teacher not liking my NANDA- help!

[lalalalexi]

hi, i have a question about a nanda that i wrote for one of my patients. i have a teacher right now who is notoriously difficult in grading careplans. because of this, i emailed my careplan to her before i have to turn it in so i can make some changes if needed. anyway, my problem is this: my patient is a 74 year old woman who is a post-op chole and developed afib after the surgery and experienced an episode of syncope a few days post-op. my patient has a history of anxiety and is on daily lorazepam with prn lorazepam also. the day i had her as a patient her anxiety was low although she told me she usually experiences anxiety during the night after her husband leaves and she is in pain and can't sleep. she said she doesn't like being away from home and her husband. she also expressed anxiety and pain whenever ambulating and talked about being afraid of fainting again and being weak. i picked anxiety is a nanda and here is how i wrote my statement:

priority problem/nanda[color=#002060]: anxiety r/t intrusive diagnostic and surgical tests and procedures, changes in environment and routines, fear, pain aeb difficultly sleeping, reports of feeling more anxiety when alone, reports of pain, reports of feeling scared while walking, hx of anxiety

individualized outcome:[color=#c0504d]patient will not require any additional (prn) doses of anti anxiety medication other than her daily dose during shift, as evidenced by no verbalization of need, absence of behavioral/physiologic signs and symptoms of ans over-activation.

my teacher was overall unhappy with this. she emailed me back saying "you have psychosocial with a nanda dx. of anxiety. what did your client exhibit to you that made you give her a nanda of anxiety? did she appear anxious??? if so, how? also, how is this outcome measureable??" even though my patient was not anxious the 7 hours i was there, i feel this is still an appropriate dx for her. so would risk for anxiety be better? and i also think her outcome is measureable. she either does or doesn't need prn meds. i do want to get a good grade though, so obviously something needs to be changed. i just can't think of where to start. any help would be very appreciated.

[FireStarterRN, BSN, RN]

That's the only thing you addressed in the careplan, her anxiety? What about addressing her pain, her a-fib (which causes decreased cardiac output and can lead to a syncopal episode). What about a knowledge deficit regarding a-fib, and doing some much needed teaching? What about her new meds to control her a-fib? How about addressing education as to why ambulation will avoid other problems such as respiratory, dvt, faster healing. This woman needs teaching!

[lalalalexi]

Oh no, that is the not the only dx I put in her careplan. That is one of many NANDAs I have, but it is the one my teacher is taking the biggest issue with.

[FireStarterRN, BSN, RN]

So maybe you should change it to 'risk for anxiety' since she didn't need the ativan and she has plenty of things that might cause her anxiety. Good luck, these careplans are annoying, they aren't really used in real life other than intuitively

[Daytonite, BSN, RN]

every nursing diagnosis (you are calling them nanda's) has defining characteristics, or signs and symptoms, just as medical diagnoses do. you can see them in the nanda taxonomy. if you have a current care plan book that includes taxonomy information you can view the list of defining characteristics for the nursing diagnosis of anxiety. it is also listed in the appendix of taber's cyclopedic medical dictionary or you can view them on these web pages:

• anxiety
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=03 - anxiety
  

diagnosing requires that an investigation of the situation be made and all the abnormal data contributing to the problem be considered (assessment).

three part nursing diagnostic statements are to be constructed in the following format: pes where p is the problem, or nursing diagnosis, e is the etiology, or underlying cause of the problem, and s are the symptoms, or evidence/proof that the problem exists. when i look at your diagnostic statement for anxiety, i find the following issues with it some of which your instructor was addressing:

anxiety r/t intrusive diagnostic and surgical tests and procedures, changes in environment and routines, fear, pain aeb difficultly sleeping, reports of feeling more anxiety when alone, reports of pain, reports of feeling scared while walking, hx of anxiety

problem (nursing diagnosis): anxiety

etiology (cause): intrusive diagnostic and surgical tests and procedures, changes in environment and routines, fear, pain

• anything that causes an anticipation of danger or impending danger is an etiology for anxiety
  
  

symptoms: difficultly sleeping, reports of feeling more anxiety when alone, reports of pain, reports of feeling scared while walking, hx of anxiety

• while insomnia is a symptom of
  anxiety
  , if it is that much of a problem, there is a nursing diagnosis called
  insomnia
  and another called
  disturbed sleep pattern
  that could be used. when this patient hears she is about to have an intrusive diagnostic test, are you saying that she can't sleep and that she feels more anxious when she is alone and gets scared when she walks? when she gets a different care giver for the day who wants to change her care routines it results in her not being able to sleep and that she feels more anxious when she is alone and gets scared when she walks? that is essentially what your diagnostic statement tells me.
  
  
• "reports of feeling more anxiety when alone" should be a subjective statement by the patient. something on the order of, "when they leave me alone in the x-ray room i start to get shaky, i can feel my heart rate start to increase and i start to get a feeling of panic." however, the way you have written it does not make me see how it a sign or symptom of the etiologies of this nursing problem. the nursing problem is that she gets anxious when she has to have tests or procedures or there is a change in her routine--that's what you say in your diagnostic statement.
  
  
• "reports of pain" are a symptom of physical pain and not a symptom of anxiety
  
  
• "of feeling scared while walking" sounds like a symptom of
  impaired physical mobility
  .
  
  
• a "hx of anxiety" is not a symptom of
  anxiety
  . it is merely a historical fact.
  
  

outcomes are based upon alteration of the etiology, or cause, of the problem. goals are what you anticipate will happen when interventions you will be planning and ordering are carried out. your outcome is:

individualized outcome:

[color=#c0504d]patient will not require any additional (prn) doses of anti anxiety medication other than her daily dose during shift, as evidenced by no verbalization of need, absence of behavioral/physiologic signs and symptoms of ans over-activation.

• your etiologies, again were: intrusive diagnostic and surgical tests and procedures, changes in environment and routines
  
  

i am assuming that you would write interventions to medicate this patient with anti-anxiety medication for her behavior/physiological signs and symptoms of the medical diagnosis of anxiety not the nursing diagnosis of

anxiety

. make sure you keep the two diagnoses clear in your mind. we cannot treat medical anxiety. we can assist the doctors in administering their medical treatments. we can also order independent nursing interventions and that is what your instructor wants you to get at:

• an outcome is generally based upon independent nursing actions
  
  
• giving medication is a collaborative action and requires a physician's order
  
  
• your aeb items (symptoms) in the nursing diagnostic statement do not supply any evidence of any specific behavior/physiological signs and symptoms of anxiety that this patient is having.
  
  
• what is being done to target this patient's anxiety about intrusive diagnostic and surgical tests and procedures, changes in environment and routines that are mentioned in the "related to" part of the diagnostic statement? you can't just ignore them. how are you going to help her overcome her anxiety of these things? because you see, if you remove the cause of the problem (anxiety about intrusive diagnostic and surgical tests and procedures, changes in environment and routines) then some of her anxiety should go away. her symptoms of her anxiety should be things like exhibiting signs and symptoms of anxiety when she needs to have a diagnostic test, surgery is mentioned, or the way her post op routine gets changed. your signs and symptoms should have actually been things that were indicative of that. in turn, your nursing interventions should be addressing them as well. then, your outcomes/goals will fall right into place.