Risk For NANDA (Care Plan)

[EricBookNSCyp]

I'm a second semester student in an ADN program. My question is about RISK FOR dx. If one is not supposed to use AEB, how does one decide if the pt is at "risk for" and how would the instructor decide if it is valid?

I'm in my OB rotation.

My pt: 22 y.o. G2 P1 natural vag delivery no complications post delivery 20 hrs. Pt has no knowledge of breastfeeding (process of milk production, feeding techniques, infant positioning, intake requirements of the infant). She thinks she has no milk to give the baby (but colostrum is present). My actual Ndx is Ineffective Breastfeeding. The characteristics and AEB match my NCP book. We also need a RISK FOR dx. I'm thinking about Risk for Impaired Parenting. The characteristics for the NANDA work but I don't really get how we justify using it if we cannot state any evidence (since it is a 2 part NANDA).

Pt. lives with mother who wants the father of the baby to marry her daughter or they need to move out. Hispanic, father is present but does not have a job. Pt is a sandwich maker at minimum wage but now has no income and may have to find a new place to live because of the mother's decision. Mother pressuring pt to let her (the mother) raise the baby, pt wants to raise the baby with father but their is the family conflict.

[Mike R, ADN, BSN, RN]

I would say the breast feeding thing is more of a knowledge deficit over what you have. But if your defining characteristics match your books definition of ineffective breastfeeding, by all means go ahead.

I think your "Risk for" works. Don't forget that you have R/T to work with to delineate your Risk for d(x). In the R/T, write something about her home life to justify.

[bhanson]

This misunderstanding is part of the reason why some nursing professors prefer to use "as manifested by" instead of "as evidenced by" for your nursing diagnoses.

An actual nursing diagnosis is made up of three parts:

- Problem

- Etiology

- Signs and Symptoms

The signs and symptoms are the defining characteristics manifested by the client that correspond with the problem.

In a risk diagnosis there are no signs and symptoms (nothing is manifested) or else they would have an actual problem and not be at risk for it. For risk diagnoses the "defining characteristics" are instead considered risk factors.

[Double-Helix, BSN, RN]

Actual diagnosis includes the following components:

(Name of Diagnosis)_______ related to _______ as evidenced by_________

Risk diagnosis:

Risk for (diagnosis)_________ related to (risk factors)________

In the risk diagnosis, the patient can't have any as evidenced by factors, because the patient doesn't have the diagnosis. Just like if someone has a risk for heart attack, they do not have any signs of a heart attack.

Here are some examples:

Impaired skin integrity related to immobility, low body mass index, and incontinence as evidenced by stage II pressure ulcer on coccyx.

Risk for impaired skin integrity related to immobility, diabetes, peripheral vascular disease, dry skin and smoking.

Hope this helps!

Ashley