Bradycardia..need assistance with nursing diagnosis

nurseprnRN, BSN, RN · Jun 1, 2012

i hear you on the "training wheels" with the medical dx/nursing dx concordance, such as it is. the problem i have with this, other than the fact that it again reinforces the idea that nursing dx is subservient to or dependent on the medical dx, is that if you rely on this sort of resource at all heavily, you will do your patients a disservice by ignoring any potential nursing dx which is not reached by this path. when do the training wheels for those come in?

for example, you'll never find a medical diagnosis that leads you to decisional conflict, spiritual distress, or readiness for enhanced decision-making. i'll bet that list doesn't include entries for social isolation, ineffective protection, or ineffective family therapeutic regimen management. how about hopelessness, caregiver role strain, or dysfunctional family processes?

Esme12, ASN, BSN, RN · Jun 1, 2012

But as long as these instructor continue to assign these projects on diagnosis :banghead: instead a real patient or scenario.......there will be this issue and I think will make the students suffer and ultimately the patients. They won't be able to develop those critical thinking skills..... :madface:

MattNurse, MSN, RN · Jun 2, 2012

When I was teaching clinicals I had to accept the care plans from the students using the schools methodology and they would assign pathology pages for the students to turn into me based on a medical diagnosis or sign/symptom. One of the parts of their patho page was nursing diagnoses. It really was a waste of time because the students could and would just copy and paste the info from care plan books and turn it in.

I actually didn't care much for the patho pages so I just skimmed this work and it added more to my workload. I would however ask a nursing student to defend anything in their care plan, if OP were to turn into me risk of poisoning then that would need to be explained. I figured if I didn't offer explanations it would give OP a lot of areas to research. I had a student do a patho page on Sepsis and I asked her what are two criteria for a diagnoses of SIRS. She had know clue even though it was all included in her patho page.

I really wish poster's would come back to the discussion for their questions. I guess you can ask for a list of nursing diagnoses but I don't know what good it does if you don't understand the thinking behind the list and I hope your instructors are making you defend your care plans.

In my opinion I feel like new nurses come out of nursing school knowing 10-20% of the job and really start critically thinking on the job. Most of these assignments are busy work.

KelRN215, BSN, RN · Jun 2, 2012

A lot of posters have offered good advice thus far, but I want to give you an example of the patients I'd deal with in my line of work who have bradycardia. Without a doubt, the most common nursing diagnosis for those patients would be "Risk for increased intracranial pressure r/t (hydrocephalus, new brain tumor, aneurysm, AVM) AEB bradycardia to 42." Nothing cardiac about it. Bradycardia can have many causes- in neurology/neurosurgery, a bradycardic patient could have Cushing's triad and impending herniation.

You can't just have a list of nursing diagnoses for bradycardia because the nursing diagnosis is specific to the patient himself and you need to understand his assessment and why he has bradycardia in order to make a nursing diagnosis. You can have 3 patients all with HRs in the 40s and none of them would/should have the same nursing diagnosis. Those 3 patients could be, off the top of my head: #1: 10 year old with a history of congenital hydrocephalus s/p VPS placement at birth presenting with 2 day history of headache/vomiting and one day history of progressive lethargy now with a HR of 48 (baseline HR 70s-90s), RR of 12 and BP of 140/60, #2: 17 yo with a diagnosis of anorexia nervosa with a BMI of 15 hospitalized with severe electrolyte derangements admitted due to risk of refeeding syndrome with a HR of 46 and #3: A 22 year old cross country runner who presents to a primary care clinic for his annual physical and his VS reveal a HR of 45.

What is going on with these patients? #1 better get to the OR NOW or he's going to die and his low HR has nothing to do with his heart. #2 is going to have chronic bradycardia due to damage to her heart from starvation. She warrants very close monitoring because she is at risk for congestive heart failure as she begins to refeed. #3 is a healthy athlete and a HR of 45 is likely perfectly normal for him.

Do you see how, though these patients all have bradycardia, they all have very different assessments and therefore, different nursing diagnoses?

Esme12, ASN, BSN, RN · Jun 2, 2012

When I was teaching clinicals I had to accept the care plans from the students using the schools methodology and they would assign pathology pages for the students to turn into me based on a medical diagnosis or sign/symptom. One of the parts of their patho page was nursing diagnoses. It really was a waste of time because the students could and would just copy and paste the info from care plan books and turn it in.
I actually didn't care much for the patho pages so I just skimmed this work and it added more to my workload. I would however ask a nursing student to defend anything in their care plan, if OP were to turn into me risk of poisoning then that would need to be explained. I figured if I didn't offer explanations it would give OP a lot of areas to research. I had a student do a patho page on Sepsis and I asked her what are two criteria for a diagnoses of SIRS. She had know clue even though it was all included in her patho page.
I really wish poster's would come back to the discussion for their questions. I guess you can ask for a list of nursing diagnoses but I don't know what good it does if you don't understand the thinking behind the list and I hope your instructors are making you defend your care plans.
In my opinion I feel like new nurses come out of nursing school knowing 10-20% of the job and really start critically thinking on the job. Most of these assignments are busy work.

I agree but some just never do......that is why I will ask for some information first to see what they have done or are willing to do to participate and learn.

