Nursing Diagnosis for diabetes

KelRN215, BSN, RN · Jan 28, 2013

Your nursing diagnosis is based on your assessment of your patient, not on their disease. You could have 10 diabetic patients and could come up with 10 different nursing diagnoses for them. Your nursing diagnosis does NOT have to be specifically related to their medical diagnosis.

Why does your instructor "hate" risk for diagnoses? I use those all the time.

CT Pixie, BSN, RN · Jan 28, 2013

I've been struggling a bit with Nursing Diagnosis for diabetes. When the patient is controlled, then I use other symptoms they are having that are impacting their life (impaired mobility, activity intolerance, etc). But they are not directly related to DM
My instructor "hates" a risk for diagnosis. The only DM related diagnosises I found in NANDA are related to imbalance nutrition which if the DM is controlled, is not accurate to use.
Am I right in focusing on the current problems when the chronic big health issue has been managed? Thanks

And why wouldn't they be accurate to use? If the patient is overweight/underweight its perfectly acceptable to use, regardless of whether they have controlled DM or not. This NANDA is in relation to body weight (under/overweight) not specifically to DM.

You should always focus on the current problems. Even if the DM wasn't controlled you need to focus on the most important issues at hand so even if their blood glucose level was showing say 289 but they were having difficulty breathing. You need to focus on the breathing aspect of the problems, not the hyperglycemia....ABC/Maslow. Like KelRN215 said, you need to base your NANDA on your assessment of the patient (head to toe) as well as their lab values etc. You can't formulate a care plan only using their medical history.

What did your assessment of the patient show? Were labs WNL?

nurseprnRN, BSN, RN · Jan 28, 2013

I've been struggling a bit with Nursing Diagnosis for diabetes. When the patient is controlled, then I use other symptoms they are having that are impacting their life (impaired mobility, activity intolerance, etc). But they are not directly related to DM
My instructor "hates" a risk for diagnosis. The only DM related diagnosises I found in NANDA are related to imbalance nutrition which if the DM is controlled, is not accurate to use.
Am I right in focusing on the current problems when the chronic big health issue has been managed? Thanks

There are problems when you start with a medical diagnosis and then try to find a nursing diagnosis to fit. That's exactly backwards.

Just for starters: What makes you think that impaired mobility isn't related to diabetes? What about peripheral neuropathy, which makes walking difficult? What about peripheral vascular disease, that gives the patient claudication and open wounds or amputation? What about cardiovascular disease that gives weakness and shortness of breath?

This is just a partial, partial list of how diabetes affects people. If you are looking at ONE person, look more widely at him/her as a complex system. NANDA-I is FULL of nursing diagnoses for people affected by diabetes. How was your patient manifesting his/her disease?

Your faculty is asking you to take a much wider view than you are. You are hampering yourself by trying to assume that you can start with a medical diagnosis and come up with one from column A, two from column B nursing diagnoses. Nursing diagnosis is NOT dependent on medical diagnosis.

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, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. THERE ARE MORE. Don't you DARE use this list on your patient if you can't substantiate it from your own assessment. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

I know you say you have the NANDA-I book, but I don't think you know how to use it properly, and this advice is for any student: 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. Free 2-day shipping for students from Amazon. 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...)

Think any of these might apply to someone with a life-long, life-altering disease with many complications? :)

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 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.

DawnJ · Jan 28, 2013

Everyone, I totally agree with what you are saying...that the diagnosis is about the patient and not the disease.

But, since we are studying endocrine, and I have an "endocrine" patient, my instructor wants diagnoses related to the "endocrine" issue. Now, my pt is well controlled and is of a good weight. So blood glucose instability, nutritional intake are not appropriate.

The end of the story is that I had a (rather long) discussion with my instructor and she came around to my point of view which is:

The priority diagnosis is the unsolved problem she is facing at the moment (impaired verbal communication, impaired physical movement) and since her DM is controlled, I can use a "risk for" diagnosis since it just needs to be monitored ongoing. Thanks everyone for your input!

DawnJ · Jan 28, 2013

Just for starters: What makes you think that impaired mobility isn't related to diabetes? What about peripheral neuropathy, which makes walking difficult? What about peripheral vascular disease, that gives the patient claudication and open wounds or amputation? What about cardiovascular disease that gives weakness and shortness of breath?

.

This particular patient had a brain bleed (likely from HTN and cocaine use) that left her aphasic, unable to bear weight or coordinate movement and with right side contractures. My assumption is that the CVA was more the cause of her mobility difficulties than DM or LE vascular issues.

nurseprnRN, BSN, RN · Jan 29, 2013

Thanks for letting us know. :: drily ::

DawnJ · Jan 30, 2013

Am I being nibbled on? :wideyed:

nurseprnRN, BSN, RN · Jan 30, 2013

No, but you're being reminded to include all relevant details when you give report.:) And CVAs are often caused by "vascular difficulties," a common complication of diabetes; even if she did it r/t to recreational pharmaceuticals she would still have been at higher risk d/t her primary diagnosis. Big picture here.

Just because you have an "endocrine patient" doesn't limit you to endocrine issues, which is what you expressed to your faculty and if she has any sense she will give you credit for. Diabetes is an endocrine issue, and so I suppose the root of all complications you can call endocrine; you need to look at the whole patient. Which brings me back to "give a complete report."