I have a patient that has a lot going on but I'm having a hard time trying to figure out which diagnosis is most priority.
She is 40 years old and just had her first baby (advanced for maternal age).
She lost her mother the week before she was admitted to the hospital for induction of labor.
She suffers from Anxiety. She smoked during pregnancy.
Her vital signs were stable up until the point where she received an epidural and her bp feel really low.
She was in some pain during the labor process, which is not uncommon.
She is also anemic.
I'm trying to find a diagnosis that kind of incorporates all of these or most of these finding but it's hard. If I chose one component out of all of these problems. I don't have a lot of supporting information that I can use for my care plan.
I hate nursing care plans so much! I've been doing so horrible thus far.
See that's the thing, I thought I did everything right by assessing the patient and collecting the data. What I collected as objective data was she is being induced for labor at 38 weeks due to the circumstances of her family member passing, she's at an advanced maternal age, she has anemia, a medical hx of adhd. Subjective was the things that she told me and what she expressed as I observed her: this is her first pregnancy and she is nervous at the fact that her baby will experience complications, she was nervous during her pregnancy and purchased a fetal monitor, she was anxious about receiving the epidural, she was worried about the decelerations on the fetal monitor. She wanted to go ahead and have the baby and be able to grieve the loss of her family member afterwards. She was in pain. She stated she has a history of anxiety attacks.
I was only with the patient for her time in labor and deliver however she didn't deliver during my care and i have to do a care plan on that day i was with her. I don't know the results of the baby or the delivery because i didn't care for her afterwards.
What makes it hard to focus is the assignment and having to come up with a nursing diagnosis that includes five outcomes, five nursing interventions and at least three assessments. Since all of these things that I have assessed are different, it puts a limit on the requirements i have to meet. For example, to me the priority is the fact that the patient is Anemic.
The only abnormal finding i can use in my assessment is the fact that her HH were low. Everything else was normal (vitals/o2) So this limits me in the amount of assessments. Infection, the only assessment finding is that she has a catheter, and sterile vag exams. I can't use infection as a dx because it's one i used before (we can't use it again). What you wrote makes sense, alot of sense, but the requirments we have to meet is what makes it difficult to actually think like a real nurse. And instead of thinking what is my priority diagnosis, most of us end up going with what give us the most information to use to meet the requirements and make a thorough detailed careplan, that list many assessments, measurable outcomes, and interventions.
Because your instructor has put so many limits on your care plan, you are justifiably frustrated. (In this forum, I also learn what NOT to do as an instructor.) What I suggest is to just care plan the patient using Esme's instruction, THEN go back and eliminate those parts of the care plan that do not fit your instructors directions.
Also, please realize that working nurses, too, do not see care of a patient all the way through from admission to discharge. Heck, I've had an admission for only two hours and had to do an initial care plan for admission. Care plans are constantly evolving tools for nursing care. You care plan based on what you see during the time the patient is yours.
Risk for complicated grieving of family member r/t anxiety of unfamiliar procedures, pain of labor, fear of fetal complications, and effects of labor on maternal health.
My assessments:
- Patient witnessed death of family member two days prior to admission to L&D for induction of labor.
- Patient states history of panic attacks before and during pregnancy.
- Patient states she was anxious about epidural procedure.
- Patient request epidural to regulate pain.
- Patient's H&H was low at both prenatal visit and admission to L&D. (28 week labs revealed Hgb of 9.9 and Hct of 28.3 / Admit labs on 4/16/14 revealed Hgb of 10.3 and Hct of 30.4). Pt takes Ferrous Sulfate 325 mg.
- Patient is currently 40 years old and is at risk for fetal complications.
Patient is 38 wks gest.
- Patient suffers from attention deficit hyperactivity disorder
(ADHD).
Patient Outcomes
The patient:
- Will verbalize feelings, acknowledgment of loss, and express how it affects her hospitalization.
- Will relate increased psychological and physiologic comfort, evidenced by verbalization of a reduction in the level of anxiety experienced.
- Will rate a pain level at or below desired pain goal of 4.
- Pulse oximetry readings will be within a normal range of 95-100%. Pt. will maintain activity level within capabilities, as evidenced by stable v/s during activity, as well as absence of shortness of breath, weakness, and fatigue.
- Will verbalize a reduction or absence of fear of complications.
This is what i have so far to support the nursing dx. The interventions are always the easiest, the nursing dx is the only thing i have problems with.
Thank you both for understanding. I promise I am not trying to just get by with this. I honestly am trying to understand it. I made 98 on my last care plan and I just feel a lot of pressure to make this one a good one so that my instructor can see that I'm making progress. I've went from an 77 to a 98 on care plans since this semester started and I don't want to be a disappointment on this last one. At times I get it and at times when I don't have much information, I get so confused about what i'm doing. I've spent so much time working on this care plan, and haven't took the time i was planning to use to study for finals. But I'm just trying to stay positive.
