I HATE NANDA!!!! - page 2

I believe a nursing diagnosis should drive the nursing process. You collect data (assessment), then define the patient's likely problem(s) (diagnosis), determine where the patient needs to be... Read More

  1. Visit  GrnTea profile page
    4
    i agree with you, (and i totally sympathize with you) but not for the reason you think. i think that students do not learn the full ramifications of assessment. doh, yeah, i know, they're students. but in my opinion, the patient in your example doesn't have a ventilation problem. as you note, he has a gas exchange and oxygen delivery problem and a vq imbalance. so why do students think this is just an air-in, air-out problem? somebody neglected to teach them physiology and nursing assessment to make nursing diagnosis, that's why. thus:

    activity intolerance: (insufficient physiological or psychological energy to endure complete required or desired daily activities (domain 4 activity/rest, class 4: cardiovascular/pulmonary responses)) related to hypoxemia due to intrapulmonary shunt (secondary to pneumonia) aeb %sat 89 on room air, respiratory rate of 28, tachycardia and fever" and probably increased sob with minimal activity. that will lead the student into ways of thinking how this can be addressed from a nursing standpoint in a addition to applying the medical plan of care. can we teach this higher order thinking? gawd, i hope so. else all we get is "iv antibiotics and treatments as ordered, continue to monitor." that's when i start looking around for the sharp sticks.

    "this "diagnosis" (ineffective breathing pattern) is equally suitable for the dying patient with cheyne-stokes respirations, the 18 year old trauma victim with a c3 cord transection, a 10 year old asthmatic who is ready to crash and burn, or an 80 year old post belly-surgery patient who won't use the incentive spirometer and is getting atelectasis."

    might be, depending on what is going on. (i know you know all this stuff, i'm just summarizing for those who don't)
    the cheyne-stokes, ok, not an effective breathing pattern...but also not much of a problem in the infinite scheme of things; more important stuff going on.
    the 18-yr-old, maybe not an effective breathing pattern due to neuro loss, but might be tied with ineffective airway clearance: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway (domain 11: safety/protection, class 2: physical injury) to do a decent job of planning nursing care.
    the 10-yr-old, his breathing is ineffective, alright, and what's the matter with knowing why (airway constriction) and what's to be done about it (bronchodilators, sedate/paralyze/vent, whatever that all leads you to)
    the 80-yr-old, that is an ineffective breathing pattern-- he won't deep breathe and he's getting atelectasis as a result. nursing can surely figure out what to do to help him with that.

    as an analogy from the medical side, this is why we have differential diagnosis. you have to look at lots of things before you can develop a treatment plan. and even though some people may have the same findings, say, a hypoxic left toe, there are all sorts of reasons this could be happening and different ways to treat it depending on what it is. (e.g., femoral clot, chf, copd, co poisoning, cyanide, vsd with r>l shunt, sepsis, massive vasoconstriction...)

    i agree that seeing "ineffective breathing pattern" all day long does induce the introduce-sharp-sticks-to-bilateral-foveas response. and just how far can a nursing program go to teach students how to do it better than that? how far are they willing to go?
    VivaLasViejas, VickyRN, nursel56, and 1 other like this.
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  3. Visit  SHGR profile page
    0
    Grntea, the way you describe the NANDA diagnoses, they make sense and seem to have value. The way they were taught to us in undergrad was not like that. They were more like, a platform for delineating nursing tasks. We didn't get to that higher-level process, that meta-level of thinking- that wasn't even presented as a possibility.
  4. Visit  nursemarion profile page
    4
    Oh I agree that care plans are a valuable learning tool. So much of it does not fit reality though. And the fact that they still use them in real work situations really irks me. So much more can be put across in simple terms:

    Problem:
    Dyspnea related to Exacerbation of COPD or even just Exacerbation of COPD

    Nursing Interventions:
    Elevate the HOB
    Allow rest periods
    Check Lung sounds q shift

    Etc, etc, etc. That is all you need.

    I agree we are not SUPPOSED to use medical diagnosis but it is more sensible and useful to formulate a care plan around a medical diagnosis. Weeping Edema, Poison Ivy, Decubitus, etc. So much easier than Alteration in Skin Integrity, or whatever the current NANDA term is. Once we understand the concepts of A + B = C then we should not have to keep proving over and over again that we can think like a nurse. We have the license, we passed the clinicals and the tests, took the boards and now we should be able to just do what we are trained to do. Physicians do not have to explain their diagnostic process, they look at the patient and the tests, and formulate a diagnosis. Why can't we let them do the diagnosis then we use what interventions we are trained to use to help the patient?

