Help with objective data

  1. I am using the dx Deficient knowledge in regards to DB&C excercises for my pt. I have objective data listed but feel I am missing something:

    Observation of inaccurate performance
    lung sounds
    family support
    lives alone
    morphine PCA and how much used

    Do I list more vitals for deficient knowldge? I feel more assessment stuff should be listed HELP! Thanks
  2. 2 Comments

  3. by   Daytonite
    you can include both objective and subjective data to support your nursing diagnosis. let me ask you why you think vital signs would have something to do with a patient's knowledge deficit? the definition of deficient knowledge, the nursing diagnosis, is: "absence or deficiency of cognitive information related to a specific topic." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 112.) the defining characteristics for this particular diagnosis are the following:
    • verbalization (the patient has stated) that the lack the knowledge
    • inaccurate follow-through of the knowledge (they are performing what they were previously taught incorrectly)
    • inaccurate performance (doing the thing wrong)
    • inappropriate or exaggerated behaviors (ex: being hysterical, agitated, apathetic or hostile while doing the actions)
    vital signs don't belong with this diagnosis as a defining characteristic. in fact, the only assessment data that you have to support this knowledge deficit is your observation of the patient's inaccurate performance.

    what you are missing is another nursing diagnosis altogether. you might want to consider ineffective airway clearance. that would account for all the other symptoms you mention and support that nursing diagnosis. you could then include the teaching of deep breathing and coughing with ineffective airway clearance or leave it in it's own nursing diagnosis if the patient has the other factors affecting his cognitive ability to learn to satisfy using deficient knowledge.
  4. by   Achoo!
    Thanks for your help. I had a tecahing project on this patient as well, which is why I went with knowledge deficit. I did have subjective data as well, and my intructor said the objective data I had was thorough. I guess my other care plans just had a longer list so I was worried. Thanks!