Need help with nursing diagnosis

MaNeTri · Mar 17, 2017

HI! Welcome to AN! The largest online nursing community!
What semester are you? Is this a real patient? I am thinking no...what a bizarre scenario. What are you studying now? Is this your psych rotation? What reference are you using for your nursing diagnosis?
I HATE these scenarios...they make no sense. Nursing diagnosis is all about the assessment of the patient. Telling me she is overwhelmed with a jerk for a boyfriend isn't a real assessment of the patient.
Here is my standard speech.....
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.
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.

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 from our Daytonite

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)

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)

Planning
(write measurable goals/outcomes and nursing interventions)

Implementation
(initiate the care plan)

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.
Another member GrnTea say this best......

thank you for your input, it's much appreciated.

I am just starting the program and we are now in the Nursing Process section and we were given this scenario. We were asked to provide an actual and a potential nursing dx. I am thinking of putting Anxiety, ineffective coping or stress overload as my actual dx but I need to choose the priority nursing dx...

Esme12, ASN, BSN, RN · Mar 19, 2017

thank you for your input, it's much appreciated.
I am just starting the program and we are now in the Nursing Process section and we were given this scenario. We were asked to provide an actual and a potential nursing dx. I am thinking of putting Anxiety, ineffective coping or stress overload as my actual dx but I need to choose the priority nursing dx...

Just so you feel better...it is a crummy scenario.

JM is 20-year old student, with 3 younger siblings, parents are both living, residing in Atlanta. She moved from Atlanta to California with her boyfriend. She is 2 weeks away from completing a course work, study for finals and buy a wedding gift for her aunt. She's having a hard time maintaining her part-time job in the gas station since she is doing 3 12-hour shifts in the clinical setting each week while squeezing in an English class every night. She lives on take out food and coffee while trying to finish her research paper and having a hard time writing it. Her boyfriend is asking her to spend more time with him

This is typical nursing school college stuff. It is difficult to pull out any diagnosis. Each diagnosis has it's own "definition" and bullet points that fit.....points that "prove" why the person/patient is experiencing that diagnosis. Have you purchased a care plan resource. If not...but one whether they require it or not. It will make your life much easier.

NANDA defines Anxiety (ref Ackley Nursing diagnosis 11th edition)

Anxiety: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with threat.

Related to: Conflict about life goals; exposure to toxin; family history of anxiety; heredity; interpersonal contagion; interpersonal transmission; major change (e.g., economic status, environment, health status, role function, role status); maturational crisis; situational crisis; stressors; substance abuse; threat of death; threat to current status; unmet needs; value conflict

Defining characteristics:

Behavioral: Decrease in productivity; extraneous movement; fidgeting; glancing about; hypervigilance; insomnia; poor eye contact; restlessness; scanning behavior; worry about change in life event

Affective: Anguish; apprehensiveness; distress; fear; feelings of inadequacy; helplessness; increase in wariness; irritability; jitteriness; overexcitement; rattled; regretful; self-focused; uncertain; worried

Physiological: Facial tension; hand tremors; increased perspiration; increased tension; shakiness; trembling; voice quivering

Sympathetic: Alteration in respiratory pattern; anorexia; brisk reflexes; cardiovascular excitation; diarrhea; dry mouth; facial flushing; heart palpitations; increase in blood pressure; increase in heart rate; increase in respiratory rate; pupil dilation; superficial vasoconstriction; twitching; weakness

Parasympathetic: Abdominal pain; alteration in sleep pattern; decrease in heart rate; decreased blood pressure; diarrhea; faintness; fatigue; nausea; tingling in extremities; urinary frequency; urinary hesitancy; urinary urgency

Cognitive: Alteration in attention; alteration in concentration; awareness of physiological symptoms; blocking of thoughts; confusion; decrease in perceptual field; diminished ability to learn; diminished ability to problem solve; fear; forgetfulness; preoccupation; rumination; tendency to blame others

What fits your patient from your scenario?

Here are a few that may apply.....like I said it is a crummy scenario.

Fatigue

Caregiver Role Strain

Deficient Diversional activity

Priority...it is usually based on what wil kill them first. The ABC's and Maslows.

Maslow termed the highest-level of the pyramid as growth needs. Growth needs do not stem from a lack of something, but rather from a desire to grow as a person.Maslow's Hierarchy of Needs | Simply Psychology

Five Levels of the Hierarchy of Needs
There are five different levels in Maslow's hierarchy of needs:
Physiological Needs
These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.
Security Needs
These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.
Social Needs
These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.
Esteem Needs
After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.
Self-actualizing Needs
This is the highest level of Maslow's hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.