Nursing Diagnoses - Am I Understanding Correctly?

[simply_viki]

I'm just having some difficulty here. For some background info, I'm a second semester (but second year - that's the part time program for you!) nursing student. I'm in med-surg clinicals. The way our professor wants us to do our care plans is to go to the chart, find assessment data, and write up a care plan for the patient before clinicals.

Do nursing diagnoses need to be "AEB" the defining characteristics of the diagnosis? Or is there room for other evidence? For example, I had a patient with urosepsis. He also had history of CVA, and English was a second language for him, so communication with this patient was difficult, to say the least. He came into the ER with a high fever, 103, which only lowered to 101.9 after administration of acetaminophen.

Now, I know that urosepsis is a result of a UTI. So, I thought that I should do my care plan on one of the urinary diagnoses. I wanted to use Impaired Urinary Elimination R/T UTI (well, my NANDA book says that's OK, but my school doesn't like things to be related to medical diagnoses, so I was going to use "infectious process in the urinary tract" instead), but I couldn't come up with the AEB part. The NANDA book says the defining characteristics of Impaired Urinary Elimination are: Frequency, urgency, hesitancy, dysuria, nocturia, incontinence, and retention.

Well, I didn't have any evidence of any of those things. Due to the communication problem, the patient wasn't able to complain of the first five defining characteristics. The last two things weren't present either, because the patient had a foley catheter in, so retention wasn't possible and incontinence was irrelevent. I was thinking I could use the presence of a foley catheter as evidence, but unfortunately, I only had knowledge of that crucial bit of data because I overheard one of the nurses talking about it while I was at the hospital collecting patient data for my pre-assignment. So I figured it wasn't admissible evidence, since it wasn't documented (I suppose he must have come in from the nursing home with the catheter in, since there wasn't an order for it in the chart).

So, I gave up on doing a urinary care plan, and moved on to my other data. My other bit of relevent data was the fever of 103 on admission. So, I took that, ran with it, and wrote up a care plan on hyperthermia. Since the definition is: "Body temperature elevated above normal range", I figured it was applicable. So I wrote out: Hyperthermia R/T infectious process in the urinary tract (I reasoned that this falls in the "illness" part of the related factors in the NANDA book) AEB temperature of 103". I didn't have any of the other defining characteristics - no headache, no flushed skin, not warm to touch (well, not documented as such, I'm betting he was warm to the touch with a fever of 103!), no tachypnea, no tachycardia, stable BP, no seizures, no convulsions, no muscle rigidity, and no confusion (well, not that could be reasonably attributed to the fever, anyway - history of CVA and communication difficulty, remember? Unable to assess).

My professor threw out the care plan at the diagnosis. She said one defining characteristic is not enough data. She also said I should have used some of the chart data about the infection (I had a WBC count, a urine culture, and some other signs of infection) in the AEB section. Um... really? Really, really? I tried showing her that none of those things were defining characteristics of Hyperthermia, but she said the little Nurse's Pocket Guide I was using wasn't comprehensive, and that other things could be used, too, that might not be included in the book, because it was so small.

Well, it's been bugging me ever since then, so I bought the official NANDA book, Nursing Diagnoses: Definitions and Classifications 2009-2011, to see if maybe there were some more defining characteristics in that book. There aren't. It's exactly the same. Am I missing something here? A defining characteristic means the things that define the diagnosis, right? Not just random bits of data, and not just data that supports your related factor, but data that supports the diagnosis.

Le sigh. Nursing school. Tell me it gets better. Or that I'm wrong, but please back it up with hardcore data, because I have been looking and looking for it, and can't find it.

[simply_viki]

Gosh. Sorry for the novel of a post, LOL! Brevity is not my strong suit.

[lillyofthevalley]

When visulizing a care plan/map, this is the defining moment when black and white nursing ends, and the real nursing world rears it's ugly head.

The point of the matter is your pocket Nurse's Pocket Guide is just that.. a GUIDE. Nursing Diagnosis in a care plan book or guide, gives a general definition of the nursing diagnosis that you are trying to use, but NO two patients are alike! Yes, your patient MAY experience nocturia, but not all patients have them. But, if a patient has an infection, there WILL be an increase in the WBC count unless the patient is immunocompromised, and you did not state that.

The question to ask yourself is WHY do you think that your patient has the nursing diagnosis Hyperthermia or Impaired Urinary Elimination.You should be able to give ample amounts of subjective and objective data. If not, then you could possibly be missing the bigger picture, or didn't gather enough assessment data.

[Daytonite, BSN, RN]

all parts of the chart should be gleaned for assessment information. check the doctor's h&p and the nursing admission assessment. i did a post about this some time ago and listed the various areas of the chart that information can be found in. the information that the doctor charts is usually a wealth of information that is usable. see post #23 on this thread: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html - health assessment resources, techniques, and forms which was originally posted here: https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html

good choice getting a copy of nursing diagnoses: definitions and classifications 2009-2011. i refer to it all the time when i am answering nursing diagnosis questions. keep in mind, however, that it is the taxonomy and the information in it is a guideline. some of the related factors and defining characteristics should not be taken literally and need more specificity when you are developing an individualized care plan.

do nursing diagnoses need to be "aeb" the defining characteristics of the diagnosis?

the aeb items need to be the evidence, or proof, of the problem (the nursing diagnosis).

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

• problem
  - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of
  taber's cyclopedic medical dictionary
  has this information.
  
