No, you don't have to use what NANDA says goes with a diagnosis, HOWEVER, you do have to keep whatever you do write with your diagnosis within the meaning of what the diagnosis is about. In their publication NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008
, which is a pocket sized book, they publish all current 188 nursing diagnoses, the definition of each, related factors (you know them as the R/T part of a nursing diagnostic statement) and the defining characteristics (the AEB part of a nursing diagnostic statement but these are actually the signs and symptoms of each particular diagnosis). These are all based on hundreds of nurses who have done research and study of them, put their information together and developed these guidelines. They published them so that we nurses don't have to sit there scratching our heads trying to come up with something to put in the R/T or AEB part of a nursing diagnostic statement and so it helps us to better understand what underlies the problem in the patients who have that particular nursing diagnosis. Choosing an etiology, or related factor, involves some critical thinking and an understanding of the pathophysiology of what is going on with the patient's disease process.
The overall main idea in writing nursing diagnostic statements as students and as new nurses is to help see the relationship between the nursing diagnosis, related factors and defining characteristics and help to learn and develop an understanding of the critical thinking that goes into it. The R/T part of the nursing diagnostic statement is the cause of the problem (in this case Excess Fluid Volume). The actual definition of this is "Increased isotonic
fluid retention" (page 91). The word, isotonic, refers to "having equal pressure" (page 1028, Taber's Cyclopedic Medical Dictionary
, 18th edition, published in 1997 by F.A. Davis Company.) This nursing diagnosis is specifically referring to osmotic pressure. We know, however, that blood pressure and changes in the vascular system can also be responsible for fluid retention. There are lots of people who have swollen feet and legs due to cardiovascular problems rather than electrolyte problems. There are other nursing diagnoses that are appropriate to use for patients with those underlying etiologies of their edema. It is important when choosing a nursing diagnosis that you understand the underlying pathophysiology of what is going on with the patient
. That is why I asked: why do you suppose she has this edema in her legs? I was trying to stimulate your thinking on this.
As I said previously, NANDA lists the following as related factors for this diagnosis:
- Compromised regulatory mechanism
- Excess fluid intake
- Excess sodium intake
But I did find another care plan author who used:
- renal dysfunction
- loss of plasma proteins
as R/T items for this diagnosis of Excess fluid Volume. The loss of plasma proteins would cause fluid to be pulled into the patient's intracellular spaces in order for osmotic fluid pressures to become equalized and result in the edema. This is very definitely a valid related factor that can go along with this nursing diagnosis (and I've written it into my NANDA book). That meets the definition of this nursing diagnosis (increased isotonic
fluid retention). When someone looses a lot of plasma proteins they develop anasarca, a condition where there is severe generalized edema throughout the entire body. You might see this in patients who have the medical conditions of nephrotic syndrome, pre-eclampsia or eclampsia. You would write a nursing diagnosis for something like this as:
Excess Fluid Volume R/T loss of plasma proteins AEB generalized body edema
The reason I wouldn't just use the +1 bilateral tibia pitting edema is because there should be edema in other areas of the body as well, not just the legs. Instead of using "generalized body edema" as the AEB item you could start to specifically list out all the areas of the body that you noticed the edema in. Some instructors might not want you to use the term anasarca saying that it is medical diagnosis. You might want to check with your instructors on that before using it.
Hope that helps clear things up for you a little bit. Your question was far from stupid. This business of nursing diagnosis is incredibly complex and takes persistence, time and a lot of working with it to master. Even I am always learning something new about it. I commend your courage to have posted on this. A good many others would have just skipped over it rather than tried to gain an understanding of it. I call that the old "sweep the dirt under the carpet" solution! You may manage to make it disappear for the moment, but it is, in reality, still there and eventually has to be dealt with.