Need help with primary nursing diagnosis #failure, #bleeding, #with, #lower, #nursing, #diagnosis, #admitted, #care, #primary,


Posted On Sep 20 2017 by

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Need help with primary nursing diagnosis

Oct 2, ’08 by Daytonite

care plan books are only good in helping with commonly encountered medical problems. if you fail to learn how to develop a care plan from scratch and depend on copying them from care plan books, you will delay in learning how to think critically. you need to use the nursing process to solve this dilemma. this is how the nursing process is used to care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl’s, look up information about your patient’s medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient’s ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor’s history and physical, information in the doctor’s progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
      • use: http://allnurses.com/forums/f205/med. es-258109.html – medical disease information/treatment/procedures/test reference websites
  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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
    • your instructors might have given it to you.
    • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
    • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
    • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber’s cyclopedic medical dictionary and mosby’s medical, nursing, allied health dictionary
    • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
      • http://www1.us.elsevierhealth.com/ev. e/constructor/
      • http://www1.us.elsevierhealth.com/me. ctor/index.cfm
  3. planning (write measurable goals/outcomes and nursing interventions)
    • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
      • improve the problem or remedy/cure it
      • stabilize it
      • support its deterioration
    • interventions are of four types
      • assess/monitor/evaluate/observe (to evaluate the patient’s condition)
        • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      • care/perform/provide/assist (performing actual patient care)
      • teach/educate/instruct/supervise (educating patient or caregiver)
      • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

step 1 assessment – collect data from medical record, do a physical assessment of the patient, assess adl’s, look up information about your patient’s medical diseases/conditions to learn about the signs and symptoms and pathophysiology – look up information about gi bleeding and what the signs and symptoms are. lower gi bleeding in the small intestine is very difficult to diagnose, let alone find. if a lesion or polyp in the colon can be identified–great. however, i was a med/surg nurse for many years and saw lots of patients who came in with a diagnosis of unknown site of gi bleeding for transfusion after transfusion with their only symptoms being low h hs. my oncologist says that cancer in the small intestines is rare, but it does occur. irritable bowel syndrome and crohn’s disease can also cause some gi bleeding in the small intestines. the result is signs and symptoms of blood loss anemia. you also should look up the signs and symptoms of dementia and hypernatremia. since the patient is having a colonoscopy there will need to be a bowel prep. don’t forget to check the complications of these things.

  • medical conditions
    • lower gi bleeding
    • rule out ulcer
    • dementia
    • hypernatremia
  • medical treatments
    • colonoscopy tomorrow

step #2 determination of the patient’s problem(s)/nursing diagnosis part 1 – make a list of the abnormal assessment data – this is all the data you provided. what were the symptoms of the dementia? any symptoms of anemia? what kind of incontinence did this patient have: bowel, bladder or both? is the skin at risk of breakdown as a result of the incontinence? since this patient has dementia, are there problems with accomplishing adls or mobility?

  • incontinent
  • bleeding from the rectum

step #2 determination of the patient’s problem(s)/nursing diagnosis part 2 – match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use –

  • deficient fluid volume
  • bowel incontinence/total urinary incontinence

To the OP I notice you threw in a lot of doctors diagnosis in the mix. Their diagnosis is a good way to see what direction youre going but focus more on the patient, and the patients needs. Also keep in mind what you as a nurse can treat, and everything should be clearer to you

I have a patient that has hepatic hypertension causing E/G varices, hepatic encephalopathy, protuberant ascites with fluid wave and + 1 edema in his hands and feet. What can I do for a pt teaching nursing diagnosis? His family has not been available except by phone. Would you pretend to teach the family? Also, many of the things I would normally do, they are not doing because his liver failure is so advanced. For example, he has significant fluid deficit with concentrated yellow urine, dry mucus membranes and slack tugor, BUT they are restricting his fluids to 50 ml in his IV PGBK, the fluid you need for NG tube medication and oral care on a stick sponge. I am doing stuff like comfort measures with lotion and oil, monitoring IO, daily weight ect, but can’t directly fix the problem. What do you suggest?
Also, does Jaundice have a ND?

Oct 2, ’08 by Daytonite

i have a patient that has hepatic hypertension causing e/g varices, hepatic encephalopathy, protuberant ascites with fluid wave and + 1 edema in his hands and feet. what can i do for a pt teaching nursing diagnosis? his family has not been available except by phone. would you pretend to teach the family? also, many of the things i would normally do, they are not doing because his liver failure is so advanced. for example, he has significant fluid deficit with concentrated yellow urine, dry mucus membranes and slack tugor, but they are restricting his fluids to 50 ml in his iv pgbk, the fluid you need for ng tube medication and oral care on a stick sponge. i am doing stuff like comfort measures with lotion and oil, monitoring io, daily weight ect, but can’t directly fix the problem. what do you suggest?
also, does jaundice have a nd?

what can i do for a pt teaching nursing diagnosis. would you pretend to teach the family?

that would be dishonest, wouldn’t it? assess the patient’s teaching needs. there are several ways to diagnose and handle a learning need.

. many of the things i would normally do, they are not doing because his liver failure is so advanced.

this sounds like a learning need.

also, does jaundice have a nd?

jaundice is a medical diagnosis. nursing diagnoses are based upon patient symptoms and abnormal data (see my other post above) and have little relationship to medical diagnoses.


Last Updated on: September 20th, 2017 at 9:05 am, by


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