagnosis and rather that you're actually basing the diagnosis on the data.
How is she COPING? Look at your coping diagnoses.
Does her anemia put her at any risks for which there are nursing diagnoses? Consider what she's been through physically (induction, birth) and how anemia may impact that and the recovery.
How is her health maintenance? Does she have any "readiness" for changes?
How is feeding going? How does she feel about it?
**Think safety above all else.**
AmyRN303 is correct. You have more than one diagnosis to consider... (you're observations span a huge number of basic human needs, both physiological and higher order/emotional) and you don't have enough data to inform yourself adequately to make any of them.
What is your assignment? What is it your instructor wants you to do?
TheCommuter, BSN, RN
Duplicate threads have been merged. Good luck with your care planning studies!
Our nursing assignment is to list risk factors and priorities but chose only one thing to use for a nursing diagnosis/concept map.
This is what I came up with so far, because it hits everything she is going through:
Risk for complicated grieving process d/t to pain of labor, fear of fetal complications, maternal health, and anxiety r/t unfamiliar procedures.
But not sure if it will make sense or if it's too much in one thing. Risk for complicated grieving is the main point and is a NANDA dx.
Risk for complicated grieving process d/t to pain of labor, fear of fetal complications, maternal health, and anxiety related to unfamiliar procedures.
My patient is going through all of this, as she lost a close family member and is being induced for labor. She has a hx of anxiety attacks, has anemia, and is in pain.
You are having trouble figuring what diagnosis to use because you shouldn't be picking the diagnosis first then fitting the patient into that diagnosis. You should begin with your assessment...of the patient.
Care plans are ALL about the patient assessment. What the patient NEEDS not what YOU THINK she needs.
Was this a section or vag birth? She was full term...how is the baby? How long was she in labor? What did she say? Is she breast feeding? Is her partner present and helpful? What is her vaginal discharge. Tell me about HER what you saw, what she said.
Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
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.
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 plan: ADPIE from our Daytonite
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)
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.
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.
Another member GrnTea say this best......
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__." "Related to" means "caused by," not something else.
By using the site, you agree with our Policies. X