Is the NANDA Dx the end-all-be-all??

[Mrs.D., BSN]

I'm writing a care plan for a patient.

I'm adding a poll, 1) because I love polls, and 2) I'm genuinly curious what YOU would do in my situation.

My current NANDA Dx is:

Hyperthermia r/t septicemia aeb temp above normal limits; flushed, hot skin; tachy-cardia/pnea; rigors

Patient vitals during crisis:

Temporal Temp - 105.2/105.3 (repeated immediately)

Telemetry HR - 170, within minutes 199, and stabilized in the 160s for 30+ minutes

Supine BP (L) - 163/102

RR - 60/bpm & shallow

O2 sat (NC 4L/min, but she was mouth breathing)- 96%

I'd like to use a diagnosis of Risk for Hyperpyrexia, as opposed to Hyperthermia (which the pt actually was experiencing). It's silly, but mostly because I have never heard of hyperpyrexia until I started doing research for the care plan, it sounds cool, and I kind of want to impress my instructor with something I found on my own. Hyperpyrexia is a temp of 106.7F. My pt was scary close to that temperature, so I believe it is appropriate.

My problem is, that Dx is not in NANDA, and I've never been taught whether RNs are allowed to use a Dx outside of NANDA. My instructor allows us freedom with our choices, so long as we show that we are able to stand by our choices in en educated way (evidence, goals, interventions, etc.). That being said, I don't want to just start making stuff up! I'd rather use the Hyperthermia, than make something up--even if that something is pretty damn cool.

So, short story turned long... Are RNs allowed to use non-NANDA diagnoses? and also, What do you think of my choices of diagnoses?

Thanks!

Ps. This was the most exciting situation I have ever seen in the hospital! I even got to transfer the patient to the ICU. I'm borderline obsessed with this situation, and it makes me want to work in the ICU STAT! Of course I feel bad for this person, and I hope they get well, but I learned so much by observing this crisis!

[smf0903]

"Is the NANDA dx the be-all-end-all?"

Yes, yes it is

[NICUismylife, ADN, BSN, RN]

Risk for complication (RC) of sepsis. RCs are nanda approved. Your patient is septic and your biggest concern is hyperthermia? This pt could go into septic shock and end up with multi system organ failure very rapidly.

[smf0903]

Risk for complication (RC) of sepsis. RCs are nanda approved. Your patient is septic and your biggest concern is hyperthermia? This pt could go into septic shock and end up with multi system organ failure very rapidly.

Agreed but this is a student still learning and putting pieces together. We didn't learn about sepsis/shock/MODS until our last semester. Students are learning how to see the forest, not just the trees. :)

[Mrs.D., BSN]

Thanks for your opinion, guys.

You know, this whole time I have been wondering what the hell happens next with this patient?? I've never heard of all of these vitals elevated. For example, usually the HR is elevated if the BP is dropping, but in this case they are BOTH elevated... what does that mean??? And what happens with this elevated temperature?? Shouldn't her brain be fried? This patient came in 6 days ago with a temp of 103.2, and it had been elevated since then (minus only a few hours in the middle of the night around 0200 where it was WNL, before this severe episode at 1700). Also had the elevated HR of 159 when coming in, and it had never been under 130--from what I saw in the chart. I didn't even know a heart could beat that fast (199 bpm!)! I mean, how fast can it go? What happens when it hits that one extra beat per minute that it takes to, what ?, Stop?... Is that what happens? No explosion, like an engine... just stopping? This experience has reinvigorated my interest in the human body. I see all these stats... and I'm talking to this person, trying to make them not freak out---even laugh and smile (which I DID accomplish while waiting for transport to and on the way to the ICU)... But if I was reading it in a book, I would have assumed this poor bastard was in a coma or something really terrible. I am just so damn curious.

So SMF, you are definitely correct in that I am just starting to put the pieces together. I am in Med/Surg, and this is my first real clinical. I had one last semester, but it was mostly to get acclimated to the hospital environment--it wasn't even the whole semester.

NICU- I see you are a CNA, so you probably see a lot out there. I don't work in the field, so my only experience is through lectures, books, and this is my third week in clinical. I'm sure I will miss a lot. I appreciate you pointing out this information, however, because it gives me something to look into, and an apparent lesson on priority setting.

[Mrs.D., BSN]

If you have the time...

I am now considering Risk for Complications of Sepsis, as NICU suggested. How would I adjust this?

I had made a care plan for Risk for Infection (in addition to the Hyperthermia one) with this patient. There is no mention of the sepsis, per say, but perhaps all of this could mean sepsis? Do you need a medical diagnosis for sepsis, or is it like a syndrome where you can infer it by all of it's parts? Is there a Risk of Complications from Infection?

