Check my nursing dx and goal?

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Hi,

We are writing process recordings for our clinical. This is our second week doing it and I was fine the first week. I'd like to be sure that my nursing dx and goal are congruent and that I have a valid etiology. Care to critique?

Nursing dx: Anxiety r/t unknown biopsy results as evidenced by client tearful state during conversation, elevated blood pressure and pulse as compared to previous readings, and client statement "I am so worried about what they might find"

Nursing goal: The client will identify healthy ways to deal with and express anxiety.

I'm sure this needs tweaking and I'd really like to learn the proper choices. Is there anywhere I can go online to find choices that work together?

TIA!

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The first problem I see is that your goal must have a time frame (according to my instructors). For instance, "Goal: Patient will report decreased feelings of anxiety within 30 minutes after talking with RN, Ativan 1 mg, deep breathing exercises, guided imagery, etc (just pick one that you think applies to the patient and situation. For instance, if there is no order for Ativan, or if you don't know that you could get an order, don't use the Ativan example.) After the patient has calmed down, you need another goal, such as, "Goal: Patient will identify healthy ways to deal with and express anxiety within one hour (or two)." You could also use deficit knowledge as another nursing diagnosis. For instance, "Deficient knowledge r/t medical procedures and hospitalization AEB patient crying, asking lots of questions, anxious, and states, "I am so worried about what they might find." The goal for this could be something like, "Goal: Patient will demonstrate a better understanding of biopsy and hospitalization within two hours." I think that your diagnosis sounds good, and it looks like you're on the right track. Good luck!

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Specializes in Emergency Nursing.

Look up the NANDA Diagnosis "Death Anxiety." It fits better than the "Anxiety" diagnosis which is more general and usually refers to irrational anxiety.

http://www.amazon.com/Nursing-Diagnosis-Handbook-Evidence-Based-Planning/dp/0323071503/ref=sr_1_1?ie=UTF8&qid=1316816754&sr=8-1

This book is a fantastic resource, and is far and away better than any online resource I've been able to find.

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You could also use deficit knowledge as another nursing diagnosis. For instance, "Deficient knowledge r/t medical procedures and hospitalization

Common issue: Remember that the portion after the R/T should be the issue that caused the knowledge deficit (like lack of exposure, lack of recall, or cognitive limitation) rather than the subject of the knowledge deficit.

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I think your goal can be more measurable. By measurable, I mean it should sound something like, "The patient will list 3 methods of controlling anxiety." Also, NANDA format requires that you have a time frame specified. Is this a long term or short term goal? If it's long term, my school usually allows "The patient will list 3 methods of controlling anxiety BY TIME OF DISCHARGE." If it is short term, "BY THE END OF THE NURSING SHIFT."

Your diagnosis sounds good- you have subjective and objective information.

Good luck!

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Thank you for the tips! My instructor encouraged me to use anxiety as my diagnosis, so I think that one's going to be my best choice, lol. Plus it really was the overwhelming point of the interview.

I hadn't thought about the time frame being included. I did see that after reading through our book.

Thanks, too, for pointing out objective and subjective information. I'll need to be mindful that I continue to do that!

I've revised the goal and this is the answer I've come up with for the whole thing. Does it fit the bill?

Primary nursing diagnosis based on Process Recording: Anxiety r/t unknown biopsy results as evidenced by tearful state during conversation, elevated blood pressure and pulse as compared to previous readings and client statement “I am so worried about what they might find”

Client goal of interaction: By end of shift the client and caregiver will review relaxation techniques for patient to use when he feels anxious about biopsy.

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Now I'm torturing myself...

The client will?

The client and caregiver will?

review, identify, describe, explain??

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By end of shift the client will verbalize decreased anxiety regarding pending biopsy results.

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Specializes in Emergency Nursing.
Common issue: Remember that the portion after the R/T should be the issue that caused the knowledge deficit (like lack of exposure, lack of recall, or cognitive limitation) rather than the subject of the knowledge deficit.

Yep it's always Knowledge deficit (what the deficit is) Related to (whatever the underlying issue is).

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