Don't apologize! It's obvious you are working very hard on this care plan. I'm not an instructor (yet!), so I will only comment on one thing I think you might be missing. You don't mention her in-hospital support system, so I assume that she doesn't have anyone at her bedside helping her. That's a biggie during L&D, so you may want to add that to your assessment data and risk factors. Also, the NANDA diagnosis doesn't sound quite right to me, given the assessment data. I do not have a NANDA book (hides from Esme's and GrnTea ) but the assessment data points to compromised coping, IMO.
Just my thoughts (and admittedly it's been a long while since I was in nursing school and wrote a care plan)...Risk for complicated grieving would relate to the loss of the loved one, the stages of grief, inability to accept the loss, etc. Perhaps a better diagnosis would be Ineffective Coping (and/or risk of). You could list all the rt.'s you did plus the grief due to the loss of a loved one.
Risk for Complicated Grieving: Risk for a disorder that occurs after the death of the significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in
functional impairment (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
There is no such nursing diagnosis as " Risk for complicated grieving process," so you cannot make it. It doesn't appear in the current NANDA-I 2012-2014, which has the only approved nursing diagnoses. You cannot make this up. I'm not seeing anything in there that relate to a puerperal state. Look around in some of the other coping and fear-related ones to see if their defining characteristics and related factors allow you to make an accurate diagnosis.
Please, please get the book. It's inexpensive and will save you a lot of grief, since you will no longer have to flail around making things up because they sort of sound good to you.
Risk for complicated grieving of family member r/t anxiety of unfamiliar procedures, pain of labor, fear of fetal complications, and effects of labor on maternal health
I am also a student and working on my postpartum care plan as I type this (I know, I know...taking a break on Allnurses doesn't count, right? lol!) I think you are trying to work too many different things into your diagnosis. Risk for complicated grieving is a NANDA, but Risk for complicated grieving of family member is not. So, your diagnosis would be Risk for complicated grieving r/t to recent death of family member as evidenced by patient verbalizing feelings of anxiety and preoccupation with thoughts of the deceased.
But, none of that has to do with physical pain or even anxiety about the epidural. Those would be different diagnoses in my opinion. Anxiety r/t to fear of complications of epidural aeb patient verbalizing feelings of anxiety, hand tremors, increased perspiration, etc.
The goals you have assigned to your nursing diagnosis need to match the diagnosis. I had an awesome clinical instructor who worked with us until we understood this. In other words, your goal of oxygen saturation of 98% doesn't have anything to do with grieving.
Does that make sense? Can you separate out all the different assessment findings you have and make a list of nursing diagnoses for each one and then pick the top three to use that are of top priority for your patient? Or we will sometimes pick three: one physical, one spiritual and one psychosocial.
Our nursing assignment is to list risk factors and priorities but chose only one thing to use for a nursing diagnosis/concept map.
This is what I came up with so far, because it hits everything she is going through:
Risk for complicated grieving process d/t to pain of labor, fear of fetal complications, maternal health, and anxiety r/t unfamiliar procedures.
But not sure if it will make sense or if it's too much in one thing. Risk for complicated grieving is the main point and is a NANDA dx.
No, and there is an answer in the (apparently) third post you have made on this patient. See nearby.
Esme says:
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.
Where is your nursing assessment of her condition? This is all medical diagnoses.
See, you are 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. 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 plan nursing care. This is complementary but not dependent on the medical diagnosis or plan of care.
I am starting to learn that somehow the idea in nursing school these days is to "choose" or "pick" a nursing diagnosis. No, it's not. You are in nursing school to begin to learn how to OWN your nursing practice-- you MAKE a nursing diagnosis based on the evidence you see before you, exactly like physicians make medical diagnoses based on evidence. In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)
Sure, you have to know about the medical diagnosis and its implications for nursing, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.
You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis comes in when you’re planning the nursing care your patient needs and deserves.
This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.
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 should come 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, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.
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, but they have defined 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??? :) Amazon.com: Nursing Diagnoses: Definitions and Classification 2012-14 (9780470654828): NANDA International: Books
I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. 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: to learn how to plan nursing care.
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:
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 and at least one of the related / caustive factors are present. If so... there's a match. Congratulations! You have made a nursing diagnosis! :anpom: 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. Make sure it's congruent with your patient's wishes-- never forget that any patient can refuse any care or intervention, any time.
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; you want the most current edition, 2011.
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.
And instead of thinking what is my priority diagnosis, most of us end up going with what give us the most information to use to meet the requirements and make a thorough detailed careplan, that list many assessments, measurable outcomes, and interventions.
) but the assessment data points to compromised coping, IMO.
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
I'm not sure what you're asking.