Help With Physiological and Psychosocial Nursing Diagnosis

[Daytonite, BSN, RN]

The op apparently did not have any guidance on this from her nursing instructors so I gave her nanda's stand on this. This particular nursing diagnosis is going to be removed from the official listing anyway next year. You should all classify this diagnosis as your instructors have advised you to do. If it differs from nanda, so be it.

Diagnosing should follow some kind of rules. I am not in school. When I answer questions about care planning and nursing diagnosis I use nanda rules because that is the universally accepted taxonomy that is used throughout most of the u.S. If your instructors are telling you different--OK. Do what your instructors tell you because your grades depend on it. But, you also need to know the nursing process and how to apply the rules your instructors are giving you. What I find from most of the questions that are asked on these forums is that many don't understand the steps of the nursing process and what is supposed to be done in each step, how to put the information together and how it comes to be a care plan (problem solving). People get so-o-o-o hung up on these nursing diagnoses that it stalls them in the whole care plan process. It doesn't have to be that way. I doubt very much that medical students get all frustrated over picking medical diagnoses the way nursing students get frustrated at picking nursing diagnoses. The fact that many who post don't understand that patient signs and symptoms are at the heart of describing each nursing diagnosis is saddening. This is not rocket science. It is very rational thinking. But people see the word "Nursing diagnosis" and rational thinking and what they've been taught about the nursing process seems to go out the window and suddenly chaos reigns.

[Daytonite, BSN, RN]

I have only seen three listings that classify the nursing diagnoses. (1) the list by NANDA classifying the diagnoses into Diagnostic Divisions. Knowledge Deficit is classified under the Teaching/Learning Diagnostic Division. (2) classification by Maslow's Hierarchy of Needs. Knowledge Deficit is classified under Safety and Security Needs. (3) classification by Gordon's Functional Health Patterns. Knowledge Deficit is classified under the Health Perception/Health Management Health Pattern.

Where do I find these lists, you ask? The NANDA list is in a book of care plans by Doenges, Moorhouse and Murr in the beginning chapters. The Maslow and Gordon's listings are in Appendix A and Appendix B of Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig.

I have not seen a listing that classifies the nursing diagnoses as psychosocial. Are you sure this isn't something your nursing instructors might have given you at some time very early in your nursing lectures on the nursing process and care planning?

[OnTheRoad]

I think for most of us, when we first start writing care plans there seems to be so much emphasis on the diagnosis part of things that many of us fail to simply start basic and look at what is going on with our patient and what we can do to improve their health, comfort, etc.

When I started writing care plans I would look through my nanda list first, grab a DX I thought might fit, then look for symptoms and RT... you get the picture. Now I look at symptoms, lab values etc first, find the problems, decide what I need to do to treat the problem or help the situation, then find the dx that matches.

I also do not start my care plan till I look up all abnormal labs, medical diagnosis, and medications as they will give me a much better idea of what I am looking at.

I think all of this can be a difficult process of learning. Sure it isn't rocket science, but it is a foreign language one needs to learn on the road to RN. If it were as easy as pie (not adpie) then anyone could do it and anyone could be a nurse eh?

[Daytonite, BSN, RN]

OnTheRoad. . .that's exactly how it is supposed to be done. Thank you for posting your wisdom and insight.

Everyone, a care plan, the nursing process, is a problem solving method. We solve problems every day of our lives and we learned how to do it from the time we were little kids. Nursing school has just given us a very systematic way of doing it, and named it. Don't let all the fancy names and jargon get you side tracked. Think about how you logically go about solving problems that come up in your life. It is very much like the nursing process. A care plan is nothing more than utilizing specific sciences, following a set of rules and committing the thinking process behind the problem solving to paper. That's all it is. Don't beat yourselves up making it harder than that.

[beckster_01, BSN, RN]

I'll go ahead and try to quickly explain what an ND is. It is a tool for developing your critical thinking skills; identifying a patient's primary problems, the evidence supporting your assessment, and you will eventually be expected to identify appropriate interventions for the problem. Quick note of advice, always think your ABC's first, or use Maslow's hierarchy to help you prioritize.

Example: You have a patient with a COPD exacerbation.

Part 1: Ineffective airway clearance- This is your Nursing diagnosis. Not to be confused with a medical diagnosis. Simply put, you are stating the obvious problem but it is beyond your scope of practice to create a medical diagnosis of COPD. But there are many interventions you can do without an MD to help this patient, which we will get to later.

