PLEASE! Need input on my nursing diagnosis

Esme12, ASN, BSN, RN · Mar 28, 2014

I think interrupted family process is a good start but without the patient family assessment I can't tell you if the apply or are "good"

michaudni · Mar 28, 2014

Thanks for the response but I just found a great nursing book resource for nursing diagnosis

nurseprnRN, BSN, RN · Mar 28, 2014

If that book is not the NANDA-I 2012-2014, you do not have the resource you must have. I don't have mine c me because I am not at my desk, but I don't think your defining characteristics ("as evidenced by" is a common way to cite them) are included in that nursing diagnosis, or the "related to" in the list of approved related/causativ factors for it either. I can check later. Note that "care planning handbooks" do not carry all that information, and that NANDA-I is updated q3yrs, so your "handbook"may well be out of date.

nurseprnRN, BSN, RN · Mar 28, 2014

Okay, now it's a few hours later and I'm back in my desk. First, some background (Esme: I changed a little of the language in the sample :) ), and then I will answer your question specifically.

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.

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, 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 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??? :) http://www.amazon.com/Nursing-Diagnoses-Definitions-Classification-International/dp/0470654821/ref=sr_1_1?s=books&ie=UTF8&qid=1393965776&sr=1-1&keywords=nanda-i+2012-2014

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:

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 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.

Now, let's look at what you have with this family.

The nursing diagnosis, "Interrupted family processes," found on page 311 in the NANDA-I book, includes the following:

Definition: change in family relationships and/or functioning

Defining characteristics:

*changes in assigned tasks

*changes in availability for affective responsiveness

* changes in availability for emotional support

* changes in effectiveness in completing assigned tasks

* changes in expressions of conflict with community resources

* changes in expressions of isolation from community resources

* changes in mutual support

* changes in participation in decision-making

* changes in participation in problem solving

* changes in satisfaction with family

* changes in somatic complaints

* communication pattern changes

* intimacy changes

* pattern changes

* power alliance changes

* ritual changes

* stress reduction behavior changes

Related factors (causes):

* developmental crises

* developmental transition

* interaction with community

* modification in family finances

* modification family social status

* power shift of family members

* shift in family roles

* shifted health status of a family member

* situation transition

* situational crises

You will note that while you may think you are describing some of these things, you must use this language to be sure. For example, you could say, "Interrupted family processes related to shift in family roles, as evidenced by ( what defining characteristic(s) and assessment data, exactly?)"

I'm not seeing "developmental transition" as a cause, because this is intended to reflect, for example, the transition of a child moving into adolescence, or an adolescent moving out of the home, or Grandma moving into the house due to increased dependence; these are related to developmental stages and would certainly interrupt family processes.

Perhaps, by your very minimal description of your assessment, one cause might be "... related to changes in availability for affective responsiveness (parents state limited opportunity for time alone)." Does that fit your assessment data?

It is also perfectly acceptable to have more than one related factor, and common to have more than one defining characteristic.

In this case, another rationale for making this nursing diagnosis might be, "... related to situation transition (new parenting), as evidenced by shift in family roles (in what way? mother not working and bringing salary? something else? I don't know, you did the assessment, maybe this doesn't even work for this family, I'm just throwing it out here for an example)."

Point is that you cannot make up related factors, which are the causes of the defining characteristics which determine your diagnosis. You also cannot make up defining characteristics, even though you think they sound completely reasonable, though you can use your assessment findings to describe the defining characteristic you identified.

You must use the defining characteristics and related factors in the NANDA-I 2012 – 2014, and if your "handbook" does not have everything in the NANFA-I 2012-2014 I quoted above, it is incomplete. Again, this is understandable, because NANDA-I does not give blanket permission to quote their entire body of work to anybody who wants to write a handbook.

And this is why you need to get the real thing. Available at Amazon.com, $29 and free 2 day delivery, or $24 and instant delivery to your Kindle or iPad. Don't put it off.