    I think we make ourselves look like we are trying to prove that we know something by continuing to fill space with unnecessary verbage. Keep it simple and save costs, time, stress, and improve nursing morale. Nurses do not want to be chained to paperwork, they want to be out caring for patients.
  5. Visit  Aurora77 profile page
    3
    Quote from nursemarion

    I agree we are not SUPPOSED to use medical diagnosis but it is more sensible and useful to formulate a care plan around a medical diagnosis. Weeping Edema, Poison Ivy, Decubitus, etc. So much easier than Alteration in Skin Integrity, or whatever the current NANDA term is. ....

    I think we make ourselves look like we are trying to prove that we know something by continuing to fill space with unnecessary verbage. Keep it simple and save costs, time, stress, and improve nursing morale. Nurses do not want to be chained to paperwork, they want to be out caring for patients.
    Therein lies the problem for me. The nursing diagnosis/plan of care is determined by, and relies upon, the medical diagnosis. Nursing is dependent upon medicine, just as the medical is dependent upon the nursing. I know that's not popular and we have to have our own convoluted "language" to prove that we're separate, but I fail to see how we are. For nurses to be good at what they do, they have to have an understanding of what doctors will do--treatments, meds, etc. They have to be able to understand the rationale for current care and anticipate what will be done next. Until nursing diagnoses and care plans actually take this into account, I feel like they do students and nurses a major disservice.
  6. Visit  tewdles profile page
    2
    I do not agree that the nursing diagnosis is determined by and relies upon the medical diagnosis. The nursing diagnosis is determined by the patients health status and deviation from normals for that patient.

    While NANDA is cumbersome, it works well in the hospice setting where the POC is based upon the nursing process. In that setting, the fact that the dyspnea is caused by COPD vs. E/S CHF simply adds to the individualization of the plan to care for the nursing problem. The nursing actions include, but are not limited to, the medical interventions. This becomes important because hospice nurses are generally teaching the family/care givers how to provide the nursing care necessary to relieve the dyspnea.

    I can understand the difficulties in the acute care setting, the practice of nurses in that setting is really more medically oriented than it is nursing oriented. Most nursing goals in the hospital ARE directly related to and rely upon the medical diagnosis and treatment plan rather than the nursing process.
    Last edit by tewdles on Mar 31, '12 : Reason: content
    GrnTea and SHGR like this.
  7. Visit  annietart profile page
    4
    I love that I don't have to use NANDA for school. We also don't do care plans either. We use SBAR and the nursing process to create a concept map that has all pieces of the patient tied together as we care for them. It's really an effective way of learning how to be a nurse, because rather than studying the pt's data the night before and creating montrous care plans. We get our assignment at clinical start, take report, go through the chart, notes, meds and labs and do a primary physical assessment. From there we map put all of the patient's immediate needs and goals, and then long term goals and needs.

    It's really taught me how to think on my feet and for myself rather than following a care plan book. We develop our own style of concept maps and no two are alike.
    GrnTea, SHGR, Aurora77, and 1 other like this.
  8. Visit  Pneumothorax profile page
    0
    this thread makes me want to jab my eyes out.

    green tea- as always your posts are chock full of knowledge


    NANDA can kick rocks...
  9. Visit  dabearrn profile page
    2
    Yup hated NANDA as a student and as a practicing RN. I felt it was nothing more than a time suck. Although, I find it an excellent tool for an adjunct in teaching pathophysiology. It really forces students to think about what is REALLY happening PHYSIOLOGICALLY. I also add - "Due to" after AEB in our Nsg Dx to make sure the students are aware of the medical situation as stated above.
    GrnTea and tewdles like this.
  10. Visit  jmqphd profile page
    1
    Quote from dabearrn
    Yup hated NANDA as a student and as a practicing RN. I felt it was nothing more than a time suck. Although, I find it an excellent tool for an adjunct in teaching pathophysiology. It really forces students to think about what is REALLY happening PHYSIOLOGICALLY. I also add - "Due to" after AEB in our Nsg Dx to make sure the students are aware of the medical situation as stated above.
    I agree. Care Planning makes students identify the patient's problem and explain the proximal cause(s) of the problem then provide assessment evidence for it... these things are golden. They put flesh on the pathophys bone. You can talk patho till you're blue in the face, but when students see it in front of them and then have to grapple with the consequences of the disease process... WOW! You can almost watch the lights come on.

    Very cool.

    But I don't agree that NANDA is necessary for that to happen and actually would argue that it gets in the way.

    First, making students adhere to NANDA officially approved "diagnoses" inhibits intellectual growth. It's as if their thoughts about the patient and his/her disease only matter if they can select the right pigeon hole to stick them in. Only the authorized diagnoses are allowed!

