interventions?

Daytonite, BSN, RN · Mar 15, 2007

the definition of ineffective role performance is: patterns of behavior and self-expression that do not match the environmental context, norms, and expectations. some of the defining characteristics listed with this nursing diagnosis are change in capacity to resume role, change in self-perception of role, change in usual patterns of responsibility, depression, inadequate adaptation to change, inadequate coping, inadequate motivation, powerlessness, inadequate role competency, role overload and role strain which might fit your patient based on what you said about him. the related factors are broken down into those of knowledge (inadequate role model, inadequate role preparation, lack of education, lack of role model, unrealistic role expectations), physiological (body image alteration, cognitive deficits, depression, fatigue, low self-esteem, mental illness, neurological defects, pain, physical illness, substance abuse), and social (conflict, developmental level, domestic violence, inadequate role socialization, inadequate support system, inappropriate linkage with the healthcare system, job schedule demands, lack of resources, lack of rewards, low socioeconomic status, stress, young age) [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international page 180-181.] so, it sounds like your diagnostic statement would need to be re-worded to say ineffective role performance r/t physical health aeb depression and inadequate coping ??? is that where you are trying to go with this diagnosis?

for blindness, you could use disturbed sensory perception: visual. with esrd, diabetes and a amputation he obviously has a tissue perfusion problem (ineffective tissue perfusion: renal and peripheral). you should also consider these: impaired physical mobility, ineffective coping, or risk for suicide. it sounds like this patient has a lot of physiological problems and a history to self-inflict harm that needs to be addressed. this tendency toward depression and suicide is not all that uncommon in a long-term chronic disease like esrd. take away the dm and the esrd and the suicide probably wouldn't be an issue unless he has other mental health issues.

futurenurse85 · Mar 16, 2007

PLEASE tell me how these nursing diagnoses sound..are they relevant to my patient you think?

-ineffective coping r/t vision loss and amputation secondary to chronic disease process AEB patient statement "i have no value and feel like a burden to my wife."

-impaired physical mobility r/t vision loss and amputation AEB complete dependence w/ ambulation."

-ineffective tissue perfusion r/t chronic disease process AEB weak tibial pulse, decreased urine output, and elevated BUN and creatinine lab value.

(i got the BUN/creatinine from my care plan book..but how is it an AEB for ineffective tissue perfusion?..i know that probably is a stupid question)

-disturbed sensory perception, visual r/t chronic disease process AEB bilateral vision loss.

-powerlessness r/t chronic illness, dependence with ADLs and inability to perform role responsibilities AEB patient statement "i have no value and feel like a burden to my wife."

-risk for impaired skin integrity r/t altered physical mobility, poor circulation and altered sensation secondary to chronic disease process.

(i forgot to mention, he also has peripheral vascular disease)

if anyone could offer any suggestions or input i would really really appreciate it! thank you!!!

Daytonite, BSN, RN · Mar 16, 2007

futurenurse85. . .is this your first time at putting together a care plan and choosing nursing diagnoses? what reference, or guidelines are you using to write your nursing diagnostic statements? the reason i am asking is because the ones you are suggesting in both of your posts have no rationale to them. the nursing diagnostic statement clearly flows so that the

nursing diagnosis

(is a statement of the patient's

problem

)--related to (the

etiology

, or what is causing the symptoms)--as evidenced by (

defining characteristics

, or the

symptoms

, the data you collected during assessment which supports and defines the nursing diagnosis)

these elements are all laid out for you in a book of nursing diagnoses or one of the current care plan books. most of them follow the nanda-i guidelines.

ineffective coping r/t vision loss and amputation secondary to chronic disease process aeb patient statement "i have no value and feel like a burden to my wife."