Here is is:

Assessment – Patient is experiencing anorexia with recent 20lb weight loss, chills, chest pain upon coughing, diffused pain all over the body, and fatigue. Patient is febril with elevated temperature, has tachycardia, tachypnea with shallow, labored breathing and rales in RLL, hypertension, elevated white blood cell count, lower than normal limit red blood cell count, hemoglobin and hematocrit, visibly infected abscess on right hand, chest x-ray positive for bilateral septic emboli, and newly diagnosed hepatitis B infection and endocarditis. Patient has a history of IV drug use.

Diagnosis – Risk for infection related to break in skin integrity and lowered natural resistance associated with intense IV antimicrobial therapy, malnutrition, and compounded infections.

Goal – to get vitals within normal limits, continue treating with antimicrobials, prevent nosocomial infections, and educate patient on a drug treatment program and on long term antibiotic therapy by discharge.

Interventions - Infectious diseases consult; chest x-ray for possible RLL pneumonia; encourage coughing & deep breathing; medicate with IV antibiotics and IV fluids; monitor vitals Q15min until stable, then Q1h thereafter; monitor pain Q4h; teach prevention of infection and malnutrition—include family.

Should I put Risk for Sepsis instead? Should I put RC of sepsis and retool the whole care plan? I really thought I had gold, but now I'm not so sure...

Thanks again!

[AliNajaCat]

Old post: https://allnurses.com/general-nursing-student/care-plan-books-901616.html

Good for you for wanting to know more about the most important thing nurses do. Yes, assessment and planning is more important, because without them, no amount of skilled handiwork will be right.

Students often fall 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 determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

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 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.

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???

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.

If you do not have the NANDA-I 2012-2014 (((NOTE: 2015-2017 is now the current edition))), 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 andsee 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.

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. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

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.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013 (()Check to see if there's a mire current edition out now))), 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.

[Kuriin, BSN, RN]

Little strange you guys would put a nasal cannula on her if you knew she was mouth breathing...lol. To answer your question, NANDA are evidenced based and supported through interventions via research. You are only allowed to use NANDA.

[Mrs.D., BSN]

Thanks for your opinion on the NANDA Dx.

She wasn't mouth breathing prior to the crisis--that was during. She just wasn't able to focus on breathing through her nose, but since her O2 was okay, intervention wasn't the most pressing at that time. She probably would have had increased anxiety about her crisis if we tried to put a mask on her. I'm sure the RNs would have put a mask on if her O2 was an issue.

Maybe be they should have done it just in case her O2 went south? I just don't know...

[AliNajaCat]

Thanks for your opinion on the NANDA Dx.

She wasn't mouth breathing prior to the crisis--that was during. She just wasn't able to focus on breathing through her nose, but since her O2 was okay, intervention wasn't the most pressing at that time. She probably would have had increased anxiety about her crisis if we tried to put a mask on her. I'm sure the RNs would have put a mask on if her O2 was an issue.

Maybe be they should have done it just in case her O2 went south? I just don't know...

Just so you know: Unless there's a standing prescription for oxygen for an individual patient, or for emergency use in a unit, you can't just slap oxygen on somebody. No, you can't.

[Esme12, ASN, BSN, RN]

Thanks for your opinion on the NANDA Dx.

She wasn't mouth breathing prior to the crisis--that was during. She just wasn't able to focus on breathing through her nose, but since her O2 was okay, intervention wasn't the most pressing at that time. She probably would have had increased anxiety about her crisis if we tried to put a mask on her. I'm sure the RNs would have put a mask on if her O2 was an issue.

Maybe be they should have done it just in case her O2 went south? I just don't know...

NANDA is the end all be all. If the patient already has a high fever it is no longer a "RISK OF"

Care plans ar all about the patient and the patients problems. 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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

[Esme12, ASN, BSN, RN]

Assessment – Patient is experiencing anorexia with recent 20lb weight loss, chills, chest pain upon coughing, diffused pain all over the body, and fatigue. Patient is febril with elevated temperature, has tachycardia, tachypnea with shallow, labored breathing and rales in RLL, hypertension, elevated white blood cell count, lower than normal limit red blood cell count, hemoglobin and hematocrit, visibly infected abscess on right hand, chest x-ray positive for bilateral septic emboli, and newly diagnosed hepatitis B infection and endocarditis. Patient has a history of IV drug use.

Diagnosis – Risk for infection related to break in skin integrity and lowered natural resistance associated with intense IV antimicrobial therapy, malnutrition, and compounded infections.

So now....looking at this assessment there are several NANDA diagnosis. Remember if the patient has the symptom it is no longer a Risk.

Hyperthermia

Impaired Gas exchange

Acute Pain

Imbalanced Nutrition: less than body requirements

Look up your NANDA and look at the "definition" if your patient has those "symptoms it is appropriate for your patient