1st semester nursing needing help with nursing diagnosis!

Lavenderper · Apr 11, 2013

Also is my diagnosis acceptable?

JustBeachyNurse, LPN · Apr 11, 2013

What in your interview/assessment leads you to that nursing diagnosis? Is there no medical condition, history, or risk for needing medical/nursing care?

What do you think interventions and what would be your goal?

How would you write this statement? Did you use the steps of ADPIE to get to this diagnosis?

willowita, ADN, RN · Apr 11, 2013

Is your diagnosis acceptable? That wound depend on the assessment data taken as a whole. Of all the data you collected, was enhanced religiosity the priority problem the data pointed to? If yes, then it's probably acceptable. But assuming that this is a person in a hospital with physiological problems, risk factors, procedures, meds, etc then it might not be the most important and priority problem you should deal with. At least, that's what I could hear my instructor telling me. If they're getting medical care, then they have an actual problem that should be addressed before we go to a wellness diagnosis. Of course, the spiritual, emotional, psychological is an important aspect of care but if the person is at risk for falls, has impaired perfusion, ineffective airway clearance, etc then those problems are higher priority issues that should be the focus until they can be resolved.

Ok, but you just stated that this was an "individual" so it could be a friend for all I know. In which case, maybe they are perfectly healthy and their problem is on the wellness side. So, what interventions would be appropriate? Well, think of it this way, how would you as a nurse help someone get in touch with their religion more? Maybe schedule a meeting with a religious leader to visit the person. Involve the family in providing religious objects, books, etc the person needs to practice their religion. Help them find a place of worship if they don't know where to go. In managing their care, provide for down time where they won't be interrupted so they can pray and practice their faith without distractions. Those are just some ideas.

Lastly, if you choose this diagnosis, you need to include "as evidenced by" or "as manifested by" in your diagnosis statement. That's where you follow it up with your supporting assessment data that lead you to your diagnosis.

nurseprnRN, BSN, RN · Apr 11, 2013

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

So.. what are the defining characteristics you assessed in your patient that lead you to make this diagnosis?

Esme12, ASN, BSN, RN · Apr 11, 2013

Also is my diagnosis acceptable?

Care plans are all about the assessment of the patient. Your entire assessment of the patient physically revealed only this?

Readiness for enhanced religiosity related to ability to increase reliance on religious beliefs

What is your focus this week? What is making the patient have an increased reliance on religious beliefs? Without information about your patient and your assessment we can't know if this is a good diagnosis or not.

What care plan book do you use? Do you have the supporting evidence from your assessment that supports this diagnosis? I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition.

Simply put.......Care plans are the recipe card on how to care for someone....logically, rationally. They tell you what is important for any particular patient....and what needs to be looked at, treated, considered first. Care plans as a nurse is a standard recipe card .....you already "know" how to bloom yeast.....as a student you look up, include the how to, and "learn" how to bloom the yeast so you can remember the how to for the future.

Care plans are all about the assessment OF THE PATIENT.....the whole patient. What is the patient assessment? What do they need? Have they had any procedures? What brought them to the hospital? How long have they been hospitalized? What are their vitals signs? What is their main complaint? 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.

These sheets may help you out.....daytonite made them (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

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....what are their vitals....what are the labs...what is their main C/O? What brought them to the hospital?

Now tell me what your assessment showed.