Nursing Diagnosis.... HELP!
- 0Nov 2, '12 by rowdysmommaI had a pt that was just finding out that she has bone cancer. I wanted to use a nursing diagnosis of "Grief R/T loss of health status AEB recent diagnosis of bone cancer, pt states a fear of what it to come, and pt's overall lack of interest in care." Does this work?? My clinical instructor is very difficult to please so since I don't have an awesome amount of evidence for this diagnosis, I am VERY hesitant to put this... Any help would be very appreciated!!!
- 0Nov 2, '12 by justin.jHey there,
So, I'll preface by saying that I'm also a student, so hopefully someone with more experience than me will weigh in! However, since there are no responses yet, these are my thoughts.
With your current diagnosis, if your professor is a stickler like mine, make sure you use the exact NANDA wording for any diagnosis. For example, NANDA doesn't use "Grief", but they do use "Grieving". I would get knocked down a point if I don't use the exact term. Also, I would make sure you don't include "recent diagnosis of bone cancer" in your AEB, or symptom section. Since we're using the PES (Problem, Etiology, Symptom) format, the diagnosis of cancer isn't actually a symptom of the grief, but perhaps a cause? So, you could consider something like: Grieving R/T recent diagnosis of bone cancer AEB (fill in the blank with appropriate symptom)
But, to be quite honest, I probably wouldn't use grieving for this pt., because as I understand it, grief is usually associated with the loss of a significant object or other. I think it's a little harder to diagnose someone with grieving the loss of their own life. Certianly not saying it can't be done, and perhaps someone with more experience could weigh in here. but I personally would be a little scared to use that diagnosis.
I might go with "Death Anxiety" or perhaps something like "Hopelessness".
Ie: Death Anxiety R/T recent diagnosis of bone cancer AEB patients report of fear of the process of dying.
Hopelessness R/T recent diagnosis of bone cancer AEB patient's lack of involvement in care.
Again, I'm definitely not an expert, but I hope that helps you out a bit. Would like to hear what others have to say as well. Good luck!
- 1Nov 7, '12 by Esme12, BSN, RN Senior ModeratorQuote from rowdysmommaWelcome to AN! The largest online nursing community!I had a pt that was just finding out that she has bone cancer. I wanted to use a nursing diagnosis of "Grief R/T loss of health status AEB recent diagnosis of bone cancer, pt states a fear of what it to come, and pt's overall lack of interest in care." Does this work?? My clinical instructor is very difficult to please so since I don't have an awesome amount of evidence for this diagnosis, I am VERY hesitant to put this... Any help would be very appreciated!!!
Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT... what care plan book do you use.
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.
Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.
Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE
- Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- Planning (write measurable goals/outcomes and nursing interventions)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.
What I would suggest you do is to work the nursing process from step #1.
Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.
What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.
Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.
This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? There is not enough information about the patient to develop a good ND.
- 1Nov 9, '12 by rowdysmommaWOW!!!! Esme12!!! YOU ARE AWESOME!!! I just got a better idea of what I am supposed to do from you than I did from anyone else I have talked to. I did not use that nursing diagnosis for my patient and dug for more clues. I am going to be using this method for my next care plan and hopefully get the grade I want. I had been using my assessment to guide me but I think I was looking at only the surface.
THANK YOU SO MUCH!