the definition of ineffective coping is "inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources" [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international page 59]. the statement "i have no value and feel like a burden to my wife" does not sound like evidence of difficulty with coping to me. this is someone who is sad and having problems with their self-esteem and role in life. based on what you said in your other post about this man i would suggest that a better nursing diagnosis to use would be situational low self-esteem for the reason that it's definition is "development of a negative perception of self-worth in response to a current situation (specify)" [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 189]. one of the related factors that nanda-i lists for this diagnosis is functional impairment which is what has happened with this man due to his chronic illness. speaking of which, his chronic illness (esrd and dm) relates back to all of this. however, nanda-i helps us out with the defining characteristics (symptoms) on this diagnosis by listing some: evaluation of self as unable to deal with situations or events, expressions of helplessness, expressions of uselessness, self-negating verbalizations, and there is more. this nursing diagnosis suits your patient to a "t". to put the nursing diagnostic statement together, let me list the parts for you:

problem: negative self-worth: situational low self-esteem due to long term chronic disease (nanda-i wants this specified)
etiology: underlying cause of the problem: functional impairment
secondary to: esrd and dm (relate this back to medical diagnoses)
symptoms: your data: "i have no value and feel like a burden to my wife."

and, this is what the final result looks like: situational low self-esteem due to long term chronic disease r/t functional impairment secondary to esrd and dm aeb patient statement that "i have no value and feel like a burden to my wife". if you read this, it has a flow and a rationale to it. his statements are a reflection of his low self-esteem and the reason is because of his functional impairment due to his chronic illnesses. make sense? http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=44 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_061.php

impaired physical mobility r/t vision loss and amputation aeb complete dependence w/ ambulation."

let's look at this. his problem is impaired physical mobility which means he has "limitation in independent, purposeful physical movement of the body or of one or more extremities" [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 138]. yes, vision loss and amputation contribute to problems with ambulation, but how do they contribute to problems of movement of the arms and legs which is what this diagnosis is aiming at? you need to get rid of the vision part as a "related to" item because it doesn't have anything to do with the movement of his extremities. however, if you look at the related factors associated with this diagnosis his depressive mood certainly does because it affects his motivation. i'm betting there are also others as well.

problem: movement: impaired physical mobility
etiology: underlying cause of the problem: (describe the specific type of) amputation and depressive mood
secondary to: dm and esrd
symptoms: complete dependence with ambulation (what does this mean? describe it. ex: needs stand by assistant and walker to ambulate, unable to maintain balance while walking without an assistant, etc.)

and, the final result will look something like this: impaired physical mobility r/t (type of) amputation and depressive mood secondary to dm and esrd aeb [symptoms] http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=35 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_047.php

ineffective tissue perfusion r/t chronic disease process aeb weak tibial pulse, decreased urine output, and elevated bun and creatinine lab value
(i got the bun/creatinine from my care plan book..but how is it an aeb for ineffective tissue perfusion?..i know that probably is a stupid question).

if you look carefully at your care plan book for ineffective tissue perfusion, it breaks this particular diagnosis down into categories of renal, cerebral, cardiopulmonary, gastrointestinal and peripheral systems. this goes to the underlying pathophysiology of your patient's disease processes. with impaired peripheral perfusion, yes, you are going to see a weak tibial pulse. with impaired renal perfusion you are going to have elevated blood pressures, elevated buns and creatinines and no urine output because the kidneys are in failure. in this patient's case it is all likely due to the atherosclerotic changes in the blood vessels secondary to his diabetes. this is common in diabetics who develop esrd. but, again, in your nursing diagnostic statement you've got to tie your symptoms to the problem which is an interruption of blood flow in both cases--that's what atherosclerosis does. so:

problem: ineffective tissue perfusion: peripheral and renal
etiology: interruption of blood flow
secondary to: dm
symptoms: weak tibial pulse, [decreased or no?, you need to specify] urine output, elevated bun and elevated creatinine

your nursing diagnosis statement will look like this: ineffective tissue perfusion: peripheral and renal r/t interruption of blood flow secondary to dm aeb weak tibial pulse, [decreased or no?, you need to specify] urine output, elevated bun and elevated creatinine. http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php

disturbed sensory perception, visual r/t chronic disease process aeb bilateral vision loss.

how is the patient's vision loss causing problems? is he walking into walls? tripping over things? having difficulty seeing where things are in his immediate surroundings? that kind of data is important to know if you are going to use this diagnosis. the etiology of disturbed sensory perception: vision is not a chronic disease process as you have suggested in your nursing diagnostic statement. the etiology for this diagnosis is: "altered sensory integration, altered sensory reception, altered sensory transmission, biochemical imbalance, electrolyte imbalance, excessive environmental stimuli, insufficient environmental stimuli, psychological stress" [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 195]. about the only thing i could imagine being the cause of his vision disturbance would be either the altered sensory integration or altered sensory reception. in both cases, meaning his vision is bad and he's not able to interpret what he's (not)seeing correctly. you might want to re-think using this. visual problems could be used as a symptom contributing to his problem of low self-esteem.

