Nursing Care Plans/Diagnosis

Long Term Care Columnist / Guide · Mar 12, 2015

Hello, and welcome to Allnurses! For best response to student questions, may I suggest posting future queries in the General Nursing Student forum. There you're likely to get more responses as it's geared specifically for the student nurse. I hope someone will come along soon to help you with your question, it's been almost 20 years since I've used nursing diagnosis for anything but the care plans I wrote in school. Best of luck to you.

madwife2002, BSN, RN · Mar 12, 2015

Moved thread to student forum for better responses

VeeVal · Mar 12, 2015

Thank you, I am new to this. I appreciate your response.

VeeVal · Mar 12, 2015

I am working on now my ageing process paper and I cannot find the proper nursing diagnosis for Anxiety with financial issues, I am working with a group on this paper and this is the Nanda project I was given. The scenario is the patient is 99 yrs old and along with other problems is she has " good days and bad days, and get very anxious about her financial issues." I thought to use anxiety, but I don't see anything for financial issues. i am wondering if I could use depression? Any help would be much appreciated.

nurseprnRN, BSN, RN · Mar 12, 2015

There is no such thing as "A Nanda." NANDA-I is an international nursing organization. Beyond that, I think the following will help you, and I'll get to the specifics at the bottom.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for instant download to your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk forâ€ diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. This poster is asking specifically for a ranking in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Third: This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning.

So, you should be prepared to present the reasoning you have applied to your diagnoses and priority ranking.

Now, as to your hypothetical elder, it's important to know what those "other problems" are. If there are only medical diagnoses given, them you may have a little more work to do, but you can also exercise your creativity more, by looking in your books and seeing what kind of symptoms of nursing diagnoses someone with those medical diagnoses may demonstrate. I can't tell you what they might be. You have to have some symptoms in mind, and then identify them in the lists of defining characteristics in the diagnoses you think might apply.

Looking at the nursing diagnosis of Anxiety (page 323), I find a very clear definition: "Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with that threat." Does this describe your (hypothetical) patient? If so, then you should be able to point to the reason(s) you made this diagnosis among the defining characteristics listed. Which of them did she demonstrate on your assessment? (You can make them up if you have to, for an imaginary patient. This is another place where your creativity comes in.)

It has a number of defining characteristics, under the headings of behavior, effective, physiological, sympathetic (this means sympathetic nervous system), parasympathetic, and cognitive. You would need to either specify or plausibly invent at least one defining characteristic in one, not all, of these headings to make this diagnosis.

There are many related factors, but major change (e.g., economic status environment, health status, role function, role status) seems to address a little information you have given us here.

Looking for the nursing diagnosis of Depression? :nono: There isn't one. "Depression" is a medical diagnosis. You can't make up a nursing diagnosis.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

VeeVal · Mar 12, 2015

Thank you so much for the information. I had the 2011 NANDA on my kindle from a previous RN program. It was so confusing and hard to navigate. I just purchased the NANDA-I 2015-2017 for my Kindle. I can see that it is more easy to find what I am looking for. You mentioned the other helpful books such as Nursing diagnoses, Outcomes, and Interventions. I just bought Nursing Care Plans 2010 could this be just as helpful?

Thank you for the information this is so helpful.

VeeVal

Whispera, MSN, RN · Mar 12, 2015

Anxiety r/t financial issues AEB -------

VeeVal · Mar 12, 2015

Thank you Whispera, I thought I had to use a NANDA r/t? I get very confused on these. Could I use Anxiety r/t Increase in wariness AEB financial issues, good and bad days and low-income living.

Home Health Columnist / Guide · Mar 13, 2015

Add to careplan "Refer to MSW for Long term care needs and financial counseling".