  
• etiology
  - also called the
  related factor
  by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  
  
• symptoms
  - also called
  defining characteristics
  by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
  
  

[simply_viki]

Lillyofthevalley - Well, I'm trying to work on thinking in grayscale instead of black and white. :)

I do understand that the pocket guide is simply a guide. But doesn't the patient have to display at least one of the defining characteristics of the diagnosis in order for you to use that diagnosis? I would've loved to use Impaired Urinary Elimination, but I didn't have any of the defining characteristics, so I threw it out. In my mind, I theorized that the patient probably did in fact have some of the defining characteristics, but since the majority of them were subjective, and due to his communication issue, he was unable to communicate that subjective data. And since the only remaining two wouldn't apply since he had a foley catheter, I had to abandon the diagnosis. I think. Should I not have abandoned the diagnosis?

I think I understood the bigger picture from the chart - the patient had urosepsis, stemming from a UTI, oh, let me see... so far I've been going on memory, let me open up my notes from that day.

OK, here's what I'd put in my notes:

Age: 75 Sex: M Race: WAdmitting Medical Diagnosis(es): Urosepsis

Past Medical History (include past surgical history): Gastroenteritis, [possible diabetes - chart inconsistency], cystitis, urinary obstruction, hematuria, functional decline, arteriosclerotic heart disease, pacemaker, pyelonephritis, aortic aneurysm, depression, hyperlipidemia, right hip fracture, transient ischemic attack, cerebrovascular attack w/ right hemiplegia, cardiovascular disease, hypertension, benign prostatic hyperplasia, former smoker, pacemaker failure, pacemaker replace (April 2009), dementia, community acquired pneumonia, abdominal aortic aneurysm, anorexia.

Present Surgical Procedures (include date): Scheduled for cystoscopy, left retrograde pyelogram, and possible ureteroscopy plus stent on 10/16/09.

History of Present Illness: Taken from ALF to the ER for fever of 103, decreased only to 101.8 with Tylenol, and increasing weakness. T 101.9, P78, RR 20, BP 143/70. Found elevated WBC (12,400), low H&H (10.8 & 33.1), high BUN & creatinine (44 & 2.0). Urinalysis showed occult blood 4+, protein 1+, WBCs >100 ("too many to count"), and 50-75 RBCs. Urine, blood, and nasal cultures were obtained. Urine culture shows 75,000 CF units/mL of pseudomonas aeruginosa. Hospital treatment plan consists primarily of antibiotic and IV fluid therapy, with scheduled cystoscopy (see above). Other assessment data: awake, alert, in no apparent distress. Chronic right facial weakness. Decreased breath sounds bilaterally with mild rhonchi.

See, I realize that he's had all this stuff going on in his history with his urinary system - hematuria, urinary obstruction, pyelonephritis (hoo boy... I know that's in the kidneys and something's inflamed. That's all I know on that one), and even the prostatic hyperplasia contributes somehow (I remember finding some statistics saying UTIs are more prevalent in older men wtih BPH). And I gleaned some info from the chart to put in the history of present illness, in order to sort of try and give the big picture. I guess what I'm having a hard time doing is putting that in NANDA format. If it's not in the book as a defining characteristic by any stretch, I'm not putting it in there.

[simply_viki]

Daytonite - Yes, I did make sure to get as much as possible from the chart (I think I might be overdoing it, really, I spend several hours in the hospital with that chart, and usually see several of my classmates come, collect their data, and leave in the time that I'm there). The doctor's H&P is great, it's usually typed up and put neatly in the chart. The nursing admission assessment is trickier - they don't have it in the chart at this hospital, usually; it's on the computer. So are the labs and diagnostics sometimes. And the current MAR. So at the end, when I've collected all I can from the orders, the older labs, and the doctor's H&P (and, if I'm lucky and this doctor has somewhat legible handwriting, the doctor's progress notes as well), I have to find a nurse who doesn't look terribly busy and ask her to print up a whole list of documents for me. I try and keep it short and sweet so I don't burden the nurses, because I could easily ask for ten documents to be printed, but I don't want to be a pain.

I'm taking a look at those posts you referenced - I like following these trail-links you post, very informative stuff.

As far as specifity in related factors and defining characteristics - how much "wiggle room" do I have as far as those go? Going still with Impaired Urinary Elimination as the example, say I take the defining characteristic dysuria. I understand that I don't simply put "AEB dysuria", I could say "AEB reports difficulty in voiding" or "AEB reports pain on urination" (well, if those things existed in the patient, anyway).

I think I have a good grasp on the format of a nursing diagnosis. Problem, etiology (cause of the problem), and evidence. And as far as I know, the evidence has to fit the defining characteristics.

If I don't have any data that can be interpreted as one of the defining characteristics, but I have data that supports the etiology of the diagnosis, can I still use the diagnosis? Or do I have to throw it out and try to find a different one that fits the data better?

[Daytonite, BSN, RN]

The patient has all the symptoms of an infection. The diagnosis you should be using is Hyperthermia.

[simply_viki]

Awesome! That's what I went with.

Hyperthermia R/T infectious process in the urinary tract AEB temperature of 103

Should I have included the WBC count and urine culture results in the AEB section? I didn't because they weren't defining characteristics of hyperthermia in the NANDA books. But then, they support the infection, and my professor seemed to think they should've been included, so... I'm just not sure.

[Daytonite, BSN, RN]

should i have included the wbc count and urine culture results in the aeb section?

no. they are not evidence of a fever.

[simply_viki]

I didn't think so... Would you change anything about my diagnosis, though?

At this point, I guess I'd have to just call it a quirk of the professor's, and just keep it in mind for my future care plans.