Case Study of ADPIE: Diagnosis (Nursing)

00:00 So once we gather all that information, right, we're going to start using this information to help create a diagnosis.

00:08 Again, a nursing diagnosis for a patient.

00:10 because that's within our scope of practice.

00:13 We are not using any medical diagnosis here.

00:16 So we're going to cluster all this information and all these defining characteristics.

00:21 We're also going to identify the patient's needs.

00:24 In all that information, we're going to formulate a nursing diagnosis.

00:29 So with Mrs. Meyer, we're going to take all that information she gave us from our health history, our head to toe assessment, and our focus assessment.

00:37 So let's review all that information that we gathered.

00:41 When we looked at that health history, we know Mrs. Myers has a history of high cholesterol, has lung disease, and she does have some psychosocial support where she lives at home with her husband.

00:53 Now, when we did our head to toe assessment, we got information that her oxygen level was pretty good at two liters at 94%.

01:01 She did have a pretty high pain score at that right hip at a 7 out of 10.

01:06 And of course, she did have that surgical incision on her right hip from surgery.

01:11 And again, if you notice the last, just to recap all the information we got, we have on focused assessment, her lungs were clear with some diminished bases.

01:20 And of course, her surgical incision, luckily, it was normal and appearance post surgery.

01:25 So, the main piece here that we've got a lot of information, right? From our health history, our head to toe, and are focused.

01:33 This is where it's important to start clustering information.

01:38 So we're going to do this to help formulate our plan of care.

01:43 So you see here in these boxes that are highlighted, we're going to cluster this information of her having a pain score out of 7 out of 10 in her right hip, with of course, her focus assessment information that that pain score is probably coming from that surgical incision that we received, or we've noted on that focus assessment.

02:03 Some other important information to gather about Mrs. Meyer is we know she has a health history of COPD or lung disease.

02:11 Now, it's important again to connect the information that her oxygen level is supported on two liters.

02:19 And also, what the status another piece of a respiratory system is auscultation.

02:25 We listen to her lungs on that focus assessment.

02:28 Her lungs were clear. She did have some diminished basis.

02:31 So as you can see here, we're clustering information together.

02:35 You see, when we're talking about Mrs. Meyers, we had all that information.

02:39 But we started making connections that with her O2 level, her lung disease, and auscultation of her lungs, you see that we have oxygen problems that we need to consider.

02:51 Also, with all that other information, we cluster the information of her surgical incision, causing her hip pain.

02:58 And then there's other information that we may need to keep in mind.

03:03 But notice these are the two priority issues: Oxygen, and hip pain for our patient for Mrs. Meyers today.

03:13 So after we gather all that information, we started the cluster that and identified two major problems there for Mrs. Meyers.

03:20 We know she had oxygen issues, and also pain from that surgical incision.

03:25 So now that we've done this, we can formulate our NANDA diagnosis.

03:29 So here, we've got those important pieces of that NANDA statement. That's really useful for you to use as your care plan in nursing school.

03:38 So we're going to start with that nursing diagnosis in our NANDA.

03:42 Then we want to make sure we connect the cause, and those signs and symptoms that go along with this to make it individualize to our specific patient.

03:50 So let's take a look at some examples for Mrs. Meyers.

03:53 So we're talking about the oxygen issue, we use the NANDA statement impaired oxygen exchange.

03:59 This gives us a precise definition of some of the oxygen issues that we're having with this patient.

04:06 Now, our cause here is related to a chronic condition.

04:10 This is the cause of that impaired oxygen exchange.

04:14 So I want to take a moment here just to note this related to.

04:19 Notice we're not saying related to her COPD, because why? Remember, COPD is a medical diagnosis and is not within our scope of practice.

04:30 However, many times as a nurse, we know her oxygen exchange is really related to that disease process or that chronic condition.

04:38 Therefore, the wording you see here.

04:41 Now plus, this is evidence by of course what we see is our signs and symptoms, or otherwise her need of her two liters of oxygen to maintain her oxygen level.

04:51 So, that's going to look like all together is impaired oxygen exchange related to her chronic condition and that's evidenced by her need and her use of that two liters of oxygen.

05:03 So now let's look at it in another form with her hip pain.

05:07 So we've got her main issue, her NANDA issue is of course acute pain.

05:12 Now what's the cause of that, guys? You remember? Well, she had surgery, right, on her right hip.

05:17 That makes a lot of sense.

05:19 And that's the cause of her NANDA issue.

05:21 Now, how do we know? What is that evidence by? What evidence that she's reporting a pain score of 7 out of 10? So all together, that's going to look like acute pain related to the cause, which is that surgery on her right hip, and it's evidenced by her report that she has a pain score of 7 out of 10.