help on nursing diagnosis

SopranoKris, MSN, RN, NP · Apr 16, 2014

Do you have the NANDA book? Look up pain and then come back and tell us how you'd rephrase your nursing diagnosis :)

Look in the Nursing Student Assistance forum for posts from GrnTea & Esme12. They have very helpful advice on how to think through your nursing diagnosis. Heed their advice, it's spot on!

jxu35 · Apr 16, 2014

thank you. i don't have NANDA book, my nursing diagnosis book only stated pain is subjective. It does not have any information on there. I don't have time to get assessment data (only 30 mins with care of four other patients on my clinical day). The only thing I known is my Pt taking lot of pain meds, she is DMII, and she stated that she has foot pain. To combine together, I think my nursing diagnosis is appropriate.

Okami_CCRN, BSN, RN · Apr 16, 2014

The etiology portion of the diagnosis should be refined; chronic pain related to damage of the peripheral nerves secondary to DMII as evidenced by verbal complaints of tingling, burning, etc.

I would invest in a care plan book just because it helps you refine and fine tune nursing diagnoses.

jxu35 · Apr 16, 2014

THANK YOU. I will definitely do that.

Esme12, ASN, BSN, RN · Apr 16, 2014

thank you. i don't have NANDA book, my nursing diagnosis book only stated pain is subjective. It does not have any information on there. I don't have time to get assessment data (only 30 mins with care of four other patients on my clinical day). The only thing I known is my Pt taking lot of pain meds, she is DMII, and she stated that she has foot pain. To combine together, I think my nursing diagnosis is appropriate.

You do not have an appropriate nursing diagnosis.

I am curious....What semester are you? What care plan resource do you use?

Care plans are all about the assessment....of the patient. Not assessing your patient in some is really not acceptable. Without an assessment you can't make a care plan.

You assess the patient every time you walk in the room. You assess the patient when you take vitals. You assess the patient when you give meds. You assess the patient when you give daily care. If you do not assess your patient it's a big problem.

I know this sounds harsh and I don't mean it to be but without an assessment you cannot make a plan of care. You have no information for me here to help you.

What are her labs? Is her glucose under control? What other co-morbidities does she have?

Esme12, ASN, BSN, RN · Apr 16, 2014

Is her pain acute or chronic? What is her pain on the scale?

pain related to altered nerve sensation from glucose intolerance secondary to diabetes neuropathy aeb XXXXXXXXX

If you didn't assess the patient how do you know that her pain is altered nerve sensation? How does she describe her pain? altered nerve sensation is a medical determination...not a nursing one. Has she been diagnosed with neuropathy?

How do you know that the patient has glucose intolerance? What are her sugars now? What meds does she take?

DM II is NOT glucose intolerance. DMII is one of the several distinct disorders of glucose tolerance.

The most widely used classification of diabetes mellitus (DM) and allied categories of glucose intolerance is that recommended by the World Health Organization (WHO) in 1985. The American Diabetes Association (ADA), however, proposed a system based on disease etiology instead of the type of pharmacologic treatment.
The major categories of the disorders of glycemia or glucose tolerance are:
Type 1 DM
Type 2 DM
Other specific types of diabetes
Gestational DM
Impaired glucose tolerance
Impaired fasting glucose

http://emedicine.medscape.com/article/119020-overview

Is her pain a burning sensation? Stabbing? Pins and needles? What evidence do you have without an assessment?

nurseprnRN, BSN, RN · Apr 16, 2014

You can think your nursing diagnosis is "appropriate" but it isn't. Why not, when it sounds so perfectly reasonable to you? It's because all approved nursing diagnoses are approved by NANDA-I, an international body of nurses who test them for validity and scientific background. There are very specific terms involved. Every approved diagnosis must come from an evidence base, from a recognized cause (related factor), and the assessment must include findings of at least one defining characteristic for that diagnosis for you to be able to make it. And so ... you (or anybody) can't just make one up because it sounds good to you.

You will not be able to pass Go without books on this. Here's the best explanation I can give you, and at the end, some books that you would be well-advised to get, because without them you will probably have a very difficult time passing your course.

Esme says:

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

Where is your nursing assessment of this patient's condition?

We are trying hard to keep you from into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to plan nursing care. This is complementary but not dependent on the medical diagnosis or plan of care.

Somehow the idea in nursing school these days is to "pick" a nursing diagnosis. No, it's not. You are in nursing school to begin to learn how to OWN your nursing practice-- you MAKE a nursing diagnosis based on the evidence you see before you, exactly like physicians make medical diagnoses based on evidence. In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)

Sure, you have to know about the medical diagnosis and its implications for nursing, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis comes in when you’re planning the nursing care your patient needs and deserves.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts should come first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

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

"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." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) 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 or iPad 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! Wonder where you learned that??? :) Amazon.com: Nursing Diagnoses: Definitions and Classification 2012-14 (9780470654828): NANDA International: Books

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for: to learn how to plan nursing care.

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...)

Now, if you are ever again 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 and at least one of the related / caustive factors are present. If so... there's a match. Congratulations! You have made a nursing diagnosis! :anpom: 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.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. Make sure it's congruent with your patient's wishes-- never forget that any patient can refuse any care or intervention, any time.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence; you want the most current edition, 2011.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can’t get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.

Episteme · Apr 20, 2014

I'm not sure what your learning objectives for the day were. You had 4 patients and 30 minutes to assess them? I don't know what your instructor wanted to teach you in that assignment. BUT one thing you have now learned from these experienced nurses is...

You cannot make a nursing diagnosis in a fact-free zone!

Maybe you should sit down and clarify with your instructor what you were supposed to be learning in that clinical experience. (And also read your syllabus. Sometimes that can help too. Learning objectives and terminal objectives for the course are usually listed.)

nurseprnRN, BSN, RN · Apr 20, 2014

You cannot make a nursing diagnosis in a fact-free zone!

Oh, I lovelovelove this! Put it your new siggy line!! Brilliant!