Trouble with relating medical dx to nursing dx

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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.

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Specializes in Pediatric Hematology/Oncology.
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.

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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.

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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 :whistling:

This whole thread makes me sad for the OP trying to learn how to do care plans.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

^^^ I agree...sigh

OP what care plan resource are you using? What semester are you?

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^^^ I agree...sigh

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.

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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.

  • Goal statement = opposite from nursing statement
  • Never past tense - to do in the future
  • Monitor, assess, perform, check, obtain, teach, follow protocols/guidelines

Implementation:

  • Actual interventions. Usually past tense
  • What care was provided for patient?
  • How did you gather data to measure against your normal ranges in your outcome criteria?
  • Frequency - How often did you obtain patient data?

Evaluation:

  • Each goal met/not met: Should read like you actually documented vital signs, assess, care on your patient
  • Which labs/dx did you check?
  • What was taught/what support measures, comfort used?

When goals not met, that justifies your need for nursing care.

http://www.austincc.edu/nursmods/cec/cec_lev2/rnsg_1260/sample_plan1/index.php

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Nursing Care Plan template from another student https://allnurses.com/nursing-student-assistance/i-need-help-665349.html

(Correlation Chart)

[TABLE]

[TR]

[TD]ASSESSMENT[/TD]

[TD]ANALYSIS[/TD]

[TD]PLANNING[/TD]

[TD]IMPLEMENTATION[/TD]

[TD]EVALUATION[/TD]

[/TR]

[TR]

[TD][/TD]

[TD]NURSING DIAGNOSIS[/TD]

[TD]GOALS[/TD]

[TD][/TD]

[TD][/TD]

[/TR]

[TR]

[TD]Subjective:

What the patient says, the family, the doctor, a nurse/

Usually in quotations

**Note if your patient is nonverbal, you can still have subjective data from other sources.

Objective: (Note your Topics to the side)

Start with a brief overview of the patient.

Example: 78 yo white male admitted 6/12/09 with COPD exacerbation

PMH: include a comprehensive past medical history of your pt

Orders: orders that are specific to your ND or that may contribute to supporting your ND statement

  • Interdisciplinary assistance such as PT, OT, RT
  • Diet
  • Activity
  • Oxygen

Radiology: report any radiological findings that may support or contribute to your ND statement

Labs: what laboratory findings are pertinent to supporting your ND statement

Medications: only medications that can support your ND statement

Assessment findings: can include an array of things, but only if relevant to support

  • Intake and Output: include if can support your ND
  • Vital Signs: usually a great inclusion to support most ND
  • Wound appearance
  • Mobility performance
  • System Assessment: that is pertinent to your ND

Example; Impaired Gas Exchange-do Resp assessment

[/TD]

[TD]P= Problem

E=Etiology

**May use Secondary to a diagnosis after the etiology if it permits

S=Signs and Symptoms

****Note that if it is a Risk for diagnosis you will only have a PE format without signs and symptoms[/TD]

[TD]PATIENT WILL…..

This is what the nurse hopes to achieve by implementing the nursing interventions

COMPONENTS

Subject: PT will

Verb: action patient is to perform

Condition: explains how the behavior is to be performed

Criteria: Time frame

BE SPECIFIC

Patient will increase mobility by the end of 3-11 shift as evidenced by independently ambulating to chair.[/TD]

[TD]NURSE WILL…..

This is what the nurse will do to assist the patient in accomplishing the goal.

COMPONENTS

Subject: Nurse will

Action verb: precision—educate, demonstrate administer

Content: the what and where of the order

Time Element: when, how long, or how often the action is to occur

Rationale: Under each statement you must support this nursing intervention with a source as to why it is important

Nurse will perform range of motion every 2 hours.

Rationale: Exercise increases joint flexibility, stability, and range of motion.

Sources: you must have at least 2 sources per care plan. We encourage use of articles and lectures as well. Format in APA.[/TD]

[TD]Goal Met…

Goal partially met…

Goal not met…

This is merely reporting that the goal was accomplished or not.

Goal partially met.

Patient ambulated with assistance of 2 to the chair at 9:30 pm.

***Note that if your goal is met or not met, you need to state what you would expect to find or what you found.[/TD]

[/TR]

[/TABLE]

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thank you very much! i am going to print this out. thanks again!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I hope this helps you and you need to get the NANDA I book it's cheap on amazon. It WILL make your life so EASY!!!!!!!!!!

[h=3]Nursing Diagnoses: Definitions and Classification 2012-14[/h]

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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

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Were you responding to a post? I merged it with the thread.....:)

Trouble with relating medical dx to nursing dx

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