    I have totally dropped the term "diagnosis". I tell the students to (I know this sounds radical!!!) "tell me what the patient's problem is." Damn... I'm such a rebel!

    Secondly, NANDA is a crutch. Once I've found the most likely officially approved "diagnosis" it doesn't matter how much data I have that doesn't match up. If NANDA says that's the closest "diagnosis" well... that's as far as the student has to reason.

    I DO stick with Maslow to make them explain their reasons for how they prioritize their "problem statements". And I stick with NANDA syntax. But I STILL HATE NANDA.
    tewdles likes this.
  11. Visit  KeepHopeAlive420 profile page
    0
    Hmm...so this is why one of my instructors constantly made me change my problem statement despite me pulling it STRAIGHT from my book? Are you that instructor? lol!
  12. Visit  Dharmamom profile page
    0
    Wow! Thank you for giving voice to a long held frustration.

    Years ago as an ADN and then an RN-BSN student, I found the nursing diagnosis system useless and demeaning to nurses. It seemed like its sole purpose was to provided alternative terminology for nurse so they didn't step on the doctor's toes by using their proprietary medical diagnosis. The whole system seemed convoluted and insincere. It certainly did not facilitate my clinical reasoning nor help me understand my patients better.

    When I began working in the real world I was relieved to discover that the nursing diagnosis system only received token acknowledgement on admission when the initial care plan was written. After that the focus shifted to the intervention plan and the diagnoses were never mentioned again.

    Several years ago when I began to consider pursuing a masters degree, my distaste for the nursing diagnosis system was a major stumbling block. I could not stomach the thought of devoting hours of study to nursing theories that might use nursing diagnosis as a foundational principle. This ultimately led to my choice of a masters program in another health related field, not nursing.

    As I read this thread I am encouraged to see that I'm not alone in my dislike of nursing diagnosis & that at least one nursing school is moving away from its use. I hope this is the start of a trend.
  13. Visit  edmia profile page
    1
    Quote from jmqphd
    I believe a nursing diagnosis should drive the nursing process. You collect data (assessment), then define the patient's likely problem(s) (diagnosis), determine where the patient needs to be (goals) then design care to get them there (actions). Followed of course by evaluation and re-designing care based upon results.

    How in the world can a NANDA statement drive clinical reasoning? I read student care plans daily. If I see the term "Ineffective breathing pattern" again I will absolutely poke sharp sticks in my eyes.

    This "diagnosis" (ineffective breathing pattern) is equally suitable for the dying patient with Cheyne-Stokes respirations, the 18 year old trauma victim with a C3 cord transection, a 10 year old asthmatic who is ready to crash and burn, or an 80 year old post belly-surgery patient who won't use the incentive spirometer and is getting atelectasis. Puh-leeeze!

    Why not just state what is wrong with a patient? How about

    "Hypoxemia related to intrapulmonary shunt (secondary to pneumonia) AEB %sat 89 on Room Air, respiratory rate of 28, tachycardia and fever"

    or something like that? It isn't a medical diagnosis and by golly, it immediately identifies the types of goals and actions that logically follow.

    I have found NANDA to be an insurmountable obstacle to teaching students clinical reasoning. They work with their patient for the day, then that night, pull out their "nursing diagnosis" text, run their finger down a list of "diagnoses" and pick something that seems to fit the majority of their assessment findings. And from there, the care plan spirals down to a bunch of superficial blather.

    Said enough. I'm sure I'm going to be flamed, but I just needed to vent.
    Why flamed? You are actually using your brain and pointing out the obvious. Thank you.

    Of course, I agree with you. Recently I read a post by a nursing student who wanted advise on what NANDA diagnosis to use. The case was an older man coming in with vitals that fit a sepsis protocol like you wouldn't believe yet the student was trying to figure out if Inappropriate Nutrition ( or whatever it's called) would be his primary diagnosis because the guy had lost 5 lbs in the last few weeks. I mean, the man was going to be an RRT in about an hour, but the student could not see the real picture as she was trying to fit her patient to the diagnosis.

    NANDA diagnosis are a huge disservice to nurses.

    Sent from my iPhone using allnurses.com
    Dharmamom likes this.
  14. Visit  Whispera profile page
    1
    When I was in my Master's program, we used medical diagnoses....hmmm...I thought that's how it was everywhere.

    And....my personal favorite: "Spaghetti brain related to nursing schools as evidenced by confusion, sleepiness, and a strong urge to either run away or hit the instructor."
    Dharmamom likes this.


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