Need Help!! R/T & AEB statement

nurseprnRN, BSN, RN · Jan 31, 2014

You are avoiding 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, which is good, even though you have gone a teeny bit astray. :) We can help.

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.

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 am assuming that your assessment included the SOB, wheezing, and crackles, and those do appear in the list of defining characteristics in the NANDA-I 2012-2014 nursing diagnosis of "Decreased cardiac output." Decreased ejection fraction and arryhthmias (like bradycardia) also appear in the list of defining characteristics. "LV damage" does not appear in the list of defining characteristics, however. You appear to want to lay all your diagnosis at the door of "LV damage" as a related/causative factor, but there are only six related factors for this diagnosis: altered afterload, altered contractility, altered heart rate, altered preload, altered rhythm, and altered stroke volume.

So then let's go back and see what your nsg diagnosis should say using the above plain English translation and the requirements for defining characteristics and causative factors in the NANDA-I.

"I think my patient has decreased cardiac output. He has this because he has (r/t) altered contractility. I know this because I see/assessed/found in the chart (as evidenced by) an ejection fraction of 15%, bradycardia, SOB, cough, and crackles (and I'll bet if you looked at the list in the book you'd recognize a lot of other things you observed or ought to have observed). "

Note that if you think about it, there are other reasons why someone could have a lousy cardiac output in the face or normal contractility. "Altered preload," for example, could mean hypovolemia, and you would see completely different physical and diagnostic imaging findings when you did your assessment. This is what the diagnostic process is all about-- looking at the evidence you have and figuring out the diagnosis based on it. "Arrhythmia" that could result in decreased CO could also mean a very rapid tachycardia. All sorts of things can cause this.

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of the NANDA-I 2012-204. 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, 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, after reading this, if anyone is 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. 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, 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.

STLauren08 · Jan 31, 2014

GrnTea – I have been in an accelerated BSN program for nearly a year now, and in that time, NO ONE has ever been able to explain something so clearly…you are like my Nursing School Ferry God Mother!! LOL, no joke, I printed your response to use as a reference from now on!! :)

I actually own the current edition of NANDA; it was actually on our required list of books since day one, however I haven’t had to use it until recently. The problem is, no one really gave us an introduction/quick tutorial about how to use it.

Which leads me to ask one more question (I just want to be clear): I understand that there has to be at least one defining characteristic present in order to be able to use the diagnosis; however can I only use the r/t factors listed for each dx?? Or does that part not always have to come from the book??

I just want to sincerely say thank you!! Writing these diagnoses has been a pain in my butt since day one, and I have been so frustrated! I didn’t think anyone was ever going to be able to make me understand how to do it properly and not make it seem so complicated!!! I appreciate the book recommendations too! I will definitely be making some purchases tonight from Amazon! :)

nurseprnRN, BSN, RN · Feb 2, 2014

GrnTea – I have been in an accelerated BSN program for nearly a year now, and in that time, NO ONE has ever been able to explain something so clearly…you are like my Nursing School Ferry God Mother!! LOL, no joke, I printed your response to use as a reference from now on!! :)
I actually own the current edition of NANDA; it was actually on our required list of books since day one, however I haven’t had to use it until recently. The problem is, no one really gave us an introduction/quick tutorial about how to use it.
Which leads me to ask one more question (I just want to be clear): I understand that there has to be at least one defining characteristic present in order to be able to use the diagnosis; however can I only use the r/t factors listed for each dx?? Or does that part not always have to come from the book??
I just want to sincerely say thank you!! Writing these diagnoses has been a pain in my butt since day one, and I have been so frustrated! I didn’t think anyone was ever going to be able to make me understand how to do it properly and not make it seem so complicated!!! I appreciate the book recommendations too! I will definitely be making some purchases tonight from Amazon! :)

I am glad they at least gave you the NANDA-I :) Thanks for the kind words.

Yes, you can only use the causative /related factors as given, because those are the ones from which the research supporting the ND are derived. Doing so helps push people into looking at the things nursing "owns" rather than things that medicine own, and decreases the chances that students and others will revert to the "I have X medical diagnosis and need three nursing diagnoses for that" meme. Note that there are many NDs where the causative factor may be a medical diagnosis. But there are many that do not do that.