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secondary nursing DX help

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Hello, I will try not to make this as short as possible. I am a 101 student and our first full case study assignment was just to find someone older than 65 an come up with a care plan for them. This is not for a grade, just for feedback. I chose my MIL who is 71. My priority nursing diagnosis is:

Disturbed sleep pattern RT frequent awakenings amb waking six or more times per night, patient states I am so tired, I haven't figured out this new c pap machine but I hope it's going to make a difference”

I am having difficulty coming up with a secondary diagnosis. She has a plethera of other medical conditions, but all are currently under control. This is her history:

Hx: Paralytic Polio age 7, multiple surgeries as a child, left leg paralysis, wears brace, ambulates with crutch

Partial hysterectomy 2005

Cholecystectomy 2012

Fatty liver disease

Increased cholesterol

High blood pressure/leaky valve

Sleep apnea/ c-pap machine

Stress incontinence

Hx of falls (Shattered knee caps 1992)

Anemia

Hypothyroidism

Before coming up with our primary diagnosis we had to come up with four. These are the four I came up with based on her history and assessment:

1. Disturbed sleep pattern RT frequent awakenings amb waking six or more times per night, patient states I am so tired, I haven't figured out this new c pap machine but I hope it's going to make a difference”

2. Risk for falls RT neuromuscular impairment amb use of crutch to ambulate, brace on left leg, hx of falls.

3. Stress Urinary Incontinence RT loss of pelvic muscle tone amb leakage of urine with coughing, laughing, sneezing, wears poise pads.

4. Impaired mobility RT neuromuscular impairment amb use of crutch to ambulate, wears brace on left leg.

Even though she has a history of falls and impaired mobility, I don't feel like those are her current or primary problems right now, but I can't seem to get together anything else to go with my first diagnosis. Can you please help? Should I just scratch it all together and go a different direction?

This is my ob and sub data from focused assessment:

Pleasant disposition. Pain of 0 on scale of 0-10, T-98.6, P-64, R-16. BP 138/80. Ambulates with assistance of crutch. Wears brace, left leg paralysis. Steady gait with assistive devices, good posture. Complains of tiredness. States I haven't figured out this new c pap machine but I hope it's going to make a difference” Sleeps 3-6 hours a night, is tired during the day, has two cats that wake her early in the morning. Does not feel well rested. Frequent yawning during conversation and dark circles present under eyes.

Thank you in advance

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Lets start back at the beginning.....

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

  1. 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)
  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)

  1. 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 careplan 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.