Nursing Diagnosis..Please help!!

nurseprnRN, BSN, RN · Oct 17, 2013

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(this/these defining characteristic/s) ___. He has this because he has ___(related factor/s)__."

"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. :)

I had a patient who had a total knee replacement of the left knee. When I saw him, he was 2 days post op. He was in a lot of pain, seven on a scale of 0-10 after his dose of 5mg of Oxycodone. He was weight bearing as tolerated and actually moved from his bed to the chair with the use of his walker. His vitals were BP: 145/95 T 98.7 HR 94 and O2 Sat 94%. His Foley was removed at 0645 and by 1200; he had not voided his bladder. The nurse said if he had not urinated by 1300 they would have to straight cath, I unfortunately left the floor before then, so I do not know what happened.
I have to come up with three nursing diagnosis for this patient. Looking at my care plan I think I would need to do one for is respiratory, pain level and maybe his limited mobility. This is what I have come up with so far. Am I on the right path?
Acute pain related to subjective data as evidenced by pain level scale.

Subjective data do not cause acute pain-- that's what "related to" means. You can see that surgery (a physical cause of pain) is a listed defining characteristic in the NANDA-I 2012-2014 book. Your evidence is not the pain level scale, it's the rating he gives his pain. So you could say, "Acute pain related to total knee replacement, as evidenced by patient reports having pain at 5/10 at rest and 10/10 with movement," or something like that.

2. Impaired physical mobility related to muscoskeletal impairment associated with surgery as evidenced by decreased strength.

Does you really know he has musculoskeletal impairment because you observed he has decreased strength? Or is his mobility decreased because he has too much pain to move well? Pain is a listed cause of impaired mobility in your NANDA-I. So you have, "Impaired physical mobility due to pain, as evidenced by (patient behavior x, y, z...)" Does that make sense?

Impaired respiratory levels related surgery as evidenced by shortness of breath..

There is no such nursing diagnosis as "Impaired respiratory levels." So you need to look in your NANDA-I 2012-2014 for an acceptable diagnosis that meets your assessment findings. Hint: You will find it on p. 214, MAYBE, but only if you have evidence of one of two very specific related (causative) factors. I don't see anything in your assessment that tells me he has a respiratory problem.

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 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!

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, 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.

Oooh, and I just got a great book for interventions. The 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 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.

Mamagoofy28 · Oct 17, 2013

Holy cow! :) Thank you so much!! I am going to have to reread a couple of things to let it sink in. This is my 2nd attempt at doing nursing diagnosis and I really appreciate all the information you gave me. I will definitely look for that book!! It sounds like it would be very helpful for me. Thanks again!!

suppaduppaCNA · Oct 18, 2013

It is best to assess your patient's comfort level if you are going with a Dx of pain.

Esme12, ASN, BSN, RN · Oct 18, 2013

I had a patient who had a total knee replacement of the left knee. When I saw him, he was 2 days post op. He was in a lot of pain, seven on a scale of 0-10 after his dose of 5mg of Oxycodone. He was weight bearing as tolerated and actually moved from his bed to the chair with the use of his walker. His vitals were BP: 145/95 T 98.7 HR 94 and O2 Sat 94%. His Foley was removed at 0645 and by 1200; he had not voided his bladder. The nurse said if he had not urinated by 1300 they would have to straight cath, I unfortunately left the floor before then, so I do not know what happened.
I have to come up with three nursing diagnosis for this patient. Looking at my care plan I think I would need to do one for is respiratory, pain level and maybe his limited mobility. This is what I have come up with so far. Am I on the right path?
Acute pain related to subjective data as evidenced by pain level scale.
Impaired physical mobility related to muscoskeletal impairment associated with surgery as evidenced by decreased strength.
Impaired respiratory levels related surgery as evidenced by shortness of breath.
Any help would be greatly appreciated. I do have more information on my patient, but wasn't sure what all was needed. TIA

You actually have objective data for pain....what happens to the vital signs with pain? Elevated B/P and heart rate?

He may have impaired physical mobility but why?

every nursing diagnosis has it own....taxotomy...a list of common factors and causes....kind of like a list of "symptoms.

For example....NANDA defines impaired physical mobility as: A limitation in independent, purposeful physical movement of the body or of one or more extremities

with the defining characteristics as: Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements

and the factors related to: Activity intolerance; altered cellular metabolism; anxiety; body mass index above 75th age-appropriate percentile; cognitive impairment; contractures; cultural beliefs regarding age-appropriate activity; deconditioning; decreased endurance; depressive mood state; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding value of physical activity; developmental delay; discomfort; disuse; joint stiffness; lack of environmental supports (e.g., physical or social); limited cardiovascular endurance; loss of integrity of bone structures; malnutrition; medications; musculoskeletal impairment; neuromuscular impairment; pain; prescribed movement restrictions; reluctance to initiate movement; sedentary lifestyle; sensoriperceptual impairments

How does your patient fit into these definitions?

You must have a care plan book of some sort in order to know what defines your patients situation. Nursing diagnosis cannot be created.....they exist.....now how does your patient fit into them as they are defined.

Critical Thinking Flow Sheet for Nursing Students.doc