Hi, if anyone can give me a little direction it would be appreciated.
My medical diagnosis is right arm suppurative thrombophlebitis.
However the patient has been on the floor for 10 days and has no pain and is an IV drug user and wants to leave the hospital desperately ... the patient needs to finish their IV antibiotic therapy first however.
My supporting subjective and objective data consist of the patients statements about wanting to leave, and observations of the patients pacing, leaving the floor at every opportunity.
I want to use a nursing diagnosis of: deficient knowledge r/t lack of interest in learning aeb patients statement of "I want to leave"... something like that...
What I don't get is, does the supporting evidence have to relate to thrombophlebitis or no?
Specializes in Complex pedi to LTC/SA & now a manager.
Yes for nursing diagnosis you need the NANDA-I 2012-14. It is the only comprehensive nursing diagnosis reference. You can even get an ebook copy from kindle or nook. Cheap on Amazon with free student super whammy whatever (?Amazon Prime I think?) shipping.
My instructor had us eliminate all labs from our careplans, which i was kind of sad about, because it was helping me learn about them. is this a common occurrence? she is my fourth clinical instructor, and the first one to do this. i still do them just for my own learning, but dont include them in what i submit to her. she also glosses over our patho (she told us to reduce it to a paragraph, i still write a whole page just for my own learning), diagnostic tests and meds, and focusses exclusively on our nursing dx and interventions.
Eliminate labs??? Why???? I have seen the single-paragraph patho but not completely getting rid of labs. We have labs constantly drilled into everything we do. That is really unusual. But, it's good that you're writing up your own patho and still keeping up with your labs. I don't think it's very common to just disregard labs and patho completely. I mean, your labs are going to dictate some interventions and are evaluations of your interventions so why disregard them? Strange. Well, hopefully your 3rd and 4th semesters will be a little more coherent.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Getting rid of labs? Wow. Wanting interventions in "layman's terms" I am not sure how to help for that is not the format I follow...it doesn't sound appropriate to me and if the other instructors require them she is putting you behind the eight ball.
Dilated pupils...he's using with his friends. I have worked at urban centers we would NEVER let an IV user go outside but if that is what the facility does then you can't change that.
Dilated pupils...he's using with his friends. I have worked at urban centers we would NEVER let an IV user go outside but if that is what the facility does then you can't change that.
As soon as I saw "dilated pupils" after being "outside with friends" I was like Mmmmm-Hmmmm
This whole thread makes me sad for the OP trying to learn how to do care plans.
OP what care plan resource are you using? What semester are you?
Each instructor provides us with a template, they all seem to be slightly to a lot different from one another. Is there a standard one? If so, I would love to see it! I am semester 2 of a 4 semester ADN.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Each instructor provides us with a template, they all seem to be slightly to a lot different from one another. Is there a standard one? If so, I would love to see it! I am semester 2 of a 4 semester ADN.
I would hope your school would be consistent...sadly that is not the case
Nursing Diagnoses: Reason patient required care of nurse.
1. NANDA statement: most instructors look for actual (rather than 'risk for') when patient is in the hospital
2. Related to: related to usually medical diagnosis or major signs/symptoms
3. As evidenced by: assess or evaluate data which supports nursing diagnosis
Patient Outcomes: Measureable outcome criteria.
Uses ranges: ____ to ____, greather than or equal to, scale, parameters
Time frame: acute (minutes, hours, days); long term (weeks, months, years)
1. Vital signs - oximeter, cardiac monitor values, ICP, etc.
2. Body systems assessments
3. Pain
4. Nutrition/Fluids
5. Meds
6. Labs/diagnostics ranges
7. Teaching learning/psychosocial
8. ADL's
9. Other/wellness items
Planning: Broad goals. Think of Kardex. Plan for oncoming shift.
The nursing diagnosis is appropriate, the r/t could be re-worded to specify IV drug use history and LOS of 10 days on the unit and include lack of knowledge regarding treatment/therapy. Your AEB should include her statement somewhere, but when I am grading care plans I look for quantitative data, such as lab values or measurement of behavior when assessing interventions and evaluation, short/long term. That is simply my own take on it, obviously always consult your NANDA guidelines first. Hopefully, I helped a bit
.thumb.gif.9c97ffa9443a5f22ff38e1eac832292c.gif){kind=avatar}
JustBeachyNurse, LPN
13,957 Posts
Yes for nursing diagnosis you need the NANDA-I 2012-14. It is the only comprehensive nursing diagnosis reference. You can even get an ebook copy from kindle or nook. Cheap on Amazon with free student super whammy whatever (?Amazon Prime I think?) shipping.