Part 2: Related to COPD- Insert medical diagnosis here. There are probably other variations that I don't remember, but I'm keeping it simple for now. This is where you identify the cause behind your nursing diagnosis.

Part 3: As evidenced by *dyspnea *increased secretion *increasing oxygen requirements etc. - This is where you list the symptoms, or evidence behind your nursing diagnosis. The list could go forever, but you generally list the most pertinent one, individualizing the diagnosis for your particular patient.

When you get to care plans you will be expected to list interventions for your patient. Including titrating oxygen per orders, delivering treatments, pulmonary toileting, keeping the head up 30 degrees. And again my list could go on. This is why you are in school. I have been a nurse for 3 years. I don't make care plans at work. But I can still create a nursing diagnosis off the top of my head because that model is how I learned to identify a problem and treat it within my scope of practice.

I would recommend finding a nursing diagnosis handbook. A quick search on amazon, there were several for $20 or less, if you specify your search for textbooks about 5 years old you can go pretty cheap, and I promise you they haven't changed much! I don't even remember what publisher I used, probably either Mosby or Pearson, but mine was an excellent guide not only for understanding what a nursing diagnosis is, but how to use them for developing care plans etc. It should provide comprehensive lists of accepted NANDA diagnoses and interventions. Unless nursing school has changed drastically in the past 3 years this a resource you will use throughout your schooling. It will save you so much time that you would otherwise spend on google or waiting for people to respond to your posts on AN!! I hope this helps and good luck with school!

Edit: So I thought that you could use a known medical diagnosis in your "related to" part, but apparently might be wrong. That is where using your appropriate textbooks/resources comes in handy

[Esme12, ASN, BSN, RN]

Now....what care plan book do you have? I use Ackley: Nursing Diagnosis Handbook, 10th Edition.

For all care plans.....you need to Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

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.

[Esme12, ASN, BSN, RN]

Care plans are based on your assessment of THE PATIENT...what THEY NEED.

You prioritize according to prioritization by the patient's most important needs. keep in mind that the care plan is a problem solving process, so each nursing diagnosis is actually a patient problem. you list the problems in the order of which is most important of needing attention first. most instructors suggest prioritizing by Maslow's hierarchy of needs. the hierarchy from most important to least important is as follows:

1. physiological needs (in the following order)
   • the need for oxygen and to breathe
   • the need for food and water
   • the need to eliminate and dispose of bodily wastes
   • the need to control body temperature
   • the need to move
   • the need for rest
   • the need for comfort
2. safety and security needs (in the following order)
   • safety from physiological threat
   • safety from psychological threat
   • protection
   • continuity
   • stability
   • lack of danger
3. love and belonging needs
   • affiliation
   • affection
   • intimacy
   • support
   • reassurance
4. self-esteem needs
   • sense of self-worth
   • self-respect
   • independence
   • dignity
   • privacy
   • self-reliance
5. self-actualization
   • recognition and realization of potential
   • growth
   • health
   • autonomy

[nurseprnRN, BSN, RN]

See, you are in danger of falling 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 (although sometimes a medical diagnosis can be a causative factor). You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, 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 and treatment plan comes in.

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. Learning this is why your faculty assigns nursing care plans over and over and over, to teach you how to think like a nurse.

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 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)_____ . 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 "defining characteristic" and 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...)

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.

[Joni's Mom]

Thanks for your reply,

Our instructors want a care plan for both a physiological and a psychosocial nursing diagnosis. I know that coping, anxiety, and fear are all psychosocial but I just wanted to know all of the psychosocial diagnosis' out there. I can only find the information that your found, and I also have the "Ackley, Cox, Halloway" nursing diagnosis books.

Good question on did our instructors give us a list, the answer is NO. They gave us the same list as you described with the divisions.

This whole entire nursing program is about teaching ourselves.

My problem is that I need a psychosocial nursing diagnosis on a 1st time mother that is happy, and content and I'm having a hard time coming up with a psychosocial nursing diagnosis.

Thanks

[lizzyberry]

Hi I was wondering if anyone knew if Disturbed thought process a psychosocial diagnosis?

[PsychNurseWannaBe, BSN, RN]

Yes, since a disturbed thought process affects the persons ability to interact with their environment.

[futurecnm]

lizzyberry said:

Hi I was wondering if anyone knew if Disturbed thought process a psychosocial diagnosis?

I don't have any book about nursing dx, but I know in our list from class, it is listed under psychosocial and it is accepted by our instructors for a psychosocial dx. We have to have one physical and one psych dx each care plan.