From new student nurse to new RN...nursing diagnosis?

[Frazzled_One]

Hi I was needing some help on nursing diagnosis....how do you make one and when....what is the rationale for a nursing diagnosis when a medical one is the one that matters?

Goal of care-Is this the 'planning' part of the nursing process and what is an example of one? Goal for nurse or patient's goals?

Planned strategies (nursing interventions)-Is this the same as nursing implementation or 'plan in action'?

HELP PLEASE....have clinicals tuesday and things I thought I was sure about....Im not.

Could u guys set up some personal experiences in your hospital setting? please?

[HamsterRN, ADN, RN]

"things I thought I was sure about...I'm not"

- That's actually a typical and even beneficial mindset as a new grad. If anything, nursing school teaches you how much you don't know.

If your hospital/facility is up to date with current practice and standards then you won't be using NANDA nursing diagnoses, you'll be focusing more on medical diagnoses as well as all the other patient problems that the diagnoses do not capture.

Goal of care should reflect the patient's overall goals, not necessarily just those related to nursing specific care. Goals are usually to return to the highest overall level of health possible given the circumstances.

Planned strategies would involve both nursing interventions as well as the interdisciplinary plan, since nursing plays a major role in coordinating, implementing, and evaluating the treatment plans of other disciplines.

You'll find that what you experience as a new nurse is different that what you were taught in school, don't let that freak you out, most of what you learn as a nurse you learn after school.

[grandmawrinkle]

what is the rationale for a nursing diagnosis when a medical one is the one that matters?

I like you, Frazzled. You are already thinking like one of us.

The rationale is that it's required academic paperwork and you need to do it to get through your program.

[wee_oneRN]

....what is the rationale for a nursing diagnosis when a medical one is the one that matters?

Medical diagnosis focuses on the physiological issue. A nursing diagnosis focuses on the many ways that that physiological issue will affect the life (physical, emotional, spiritual, educational etc.. ) of the pt.

For instance: You have a pt with a Medical Diagnosis of Diabetes Mellitus. Your main goal is to achieve stability of blood sugar. So you feed, give insulin etc.. That is all 'medical'

Nursing diagnosis says lets look at the big picture: (these are just plausible for that diagnosis each pt is different of course):

Knowledge Deficit

Imbalanced Nutrition

Anxiety

Risk for Hyper/Hypoglycemia

Ineffective Regimen management

So, while the medical diagnosis stabilizes the pt and discharges them from the hospital, the nursing diagnosis is more holistic and is meant to focus on keeping the pt out of the hospital and developing further complications.

It is not meant to take the place of the medical diagnosis but to compliment it.

Another example: pt with Diarrhea. Medical diagnosis makes you think of giving fluids, meds, checking lytes. Great, now what about tissue integrity? This pt is 80 and can't ambulate well. Will the medical diagnosis look at that? No, but nursing diagnosis will focus on regular positioning and keeping the pt clean and dry to maintain skin integrity. If you have ever seen a Stage IV decub, you will understand that skin is also important. Nursing diagnosis does matter!

[dudette10, MSN, RN]

Hi I was needing some help on nursing diagnosis....how do you make one and when....what is the rationale for a nursing diagnosis when a medical one is the one that matters?

You make one from what you see in the patient. It is done immediately after you assess the patient. From those assessments, you build a nursing diagnosis. The rationale for it? I have yet to figure that one out. But, you will see them already pre-written and pre-printed on nursing flowsheets. The nurse then goes through the flowsheet and puts a checkmark next to the one that applies to the patient, based on the assessment.

Goal of care-Is this the 'planning' part of the nursing process and what is an example of one? Goal for nurse or patient's goals?

It is always patient-centered, never nurse-centered. Once you have the diagnosis, the goal of care is determined. "The patient will...." It should be achievable, measurable, and time-limited.

Planned strategies (nursing interventions)-Is this the same as nursing implementation or 'plan in action'?

Yes, it's all the same. It's what you are going to do to help the patient reach the goals.

Could u guys set up some personal experiences in your hospital setting? please?

I'm a student (who wants to eventually be a nurse educator...so thanks for the practice!), but here is an example from my clinicals and care plans. I'll do an easy one for a 1-day post-op patient.

Assessment: Patient shows facial grimacing, guarding of surgical site, rates pain as 9/10, moans with movement, states "it hurts really bad"

Nursing diagnosis: acute pain r/t post-operative status a/e/b [insert assessment data above]

Outcomes/Goals: Patient will verbally and nonverbally express pain relief within 30 minutes after interventions.

