First Time Nursing Diagnosis

hi, wsustudent, and welcome to allnurses! :welcome:

a doctor makes his medical diagnosis based on the symptoms the patient has. a nurse makes his/her nursing diagnoses the same way, based on the symptoms the patient has. nanda has renamed the symptoms defining characteristics. so, when you are looking at a book of nursing diagnoses, the defining characteristics listed under each nursing diagnosis is actually the symptoms that are the criteria for that nursing diagnosis. if you use that diagnosis, your patient should have one or more of those symptoms.

you have listed several symptoms that your patient has. maybe you didn't recognize them as symptoms, but they are. if you are looking in your nursing diagnosis books you will look for these as defining characteristics. the symptoms you listed for your patient will serve as an example for what i am trying to teach you:

• wheezing
  
• slight crackles
  
• congested nonproductive cough
  
• diminished lung sounds
  
• clubbing
  
• pursed breathing
  
• low income

to choose a nursing diagnosis you need to determine which nursing diagnoses some of these symptoms fit. it takes time and experience working with nursing diagnoses to recognize that a group of symptoms represents any particular nursing diagnosis. sometimes it means thumbing through a book of nursing diagnoses and looking for likely candidates. using the index helps. but, from your list of symptoms i can see several.

• ineffective airway clearance r/t retained secretions aeb wheezes and crackles in lungs, diminished breath sounds and nonproductive cough
  
• ineffective breathing pattern r/t hyperventilation aeb pursed lip breathing
  
• ineffective tissue perfusion, peripheral r/t exchange problems aeb clubbing of digits [other signs and symptoms that you might have missed might have been other skin changes, weak pulses and edema in the extremities. look at the defining characteristics listed under this diagnosis]

now, the low income is a problem that needs more expansion. how is the low income affecting the patient. is she able to purchase her medications, food and other things that she needs? what i'm getting at is how is her low income affecting her being able to supply her needs and accomplish her adls? these things then become symptoms that you can use to determine nursing diagnoses. as itself, "low income" is not specific enough to determine a nursing diagnosis. it can, however, become an etiology (cause) for a nursing diagnostic statement.

let me address how you put together a 3-part diagnostic statement. there is a method to it. it follows this formula:

you cannot use a medical diagnosis in a nursing diagnostic statement with the exception of clarifying an etiology and stating that it is "secondary to [a medical diagnosis]". the etiology, or related factor/s, are a kind of label for groups of your symptoms (defining characteristic/s) and you can have more than one. etiologies are often grounded in the pathophysiology of what is going on with the patient's disease process, but not always.

your suggestion to use "ineffective airway clearance related to congested cough secondary to copd exacerbation" has a problem. the congested cough is a symptom and not a related factor so it doesn't belong in that spot of the diagnostic statement. ineffective airway clearance, if you read it's definition, has to do with the patient being unable to maintain a clear airway. so, the reason for the airway being obstructed is what needs to go in that spot. the congested cough is a result of the obstruction. clear the obstruction and the congested cough goes away. the congested cough (what you actually listed before it was "congested nonproductive cough" -- i think that is an important distinction) becomes an aeb, or symptom, that is the criteria for choosing that diagnosis. it is also the symptom that you will design nursing interventions around in the planning stage of the care plan.

now, once you have determined your patient's nursing diagnoses, the remainder of your care plan is to write goals and interventions. these are based upon your patient's symptoms that are listed as the aeb items under each nursing diagnosis. goals are nothing more than the predicted results of the nursing interventions you are going to order. they must be measurable, patient centered and specific.

in rereading your post again you say your patient fits activity intolerance, deficient knowledge, and risk for infection. in order to use these nursing diagnoses, she must have the symptoms of these diagnoses. look at the defining characteristics under each of these diagnoses in your nursing diagnosis books. does she have any of the symptoms that are listed? did you forget to write them down when you were doing your assessment of this patient? now, you need to write them down because now they are going to be important if you are going to be using these diagnoses. you have to have the symptoms (defining characteristics).

i write about this all the time in many posts. when you take your car into a mechanic to get it fixed, the mechanic doesn't just point at it and say "blown gasket". first, he listens to what you have to say (subjective information). then, he makes his own inspection (physical exam). he gathers his abnormal data and makes a diagnosis and then gives you the bad news! a diagnosis is nothing more than

the resulting decision or opinion after the process of examination or investigation of the facts. don't let the word scare you. people in all kinds of professions "diagnose" problems all the time as part of their job--they just don't call it diagnosing. and, they don't all have a written taxonomy (list of diagnoses with etiologies and defining characteristics) provided for them like nanda has done for us nurses.

now, read over what i have said. take a break and watch some tv or something, and then read it again when you are not tired. do not be discouraged at your frustration in understanding all this nursing diagnosis stuff. it is immensely complex. it will take you many, many care plans to get a good grasp of what is going on. care planning is problem solving and putting the steps down on paper. that's all it is. there are just a few little rules that you have to follow. unfortunately for us, car mechanics, plumbers, etc., don't have to follow all the rigmarole of getting to the diagnosis that we do. we're just lucky.

You are welcome. Let this information digest a little. Use your nursing diagnosis books to help you classify your patient's diagnoses. That's what you bought them for and how you will get the most use out of them!

. . .an appropriate ND in this case would be "Inneffective airway clearance r/t increased mucous, ineffective cough, AS EVIDENCED by WHEEZING, NON-PRODUCTIVE COUGH, ETC."

Remember you always have to show why you are giving this ND to the pt.

Amy

al7139. . .Amy. . .since you have a copy of Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig, I want you to take a look at page 164 (Ineffective Airway Clearance) and see that "ineffective cough" is NOT a related factor for this diagnosis, but is, in fact, listed under the defining characteristics! Go back and read pages 2 through 15 of the book and pay particular attention to page 5 and the discussion on " 'related to' Phrase or Etiology". I don't think you are fully understanding the concepts of what an etiology and a defining characteristic are.