1) Risk for infection
2) Imbalanced nutrition
3) Activity intolerance
4) Caregiver role strain
5) Acute pain
Each diagnosis is normally followed by: "related to" and "as evidenced by." The information that helps make up these diagnoses is patient specific and may change from shift to shift. I will provide an example below so that it is easier to understand just what a nursing diagnosis is for a patient. Please note that this case is completely fictional and will only useful for the purpose of explaining a nursing diagnosis.
The case and diagnosis:
A 2-year-old patient was diagnosed with neuroblastoma. His treatment plan included surgery and radiation to remove and shrink the tumor. Nurses are responsible for caring for this patient post-operation and post-radiation therapy.
One likely diagnosis:
Acute pain related to previous surgery as evidenced by grimace and cry from child during movement.
Once a nurse realizes actual and potential nursing diagnoses, she uses these to guide her plan of care. The remaining parts of care include the anticipated or expected outcome of the patient as well as any interventions that the nurse may provide to meet care needs. In the instance of the example case above, a likely outcome would be that the patient's pain would be controlled during the nurse's shift. This goal would be achieved by providing appropriate measures to reduce pain and would be evident when the child does not cry or grimace. Appropriate measures may be something like administering ordered pain medications as scheduled or using distraction with toys to soothe the patient.
Original picture found here |
Well, we have come to the final post for my assignment...
Thanks for reading!
This blog is dedicated to my nephew who was diagnosed with neuroblastoma just weeks after being born. He is such a blessing and life would not be the same without him!