Self-care deficit and etiology format.

[tnstudent21]

I have to do a diagnosis for self-care deficit. I have a few questions on the format.

I know that I am allowed to have multiple R/T factors. Do these factors have to be related? May I say Self-care deficit r/t cognitive impairment, physical immobility and fatigue.

Also, my patient has a history of dementia. Must I include "cognitive impairment secondary to dementia", or is that optional?

[Esme12, ASN, BSN, RN]

Welcome to AN! The largest online nursing community!

What semester are you? what format does you program want you to use?

[tnstudent21]

First semester. I am in fundamentals. We are required to use the PES format. The problem related to etiology, as evidenced by signs/symptoms.

[Esme12, ASN, BSN, RN]

What care plan book do you use?

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

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.

Step #1 of the care planning process is the collection of data about the patient. If this were a real patient you would use information from the patient's medical record as well as the information you gathered from your own assessment of the patient.

step #2 of the care planning process, you will use the signs and symptoms to determine what nursing diagnoses to use. These symptoms, or defining characteristics, become the basis and reasoning that supports choosing each particular nursing diagnoses. You form a nursing diagnostic statement that usually consist of three parts and place them in order of priority according to Maslow's hierarchy of needs. For PES.....these statements have 3 elements:

• the p (problem) which is the actual nursing diagnosis
  
• the e (etiology) which is the cause of the problem
  
• the s (symptoms) or defining characteristics which are associated with the problem
  

Nanda (North American Nursing Diagnosis Association) has specified the exact language that is to be used for nursing diagnoses. They have also defined each nursing diagnosis. Each nursing diagnosis has a specified list of defining characteristics (symptoms) and related factors (causes or etiologies) which are very helpful to use when determining which nursing diagnoses will be appropriate to use........ r/t stands for "related to" and aeb stands for "as evidenced by".

From our beloved Daytonite(RIP)

how do you construct the 3-part nursing diagnostic statement?

https://allnurses.com/nursing-student-assistance/nursing-diagnosis-370604.html

the 3-part diagnostic statement consists of 3 elements that can be represented by the mnemonic pes:

• p (problem) - this is the nursing problem--the nursing diagnosis. the nursing diagnosis is actually a label, or phrase, that gives a short description of the problem. a much longer explanation of the problem can be found in a nursing diagnosis reference book.
  
• e (etiology) - this is what is causing the p (problem) to occur. it is often the underlying pathophysiology of the patient's medical condition but it can be psychosocial and risk factors depending on the type of problem being addressed
  
• s (symptom) - also called defining characteristics, these are the bits of evidence that you find during your assessment of the patient. it is abnormal data that prove the existence of the p (problem).
  

once you have the information for these 3 elements it is a matter of putting it together in the correct order. the words "related to" or the abbreviation "r/t" are inserted between the p (problem) and the e (etiology). and the words "as evidenced by" or "as manifested by" or the abbreviations "aeb" or "amb" are inserted between the e (etiology) and the s (symptom). the final 3-part nursing diagnostic statement follows the formula of p - e - s. some examples are:

• ineffective airway clearance r/t retained secretions aeb diminished breath sounds bilaterally, crackles over upper lobes and persistent coughing
  
  • problem: ineffective airway clearance (definition: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway)
    
  • etiology: retained secretions
    
  • symptoms (the evidence): diminished breath sounds bilaterally, crackles over upper lobes and persistent coughing
    

  [*]deficient knowledge, tobacco cessation r/t lack of interest in learning aeb statements of refusal to accept the health risks associated with smoking

  • problem: deficient knowledge, tobacco cessation (definition: absence or deficiency of cognitive information related to a specific topic)
    
  • etiology: lack of interest in learning
    
  • symptoms (the evidence): statements of refusal to accept the health risks associated with smoking
    

  [*]imbalanced nutrition: less than body requirements r/t illness and homelessness aeb lost 50 pounds in the past 3 months and not eating regular meals

