assessmentso that apply to diagnosis

nutella, MSN, RN · Mar 14, 2017

I'm having a hard time with this on a care plan..ok if the diagnosis are anxiety what does it mean when it says Assessments that apply to diagnosis please help me..thanks

Can you elaborate on what it is that you do not understand and what your thoughts are?

Do you have the course book / text book?

meonemine · Mar 14, 2017

yes I have the book NANDA. & in the care plan it says assessments to the diagnosis. but the client was diagnosed with anxiety

sallyrnrrt, ADN, RN · Mar 14, 2017

What are your thoughts on this

Susie2310 · Mar 14, 2017

I assumed you are referring to anxiety as a nursing diagnosis not as a medical diagnosis. Also, you didn't say what the anxiety is related to/presumed to be related to. Some assessments I can think of for a nursing diagnosis of anxiety are: What the client perceives as triggers for their anxiety/what the client experiences as the cause/s of their anxiety; severity and frequency of their anxiety; effects of anxiety on the client and on their ability to function in their life; client's normal coping mechanisms and how well they work; client's support system; client's knowledge of community resources that could help him/her manage their anxiety; client's desire to receive help from a qualified professional for their anxiety; efforts client has made at managing their anxiety - what they were and how well they worked; factors that make the client's anxiety better or worse and factors that are within the client's power to change; client's interest/willingness in trying meditation to help with their anxiety.

Double-Helix, BSN, RN · Mar 14, 2017

yes I have the book NANDA. & in the care plan it says assessments to the diagnosis. but the client was diagnosed with anxiety

Was the patient diagnosed with anxiety by the medical team, or did your assessment of the patient point you to a nursing diagnosis of anxiety?

These are very different.

Your care plan needs to be driven by nursing diagnoses. Did you do an assessment of the patient? What did your assessment reveal? Using your NANDA list of nursing diagnoses, which ones best fit your assessment of the patient? You make nursing diagnoses based on your nursing assessment, not the patient's medical diagnosis.

meonemine · Mar 14, 2017

ok the diagnosis was from an assessment it was a nursing diagnosis related to health issue that the client was dealing with

nutella, MSN, RN · Mar 15, 2017

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
Anxiety
Powerlessness
Fear

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

3.impaired communication

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.

meonemine · Mar 15, 2017

omg!!! this does help so much..thank you very much

Susie2310 · Mar 15, 2017

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
Anxiety
Powerlessness
Fear
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
3.impaired communication
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.

This is good, but I wanted to add that the way I was taught (and possibly you meant this, but because you didn't state this I didn't assume it), goal setting was to be done in collaboration with the patient and their family. Otherwise it is just us (nurses) with our ideas about what the patient needs, when the patient may not want our interventions or may not be experiencing the difficulties we think they are. Patients and their families should be included in goal setting and in determining the interventions to meet the goals, and in determining how the outcomes will be measured (outcomes must be measurable and realistic for the patient to attain).

meonemine · Mar 15, 2017

ok..thank you!!! you have sumed it up for me

Esme12, ASN, BSN, RN · Mar 17, 2017

Here is my standard speech.....

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.

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.

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 from our Daytonite

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.

Another member GrnTea say this best......

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

"Related to" means "caused by," not something else.