Please help!

cayenne06, MSN, CNM · Nov 17, 2014

Sounds like a valid diagnosis (but I am NOT a nursing dx expert by any stretch, nor do I have the NANDA book). However, is part of your assignment to identify the PRIORITY problem? If so, make sure you think about any other issues that would take precedence over psychosocial problems like fear. And is her anxiety related to her health status, or is it related simply to being hospitalized, or does she have underlying cognitive problems that are contributing (etc etc)?

RNstude · Nov 17, 2014

Thank you for responding Cayenne06! No, the assignment is not really to identify a priority problem (but I know that when we are doing a nursing diagnosis, airway, breathing and circulation take precedence over everything else). I looked through the NANDA book and this diagnosis 'Fear related to...' matched perfectly with my client. Thanks again for your input.

my3boysleiter · Nov 17, 2014

Anxiety is a good psychosocial care plan. If you need a medical one, I would chose

Risk for Bleeding r/t GI bleeding

c - vomiting blood

c - dark, tarry stools

c - low hct, hgb

Goal: The patient will maintain stable vital signs and remain free from bleeding.

Interventions: Monitor Vital Signs, Labs, signs of bleeding, give Vitamin K as ordered, implement safety precautions to avoid fall.

Teaching: Teach pt to report signs of blood in stool, report any nose bleeds, report signs of blood in vomit. Teach them importance of safety to avoid falls, such as sit if dizzy, use walker/cane/ as appropriate, reduce use of NSAIDs if appropriate to reduce risk of bleed.

These are just ideas, I'm not perfect at these but I've done a truck load of them :-)

Good luck!!

RNstude · Nov 17, 2014

Thanks for the info my3boysleiter...sounds good! I'm sure not if I could use 'related to GI bleeding' as that is a medical diagnosis. Thank you and good luck to you too! :-)

SHGR, MSN, RN, CNS · Nov 18, 2014

Yes, you are definitely on the right track. Do you have to have several nursing diagnoses for this patient? What about your interventions?

Esme12, ASN, BSN, RN · Nov 20, 2014

Hi! Welcome!

What semester are you? What care plan resource do you use?

Care plans ar all about the patient and the patients problems. 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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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

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)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

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.

Now...tell me about your patient.

RNstude · Dec 27, 2014

Hi and thank you Esme12! :-) I recently finished 1st semester and I used the Nursing Diagnosis Handbook by Ackley. I am just seeing your post, and submitted the assignment already...needless to say, I don't even remember which patient it was. Thank you again for the wealth of information; I will certainly refer to this going forward!!

Esme12, ASN, BSN, RN · Dec 28, 2014

Come anytime we'll help. Show us what you have an we will jump right in!

nurseprnRN, BSN, RN · Dec 29, 2014

Thanks for the info my3boysleiter...sounds good! I'm sure not if I could use 'related to GI bleeding' as that is a medical diagnosis. Thank you and good luck to you too! :-)

There is a pervasive and persistent myth that medical diagnoses cannot be relied upon for related factors (causation) for nursing diagnoses. This is horsepucky, as anyone who has the NANDA-I 2015-2017 (the current edition) will be able to demonstrate to any TA or other faculty who makes that assertion.

The nursing diagnosis, "Risk for bleeding" (Defined as: Vulnerable to a decrease in blood volume, which may compromise health) does not have related/causative factors or defining characteristics. Like all Risk for... diagnoses, it has RISK FACTORS.

They are:

aneurysm

circumcision

disseminated intravascular coagulopathy

gastrointestinal condition (e.g., ulcer, polyps, varices)

history of falls

impaired liver function (e.g., cirrhosis, hepatitis)

inherent coagulopathy (e.g., thrombocytopenia)

insufficient knowledge of bleeding precautions

postpartum complications (e.g., uterine atony, retained placenta)

pregnancy complication (e.g., premature rupture of membranes, placenta previa/abruption, multiple gestation)

trauma

treatment regimen

You will notice that all of these, with the exception of history of falls and the insufficient knowledge of bleeding precautions, are medical diagnoses.

You obviously could not make this nursing diagnosis or someone who is already bleeding-- the risk has already resulted in a bleed, so he is no longer at risk, he's bleeding. If he has stopped bleeding actively, then you can go back to the possibility of risk.

Also, when you're looking at nursing interventions, look at nursing interventions: "administering drugs as prescribed by a physician" is not a nursing intervention, it's nursing implementing part of the medical plan of care.

As to making a nursing diagnosis, you must identify at least one defining characteristic and at least one related/causative factor for a diagnosis to make it. So, if your patient has already been diagnosed with a GI bleed, what other assessments have you made that suggest a physiological problem for which nursing has independent measures to apply?