Interventions: This is everything you will do to help relieve the patient's pain.

Evaluation: You would go back after 30 minutes to re-assess the patient and figure out if your interventions worked.

Good luck on Tuesday and with your education!

[Fribblet]

In my corner of the hospital settings nursing diagnoses are not used. Partly because we don't have time to formulate a diagnosis and a correlating care plan, but mostly because they're stupid.

[dudette10, MSN, RN]

In my corner of the hospital settings nursing diagnoses are not used. Partly because we don't have time to formulate a diagnosis and a correlating care plan, but mostly because they're stupid.

I've seen them on nearly every rotation I've been on, even if it's just little checkmarks on the pre-printed flow sheets. The one rotation in which everything was computerized, I didn't see them, though.

While I still despise care plans, I have come to terms with them. For nursing students, they are helpful to organize our thinking. I mean, we walk into a patient's room for the first time, and we can tick off everything we see wrong patho-wise, but then it's "Now what?" The painful care planning we do in school gives us the answers to that.

[wee_oneRN]

In the 'real world' most hospitals have pre-formed Care Plans with the most common Nursing Diagnosis for the that floor. In school, you will be expected to make your own completely from scratch. There are many books on Care Plans that you can purchase. I suggest you find one as it will list the many NANDA-approved Nursing Diagnosis.

Here is a basic breakdown of how it works:

Diagnosis

You must use an approved diagnosis that is related to the medical diagnosis. For instance, 'Knowledge Deficit related to newly diagnosed Diabetes Mellitus'. Another example: 'Activity Intolerance related to Dyspnea'.

Goal

Your goal should be very specific and related to the diagnosis. A goal for our first example could be: Pt will state normal blood sugar range and demonstrate use of accucheck monitor by 07:00 9/26/10.

A goal for our dyspneic pt might be: Pt will demonstrate increased tolerance to activity by 19:00 9/24/10.

Interventions

You should have 3-4 interventions that you will take to help pt acheive the above goal. Again, must be very specific and be things that you will do during that shift (unless you are writing a long-term Care Plan)

Pt/Goal #1

a. Nurse will choose best time to educate pt: lights on, pt feeling well

b. Nurse will educate pt on proper use of bs monitor and normal bs range

c. Nurse will have pt demonstrate use of bs monitor and state bs limits

Pt/Goal #2

a. Nurse will teach pt on use of Incentive Spirometer

b. Nurse will monitor heart rate and resp. rate

c. Nurse will encourage physical therapy/ambulation as ordered and adjust per the pt ability.

Evaluations

Write a short note of how the interventions worked and whether goal was reached.

Pt #1

Goal acheived; Pt demonstrated proper use of bs monitor and stated normal limits for bs.

Pt #2

Goal partially achieved; Pt demontrated use of IS; pt became dizzy while ambulating hall with PT. Further observation suggested with gradual increase in activity.

One thing I learned in Nursing school, each instructor has their own way of doing this so be sure to ask lots of questions!

[Bandaide, ADN]

On the first day of nursing school (last Monday), our instructor told us that the whole purpose of care plans was to teach us to think like nurses. The things we map out are the actions that an experienced nurse takes without even thinking about it, and in the hospital they are used only to keep nurses on the same page.

[Fribblet]

I've seen them on nearly every rotation I've been on, even if it's just little checkmarks on the pre-printed flow sheets. The one rotation in which everything was computerized, I didn't see them, though.

While I still despise care plans, I have come to terms with them. For nursing students, they are helpful to organize our thinking. I mean, we walk into a patient's room for the first time, and we can tick off everything we see wrong patho-wise, but then it's "Now what?" The painful care planning we do in school gives us the answers to that.

In the ER I've never seen them, but they're not too useful down there. If nursing school did a better job of teaching the pathophysiology of diseases, then nursing diagnoses would have even less of a purpose. Once you know the patho, the rest should fall into place pretty easily.

But, that's just my opinion.

[grandmawrinkle]

From what I have heard from my manager, nursing diagnoses are actually frowned upon by TJC because they are not conducive to formulating an interdisciplinary care plan, which happens to be TJC's schtick right now. No one understands nursing diagnoses except nurses.

However, academia is still stuck on them.

[Fribblet]

From what I have heard from my manager, nursing diagnoses are actually frowned upon by TJC because they are not conducive to formulating an interdisciplinary care plan, which happens to be TJC's schtick right now. No one understands nursing diagnoses except nurses.

However, academia is still stuck on them.

I'd go so far as to say that most nurses don't understand them either.