Help with Nursing Diagnoses

4boysmama · May 4, 2013

So she's currently incarcerated? So any dx that would relate to using drugs would be moot, since she's not actively using at the moment. But, there's still lots of damage done by her past actions that are still reverberating now and give you good opportunities for dx.

What's her self-esteem like? Does she express guilt, shame, negative self talk?

is she chronically fatigued? Sleeping a lot?

how about her anxiety level? Surely she's being properly medicated while incarcerated, but I'd be willing to guess that she's still feeling anxiety....

what's her social status like? is family visiting? Does she have friends in the prison, or is she socially isolated?

nurseprnRN, BSN, RN · May 7, 2013

I am having a really difficult time with coming up with nursing diagnoses for my client. This is my first semester working on nursing diagnoses and I cant seem to understand much of it. I do have a Nursing Diagnosis Handbook, but am confused how to word them for my particular client.
Ineffective health maintenance r/t substance abuse AEB patients reports to using crack cocaine and ecstasy. Teachers comment: she is not using she is in jail-should be risk for.
Ineffective coping r/t inadequate level of perception of control AEB fear of being able to stay sober when no longer incarcerated. Teachers comment: so her level of perception of control is causing the ineffective coping? That does not make sense. Maybe it is not reflecting what you want it to say.
Powerlessness r/t feeling unable to change patterns of drug abuse AEB expressions of dissatisfaction over inability to perform previous activities. Teachers comment: Cause-I think your cause is a definition of powerlessness. What is the cause of her feelings of powerlessness?
Readiness for enhanced Family processes AEB expresses willingness to enhance family dynamics and by stating she wants to rebuild a loving relationship with her children.
Powerlessness r/t illness-related regimen AEB expressions of dissatisfaction over inability to perform previous activities. Teachers comment: If she feels powerless you might want to avoid a readiness
Readiness for enhanced coping AEB seeking social support through AA and NA meetings, and using spiritual resources through her pastor to strengthen her over all sense of self.
So I am struggling. I am trying really hard but just cant seem to get the concept. If anyone can help me I would really appreciate it!
Thanks!

First, there can be no "struggle" to figure out how to word nursing diagnoses. All permitted nursing diagnoses in present use and existence come from the NANDA-I 2012-2014. You cannot make a nursing diagnosis because it sounds good. It, and its defining characteristics and related factors, are right out of this book. And you must use them as given.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one of the defining characteristics and one related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

So let's take a look at a few of the ones you give here.

1) "Ineffective health maintenance r/t substance abuse AEB patients reports to using crack cocaine and ecstasy."

This nursing diagnosis is defined in NANDA-I 2012-2014 as "Inability to identify, manage, and/or seek out help to maintain health."

"Substance abuse" does not appear in the list of related factors for this diagnosis. "Use of illicit drugs" does not appear in the list of defining characteristics. So where, exactly, did you get the data you needed to make this diagnosis? I hasten to add that there may be some of the answers you seek in NANDA-I lists, but you have to find them. I can't do that for you because I don't know your patient and didn't do your assessment. If you do find them in the list and can justify them by objective findings from your assessment, your faculty member cannot deny the diagnosis. She can't. You can show her the book.

2)"Ineffective coping r/t inadequate level of perception of control AEB fear of being able to stay sober when no longer incarcerated." This nursing diagnosis is defined as "Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources."

You do have a listed related factor, "inadequate level of perception of control," so you need to give your faculty exact data you assessed in this woman to support that. Your defining characteristic, "fear of being able to stay sober when no longer incarcerated," however, does not appear as one of the defining characteristics necessary to make this diagnosis. Therefore you have not supported your diagnosis. Perhaps one or more of the defining characteristics really are present; document one or more, and you're home free on that one.

So do you see where I'm going with this? You must have the required elements for nursing diagnoses, and you have to have them from the authoritative source. This is nonnegotiable; it also bestows tremendous power. If you do have the required elements, and you can demonstrate that you have them, then you are in a position to defend your work to your faculty, and she cannot deny it. Yet another reason to go online and order this now, Tuesday, and you'll have it by Friday.

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse. Fake out your faculty, too.