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.Įvery single nursing diagnosis has its own set of symptoms, or defining characteristics. what you want to happen as a result of your caring for them. your plan of how you are going to care for them. Think of the care plan as a recipe to caring for your patient. It is trying to teach you how to think like a nurse. From what you posted I do not have the information necessary to make a nursing diagnosis.Ĭare 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. 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. It is what the patient has not necessarily what the patient needs. The medical diagnosis is the disease itself. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is your assessment? What are the vital signs? What is your patient saying?. Let the patient data drive the diagnosis. You need to assess your patient, collect data then find a diagnosis. You need to know the pathophysiology of your disease process. Do not try to fit the patient to the diagnosis you found first. Why was she admitted? What were her labs? Why was she chair bound? What were her labs? What is her history?Let the patient/patient assessment drive your diagnosis. Care plans are all about your assessment. You are in the spot nursing students get ciding a nursing diagnosis then try to make the patient fit.
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