  • problem: imbalanced nutrition: less than body requirements (definition: intake of nutrients insufficient to meet metabolic needs)
    
  • etiology: illness and homelessness
    
  • symptoms (the evidence): lost 50 pounds in the past 3 months and not eating regular meals
    

  [*]risk for infection r/t possible exposure to communicable disease

  • problem: risk for infection (definition: at increased risk for being invaded by pathogenic organisms)
    
  • etiology (risk factor): possible exposure to communicable disease
    

how do you choose a nursing diagnosis?

i like to use some analogy here. how does a doctor diagnose someone? they do a history (ros - review of systems), physical exam and often diagnostic tests. then they analyze this data and make a decision: the medical diagnosis. when you take your car to a mechanic you tell him what symptoms your car has been having. the mechanic also does an inspection first in order to determine what the problem in. you expect him to give you a report and estimate of what the repair will be. this is diagnosing. a plumber does the same. many other types of repairmen do similar types of diagnostic and repair work. what they all have in common with us is this problem solving. assessment is always done at the beginning of problem solving. for us nurses, assessment consists of:

• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications they are taking
  

during all that assessment activity we are constantly on the lookout for what isn't normal. anything that is abnormal (like rhonchi in the lungs, edema in the legs, bruises on the body, bleeding from anywhere, spots where there shouldn't be spots) are automatic symptoms of something. the frustration for us is to figure out what they are a symptom of! what confuses many is separating the difference between symptoms of a nursing diagnosis and the symptoms of a medical diagnosis. medical diagnoses and nursing diagnoses are as different as apples and oranges. every nursing diagnosis has a list of signs and symptoms. yes, it does. they can be found in a nursing diagnosis reference book or a care plan book that includes the nanda (north american nursing diagnosis association) taxonomy. the taxonomy includes the definition, related factors (etiologies) and defining characteristics (signs and symptoms) for each nursing diagnosis. to diagnose someone with a nursing diagnosis we must have done some degree of assessment and found some signs/symptoms to support the existence of that diagnosis. if you can satisfy the p-e-s elements, then you have yourself a problem.

Another frequent contributor of AN GrnTea.....says it well.....

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

[Esme12, ASN, BSN, RN]

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the patient?

[tnstudent21]

I am in my first semester. My program wants us to use the PES system, just like you described above. That is very helpful. However, my main concerns are whether or not my related factors have to be related to each other, and if I must include the "secondary to dementia"?

[Esme12, ASN, BSN, RN]

Yes you can....but you haven't supplied enough information for me to tell you whether or not it's OK in this case. Click on that link I provided and there are a few examples of ND statements.

NANDA describes/defines self care deficit as: Self-Care Deficit: Impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting

Common Related Factors (why they have a deficit) are:

Neuromuscular impairment

Musculoskeletal impairment

Impaired mobility or transfer ability

Cognitive impairment (dementia)

Perceptual impairment

Fatigue, weakness

Pain

Severe anxiety

Decreased motivation

Environmental barriers

with Defining Characteristics ( as evidenced by) :what the patient demonstrates

Inability to feed self independently

Inability to dress self independently

Inability to bathe and groom self independently

Inability to perform toileting tasks independently

Inability to transfer from bed to wheelchair

Inability to ambulate independently

Inability to perform miscellaneous common tasks such as telephoning and writing

I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) /(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

So looking at this....the patient has self care deficit related to (what defining characteristics you have assessed) AEB (as evidenced by)....defining characteristics (that you found on your assessment).

[tnstudent21]

Thank you for your help.

[nurseprnRN, BSN, RN]

I always used to tell my students it's perfectly possible to have more than one thing wrong with you. Sure, your patient could be demented, physically impaired, and exhausted. You would want to identify all the reasons she had a self care deficit so you could then figure out the best way to manage her to minimize their effects and put those ways in your plan of care.

:flwrhrts: