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self care evaluations

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Denuus Denuus (New) New

Hello all, I am writing a care plan on my patient. My NDx is Readiness for enhanced self-care as evidenced by patient's positive attitude toward the opportunities in life, i have all the nursing interventions and rationales,

what i do not understand is how to write evaluations at the end?

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 15 years experience.

It's been years since I've had to do a care plan, but there are a few experienced posters here who have given wonderful advice. First, ensure you have the actual NANDA book, which is something recommended by GrnTea. Second, use the search field (opens when clicking on the magnifying glass at the top of the screen). Try using search terms such as GrnTea, Esme (another experienced poster with excellent advice), and nursing care plan. You will find quite the wealth of information.

Hello all, I am writing a care plan on my patient. My NDx is Readiness for enhanced self-care as evidenced by patient's positive attitude toward the opportunities in life, i have all the nursing interventions and rationales,

what i do not understand is how to write evaluations at the end?

Thank you, RoseQueen, for the generous endorsement for esme's and my efforts. :)

Denuus, 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. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

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 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.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

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'm making the nursing diagnosis of/I think my patient has ____(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."

Yep, it really is that simple.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at 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!

If you do not have the NANDA-I 2015-2017, 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. Free 2-day shipping for students from Amazon. 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. If so... there's a match. CONGRATULATIONS! You 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.

About Risk for” diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. Sometimes your instructor is asking specifically for a ranking in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Third: This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning.

So, what is the reasoning you have applied to your ranking, as applied to a specific patient or to people in general?

Now as your specific question:

I am not seeing that as a defining characteristic for this nursing diagnosis, and we are not allowed to make them up. From the 2015 – 2017 edition (page 246, Domain 4, Activity and rest), the most current and the only one you can use now:

Definition: "A pattern of performing activities for oneself to meet health-related goals, which can be strengthened." Is this what you are observing in your patient?

Defining characteristics:

*expresses desire to enhance independence with health

* expresses desire to enhance independence with life

* expresses desire to enhance independence with personal development

* expresses desire to enhance independence with well-being

* expresses desire to enhance knowledge of self-care strategies

* expresses desire to enhance self-care

Note that readiness diagnoses do not always have related factors, so you don't need to say what they are for the ones that don't. This one doesn't.

However, as you see, there is nothing here about patient's "positive attitude toward opportunities in life" (whatever that means) that you can use as a defining characteristic to allow you to make this diagnosis. Therefore, I don't see how you can say you have appropriate nursing interventions and rationales, because properly those must be tied to the defining characteristics. Which you have not identified. This is why you can't think of outcomes measurements.

This is one reason why students get into trouble with nursing diagnosis. They think that if they just copy something out of a handbook, they will have created a plan of care for a given individual, which that can then be implemented and/or delegated as appropriate. However, if you don't have the data to make a diagnosis, you can't apply a remedy for that diagnosis. See the example about leukemia at the top.

So let's go back and see if your patient did in fact express any of those desires. If she did, then you would tailor nursing interventions to her individual characteristic(s). What did she tell you? What did you assess?

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 NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

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.

I am quite content in writing the actual nursing diagnosis. Frankly I am writing a health promotion one so my ndx fits well with my subjective and objective data. I just don't understand the evaluations how to write those

I am quite content in writing the actual nursing diagnosis. Frankly I am writing a health promotion one so my ndx fits well with my subjective and objective data. I just don't understand the evaluations how to write those

Your contentment has nothing to do with it. You cannot create a new nursing diagnosis. Period. It's not up to you. Nobody can, I can't, esme can't, your faculty can't, you can't. You can make a health promotion nursing diagnosis for a patient if s/he meets the mandatory criteria for it. If s/he doesn't, you have no data from which to make the diagnosis. The diagnosis you make (not "make up") is SUPPOSED to derive from your data. Did somebody give you the idea that's exceptional?

I don't know how to make it any clearer than that. Anybody else want to give it a shot?

I'm sorry I'm not here to argue, but when did I say I was creating anew nursing diagnosis. I am well aware that the data is supposed to give me the diagnosis. I'm wondering what the evaluations portion is, how do I look at it? Remember ADPIE?

I am sorry I am not being clear enough. I didn't mean to say you were creating a new nursing diagnosis. I meant to convey the idea that you can't chose a nursing diagnosis off a list and then make up a new defining characteristic for it. You may think you have data to support a diagnosis, but if your data do not appear in the approved defining characteristics for making that diagnosis, you don't have the data to make it.

There is a specific definition for the nursing diagnosis of "Readiness for enhanced self-care." It is:

Definition: "A pattern of performing activities for oneself to meet health-related goals, which can be strengthened."

And its defining characteristics are:

Defining characteristics:

*expresses desire to enhance independence with health

* expresses desire to enhance independence with life

* expresses desire to enhance independence with personal development

* expresses desire to enhance independence with well-being

* expresses desire to enhance knowledge of self-care strategies

* expresses desire to enhance self-care

As to your specific question about how to evaluate the success of your planned interventions, your interventions would have to address/relate to the defining characteristic(s) by which you made your diagnosis.

So for example, if you made the diagnosis because your patient said something like, "I want to be more independent with my health care, take care of myself better so I don't have to see my physician / the clinic / the CDE / go to the hospital so often." Then you would probably think of things to make it easier for her to do that-- perhaps there are specific self-monitoring things she could learn to do (like how and when to do a daily weight to monitor early fluid retention, to get help or self-treat before the CHF gets symptomatic, increase her exercise, learn some focused meditation skills, join a wellness group at the community center ... ).

Then your eval of how well your plan for nursing intervention(s) went might include things like, "She says she feels more in control; she had fewer visits to the NP over the next twelve weeks; her weight stayed stable and her labs were WNL; she reports a higher subjective level of well-being..."

Is that clearer?

Edited by cafeaulait

Very. My dude he says he wants to enhance his health because he smokes a pack a day and so to compensate for that he goes to the gym everyday for two hours to try and keep his body to optimum health. He is on a nicotine patch and ecigs just to get him to break his habit. So the defining characteristics do I include one of those in my nursing diagnosis then?

OK. What you would say is something like,

"..... as evidenced by expressing desire to enhance self-care, i.e., "I know smoking is bad for me and I am trying to stop. I go to the gym every day to make up for the smoking."

So goals for him, which you would make with him, not for him:

Smoking cessation and stop use of all nicotine-containing substances by (date); taper program should be medically supervised

Weight management (the gym will help that a lot)

(other measures of improved post-smoking health ? like ..?)

Some actions to help him with the goal of better self-care might be...

... education on the idea that gym membership is a great idea but it won't really make up for the damage he does himself by smoking AND by continued use of nicotine products...

... set up membership in a medically-supervised cessation program

... track endurance and fitness improvements over time, work c personal trainer at the gym on a program

Evals for success of these actions (and others you might think of with him)

... (what do you think would give you data to tell you how successful things have been/indicate revisions needed?)

So... Readiness for enhanced self care aeb patients positive attitude toward the opportunities in life, increased exercise to maintain health and desire to enhance independence in maintaining health...won't work?