powerlessness r/t chronic illness, dependence with adls and inability to perform role responsibilities aeb patient statement "i have no value and feel like a burden to my wife."

this is nearly the same as the situational low self-esteem above. these two diagnoses are so closely related that i would suggest that you read up on them and pick one or the other to use, but you can't use both. this one might carry a higher burden of sadness and self-esteem that can't be recovered from with it. check out the nursing interventions (i've given you links for both diagnoses) and see which seems more appropriate to the situation since you know the patient and i don't. http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=42 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_057.php

risk for impaired skin integrity r/t altered physical mobility, poor circulation and altered sensation secondary to chronic disease process.

(i forgot to mention, he also has peripheral vascular disease)

i don't like the word choices you've used. the risks factors for this diagnosis are: chemical substnace, excretions, extremes of age, hyperthermia, hypothermia, humidity, shearing forces, pressure, restraint, moisture, physical immobilization, radiation, secretions, changes in pigmentation, changes in skin turgor, developmental factors, obesity, emaciation, impaired circulation, impaired metabolic state, impaired sensation, immunologic factors, medications, psychogenetic factors, and skeletal prominence [nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international, page 200]. my best guess based on what you revealed about this patient would be: risk for impaired skin integrity r/t impaired peripheral circulation and sensation secondary to dm. http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=54 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_071.php

that leaves you with four nursing diagnoses by my count. they should be sequenced in priority like this:

ineffective tissue perfusion: peripheral and renal r/t interruption of blood flow secondary to dm aeb weak tibial pulse, [decreased or no?, you need to specify] urine output, elevated bun and elevated creatinine.
impaired physical mobility r/t (type of) amputation and depressive mood secondary to dm and esrd aeb [symptoms]
situational low self-esteem due to long term chronic disease r/t functional impairment secondary to esrd and dm aeb patient statement that "i have no value and feel like a burden to my wife".
risk for impaired skin integrity r/t impaired peripheral circulation and sensation secondary to dm.

IrishIzCPNP, MSN, RN, APRN, NP · Mar 16, 2007

I wanted to throw in here that I think it is EXTREMELY important that people own a copy of either the current NANDA diagnoses book or another one that is available in order to understand the definitions.

My school did not require one and when it was brought to their attention that the care plan book we have is crap and there are better books I was told to put it on the eval. Apparently some of the instructors wanted to change the book and with our input it will happen.

I personally feel that many of the diagnoses have a different meaning then what you expect. So without knowing the real meaning you cannot know if it's appropriate.

This past clinical weekend there were a couple people I was helping who picked a diagnosis and when the definition was looked up...the diagnosis wasn't right and we were able to find something that was accurate.

You need to know the definition of the diagnosis and realize the definition is not always what you would expect.

The NANDA book can be bought from their website (takes a while to ship) for about $23. There is another site that sells it for a little less and they might even ship sooner but I don't know.

You need to have a book with the definitions...IMO.

Daytonite, BSN, RN · Mar 17, 2007

if you just want the bare bones facts about each of the current 188 the nursing diagnoses (definitions, defining characteristics and related factors) you can get them directly from nanda-i in this book which has recently been released: nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. it cost me only $19.95, but i am a member of nanda. it is only a few dollars more if you are not a member. i received mine 2 weeks after ordering it.

what the current care plan and nursing diagnosis books have to offer you is not only the nanda information of nursing diagnosis definitions, defining characteristics and related factors, but usually noc (nursing outcome classifications developed at the university of utah), nec (nursing interventions classifications), and other unique features that each of the various authors has to offer to entice you to buy. the ackley/ladwig book is especially appealing because it contains a 128-page alphabetized index of symptoms, problems, medical diagnoses and clinical states where you can look to find suggestions of nursing diagnoses for particular problems. others have forms for assessment that you can xerox and use. depends on what floats your boat as to why you would buy any particular one.