question about a careplan

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:

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

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

• 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.