As homecare RN, > 60 patients don't have meds on first visit as unable to pay or not on insurance drug formulary. Getting Social work services started while in hospital helps to reduce med issues, inability to pay bills and hospital readmission rates.

nurseprnRN, BSN, RN · Mar 13, 2015

Thank you so much for the information. I had the 2011 NANDA on my kindle from a previous RN program. It was so confusing and hard to navigate. I just purchased the NANDA-I 2015-2017 for my Kindle. I can see that it is more easy to find what I am looking for. You mentioned the other helpful books such as Nursing diagnoses, Outcomes, and Interventions. I just bought Nursing Care Plans 2010 could this be just as helpful?
Thank you for the information this is so helpful.
VeeVal

The 2010 Nursing Care Plans is a problem, not the least reason of which is that it is not one, not two, but three versions behind of the current NANDA-I nursing diagnoses, it probably being based on (at best) the 2009-2011 issue, and more likely the one before that, given the amount of time it takes to get a textbook into production. A number of nursing diagnoses have been withdrawn since then, and terminology and defining characteristics much improved. You've already noticed the improvement in the latest issue compared to your old one.

You can't use an outdated manual for planning your nursing care or how to delegate it (an RN responsibility which you will also be learning) any more than you could use an out-of-date hematology text to teach you about current work in, oh, leukemia.

The other problem I have with "care plan books" is that students just copy them down into their work and don't learn anything much except copying skills. There's no critical thinking involved in copying. NO patient is just like any other; if you have four people with, say, diabetes, you cannot possibly assume that the care plan book's plan of care is appropriate for each of them.

Yet when students are assigned a "care plan handbook", it is almost always organized by medical diagnosis, which reinforces the totally wrong idea that nursing diagnosis is dependent on medical diagnosis AND discourages students from looking at nursing diagnosis as more broadly applicable to people with many different reasons for being in care.

As an example: Let's look at a nursing diagnosis that I have never, NEVER seen in a student plan of care, and hardly ever seen in any plan of care, "Ineffective sexuality pattern."

Ineffective sexuality pattern, Domain 8, Sexuality; Class 2, Sexual function

Definition: Expressions of concern regarding own sexuality

Defining characteristics:

* Alteration in relationship c significant other

* Alteration in sexual activity

* Alteration in sexual behavior

* Change in sexual role

* Difficulty c sexual behavior

* Difficulty c sexual activity

* Value conflict

Related (causative) factors:

* Absence of privacy

* Absence of significant other

* Conflict about sexual orientation

* Conflict about variant practice

* Fear of pregnancy

* Fear of sexually transmitted infection

* Impaired relationship c significant other

* Inadequate role model

* Insufficient knowledge about alternatives related to sexuality

* Skill deficit about alternatives related to sexuality

Now, I don't know about you, but when I had back surgery two years after I got married, I worried a LOT about sex with my sweet husband ("inadequate knowledge about alternatives related to sexuality"). I had awful pain that made movement and a lot of (umm, all but one) positions difficult or impossible ("alteration in sexual activity"). This experience made me learn to ask my back pain patients, when I did my initial eval, "When I ask you about sex, which of two common answers are you going to give me: 'Oy, it hurts so much I don't want to think about it,' or 'Oy, it hurts so much sex is the only thing that takes my mind off it!' ?" They laughed, but they all answered me one way or another. And by then I had developed and researched some alternatives to help them out, and the ability to communicate them (the plan of care).

Now, if you're a nursing student with a back surgery patient, you're going to think about assessing for and making plans to address pain, knowledge deficit about postop care, risk for infection, risk for injury, mobility, and self-care deficit. And you'd be right. But then you'd miss a golden opportunity to look at your patient as more than "the back surgery in 201B," and assess and address a very significant part of his (or my) life. THIS is why you don't want to use a "care plan handbook" that's dedicated to the proposition that all nursing plans of care stem from medical diagnosis.

Whispera, MSN, RN · Mar 13, 2015

I'm not aware that NANDA has specific "related to" parts. If you refer to a what GrnTea wrote in another thread about the same situation, you'll see lists of the NANDA diagnoses. They are short phrases. You use them as the beginning part of your care plan nursing diagnoses and add the details from what you assess in your patient.

So, the format for a care plan would be:

NANDA phrase from the list...R/T -----... AEB ----

The R/T part is what caused the diagnosis. The AEB part is what tells you the diagnosis and its cause are possible.

Nursing Care Plans/Diagnosis

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