Quote from meonemine
ok the diagnosis was from an assessment it was a nursing diagnosis related to health issue that the client was dealing with
I think your problem is that you do not have a good understanding of what a nursing diagnosis is versus a medical diagnosis.
Nurses do not diagnose medical conditions.
Nurses "diagnose" based on an assessment
Nanda Care Plan for Anxiety | NCP NANDA
The Nanda has this suggestion :
Nanda Nursing Diagnosis for Anxiety
- Breathing pattern, ineffective
- Individual coping, ineffective
- Verbal communication, Impaired
Now - your job as a nurse is to look at it at develop a care plan with items that will help the patient to cope or make "things better". Physicians typically will diagnose a condition and prescribe medication, lifestyle changes, perhaps refer to a therapist and so on.
Nurses address this problem in a different way. Yes - you would give the medication that the MD has ordered but there is more. When you go to the above webpage there are examples of implementations and evaluations.
Practical example to make it more real from my daily work as a nurse in palliative care hospital team:
50 y old male with advanced metastatic disease (cancer), no chemotherapy, had some radiation, no other therapies available.
I see the patient for an initial nursing visit and conduct a nursing assessment
. I notice with the assessment that the patient is avoiding to talk about the diagnosis, starts to shake, appears anxious, his breathing gets fast and labored. He says "I can't breath". His family reports that they are having a hard time because he started drinking alcohol regularly especially in the evening to help him fall asleep but he wakes up at night and wanders around in the house. He fell already 2 times. His wife is worried because he is not eating and drinking well and when she tries to talk to him about the illness he gets angry. She would like to talk to him about "the future" but he walks out the room or turns the TV on.
The MD has recommended hospice care but the patient does not wish to start hospice care because "I am not giving up - the cancer doctor said that there could be a new cure right around the corner".
So - my nursing diagnosis could be :
1. breathing pattern ineffective
2.individual coping ineffective
4. Imbalanced nutrition - less than body requirement
5. Knowledge deficit - disease process , symptom control, end-of-life options
6.impaired family process
Now after I identified what needs to be addressed I think about a goal because nursing process should be intentional - right ? We are a profession and think about what we are doing.
Some goals could be :
Patient will be able to recognize symptoms of anxiety and use deep breathing to slow down respirations within 7 days
Patient verbalizes understanding of his medical illness within 3 days
Patient communicates effectively with family about advanced directives within 7 days
I might even break it down further if I am seeing a patient several times.
I think it is hard to see the whole potential of the nursing diagnosis and the planned nursing process. It is even hard to see how this is beneficial for a lot new nurses or even experienced nurses because in reality most bedside nurses spend their shifts with an endless list of "tasks" without much time to reflect on what nursing intervention could be appropriate.
Your day may be totally consumed by medication administration, wound care, tube feeds, some teaching, admission and discharges to the extent that you do not have the time to reflect on the individual care goals and care plans
Every patient should have at least 2 nursing diagnosis, which are knowledge deficit and discharge planning - anything else depends.
It is important to reflect and think about what we are doing as nurses.
There is a difference between other nurses or MD asking "what is your goal for palliative care" and me saying "the usual - I will give him a brochure" or me saying
"I will come back tomorrow after the patient has received medication for anxiety and talk about coping strategies for patients with advanced cancer, talk about nutrition and hydration strategies, I will help the patient with a list of questions to ask the oncologist to structure their conversation and to facilitate understanding of dx and prognosis, I will refer to social work for additional support, I will ask the patient about spiritual needs, I will meet with the wife to offer empathic listening and assess if there are additional resources I can offer. I will come back tomorrow and schedule a joined meeting for the patient and family to meet with our palliative care physician and the oncologist."
It is really about thinking what you are seeing, the problems and to make a plan that will actually help.
Another example :
I see patients with endstage heart failure - my assessment reveals that the patient drinks 3 liters of water a day instead of 1.5, eats a lot of salty snacks, does not take medication regularly, does not move much other than to the kitchen, the family does not cook - they eat "ready meals and do not understand the diet restriction.
So beside "knowledge deficit" and "discharge planning" I would also add "excess fluid volume" and "exercise intolerance" and "fatigue" and plan the goals, interventions and evaluation.
goal: patient can verbalize clearly how many cups of water he can drink a day, the consequences of too much fluid, patient can identify sodium content on food label, alternative sources of food - meals on wheels ...
intervention could be teach
patient to monitor fluid intake to track amount of fluids
teach strategies to cope with thirst
I hope that helps!It is about putting the bigger picture together.