VickyRN, MSN, DNP, RN · Jun 3, 2012

A lot of posters have offered good advice thus far, but I want to give you an example of the patients I'd deal with in my line of work who have bradycardia. Without a doubt, the most common nursing diagnosis for those patients would be "Risk for increased intracranial pressure r/t (hydrocephalus, new brain tumor, aneurysm, AVM) AEB bradycardia to 42." Nothing cardiac about it. Bradycardia can have many causes- in neurology/neurosurgery, a bradycardic patient could have Cushing's triad and impending herniation.
You can't just have a list of nursing diagnoses for bradycardia because the nursing diagnosis is specific to the patient himself and you need to understand his assessment and why he has bradycardia in order to make a nursing diagnosis. You can have 3 patients all with HRs in the 40s and none of them would/should have the same nursing diagnosis. Those 3 patients could be, off the top of my head: #1: 10 year old with a history of congenital hydrocephalus s/p VPS placement at birth presenting with 2 day history of headache/vomiting and one day history of progressive lethargy now with a HR of 48 (baseline HR 70s-90s), RR of 12 and BP of 140/60, #2: 17 yo with a diagnosis of anorexia nervosa with a BMI of 15 hospitalized with severe electrolyte derangements admitted due to risk of refeeding syndrome with a HR of 46 and #3: A 22 year old cross country runner who presents to a primary care clinic for his annual physical and his VS reveal a HR of 45.
What is going on with these patients? #1 better get to the OR NOW or he's going to die and his low HR has nothing to do with his heart. #2 is going to have chronic bradycardia due to damage to her heart from starvation. She warrants very close monitoring because she is at risk for congestive heart failure as she begins to refeed. #3 is a healthy athlete and a HR of 45 is likely perfectly normal for him.
Do you see how, though these patients all have bradycardia, they all have very different assessments and therefore, different nursing diagnoses?

A most excellent post, KelRN215. Thank you :)

nurseprnRN, BSN, RN · Jun 3, 2012

"risk for increased intracranial pressure r/t (hydrocephalus, new brain tumor, aneurysm, avm) aeb bradycardia to 42."

alas, there is no such nursing diagnosis as "risk for increased icp." it's absolutely a good avenue to pursue if you're participating in a team looking for a medical one, though-- differential diagnosis for brady could certainly include diagnostics for increased icp, and your three examples are disparate enough to make the point well.

KelRN215, BSN, RN · Jun 3, 2012

Ok, sorry... that's how it was always written on our management plans. Either that or "risk for alteration in neuro status"; I knew the latter wasn't an official nursing diagnosis and I thought I remembered a diagnosis for ICP from nursing school. Of course, NANDA diagnoses have probably changed since 2004 and I could easily be remembering incorrectly.

Esme12, ASN, BSN, RN · Jun 4, 2012

They change ever couple of years.......to sell more books. :smokin:

nurseprnRN, BSN, RN · Jun 4, 2012

esme! bite your tongue! :nono: don't make me call in the flying monkeys!

for what it's worth, the update for 2009-2011 was a major overhaul that made such an improvement in the whole thing. honest to god, if all you know about nanda is what you got out of the old book, you don't know nanda-i. the current edition (2012-2014) has gotten rid of a few old diagnoses (though not, alas, the "disturbed energy field" that, well, disturbs the crap outta my energy field every time i see it).

it also includes some really good descriptions and scenarios for nurses to self-teach, especially useful if your school insists on doing this kind of exercise operating from the basis of medical diagnosis. here's a review of it from a magazine i read a year or so ago. it's for the 2009-2011 edition, but explains it really well, i think.

nursing diagnosis: definitions and classification 2009-2011

nanda international

blackwell publishing, chichester, west sussex, united kingdom 2009

isbn 978-4051-8718-3

issn 1943-0728

since our practice is based on the nursing process, this small volume is an essential reference for all nurse life care planners. those whose only exposure was to the comparatively incomplete work of the north american nursing diagnosis association in previous editions will be very pleasantly surprised by this completely rethought work. it has a great deal to offer the new and seasoned nurse life care planner in planning, education, and supporting nursing process as the theoretical underpinnings of our professional practice.(e.g., at deposition or trial).

part i opens the volume with a chapter on clinical diagnosis and assessment, and how these are integral to nursing diagnosis in practice. as an aside, it also has material on nursing diagnosis in nursing education, informatics, research, and administration. these may also give the nurse life care planner some insight into using it in other non-traditional settings—like life care planning. a list of the 21 new nursing diagnoses in this edition, and their authors’ names, also appears here.

part ii, the thirteen domains and diagnoses themselves, are completely reformatted and now include each diagnosis’ definition, defining characteristics, and related factors. listing the domain and class of each allows easy cross-referencing. many diagnoses have references from the literature, some extensive.

while a busy nurse life care planner could be forgiven for stopping right there, part iii offers the interested reader more insight into the historical and contemporary development of the current taxonomy, how various organizations recognize it and use its contents as standards; this could be of use in litigation. part iv lists diagnoses that have been retired; part v asks the reader to become involved in this seminal work’s future by giving a full description of the review process for new diagnoses.

this reviewer’s pet peeve about previous editions was the weakness of the index, essentially a re-listing of the headers from each diagnosis’ page with no alternatives. this edition’s greatly expanded index cross-references many possible nursing diagnoses for a given condition or risk factor. this opens up many avenues for thought, research, and action, thus making your work much richer. for example, the entry for “self care” points to its place in the taxonomy (see sidebar) and then to entries for deficits in bathing, dressing, feeding, and toileting, and readiness for enhanced self-care.

this classic work should be on every life care planner’s reference shelf; it will gratify and reward the working nurse in any setting.

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