62 yo male, paraplegic- need help determining 3 nsg dxs

Esme12, ASN, BSN, RN · Mar 30, 2014

You are using an outdated book? That can be the reason you aren't getting the right ones. They have changed from 2011...A LOT! Was this the book that was recommended?

In use Ackley the 10th edition there is a care plan constructor feature which you would find helpful. I also use the total package of nursing diagnosis resource the NANDA I book. These books would make your life so much easier.

Ineffective Breathing Pattern

Ineffective Coping

Fear

Grieving

Hopelessness

Risk for compromised Human Dignity

Ineffective Impulse Control

Moral Distress

Impaired physical Mobility

Acute Pain

Chronic Pain

Post-Trauma Syndrome

Powerlessness

Impaired individual Resilience

Self-Neglect

Chronic low Self-Esteem

Impaired Skin Integrity

Social Isolation

Stress overload

These are based on the information you provides and I didn't even include the feeding tube, infection or respiratory failure. Some of these are more appropriate than others. Each ND has a certain set of characteristics/definitions and requirements that have to fit the patient in order to use them.

What meds is this patient on? How long has he been a paraplegic? Does he have a temp? Are they in rehab? What does the CXR show?

Care plans are all about the assessment of the patient and what the patient needs

Esme12, ASN, BSN, RN · Mar 30, 2014

Outcomes are the predicted results of our independent nursing actions. Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. An expected outcome is measurable, patient centered, and specific. When you identify an outcome, you accept responsibility and accountability for helping the patient achieve that outcome. outcomes describe patient states that follow and are expected to be influenced by an intervention.

Goals are the predicted results of collaborative nursing actions. Collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. Goals may also be measurable, patient centered and specific.

What differentiates a goal from an outcome is that the nurse cannot take full responsibility and accountability for helping the patient to achieve a goal. Goals are achieved because of the collaborative management of many.

The goal is aimed at the nursing diagnosis.

The expected outcomes are aimed at meeting the goal.

1. must be patient-centered.

2. Address only

ONE

response.

3. include observable and measurable factors.

4.

need a target date

5. use behavioral verbs.

The patient will state 3 ways to treat hypoglycemia by 05/01/05.

It was patient centered (the patient will), only one response (treat hypoglycemia), was observable and measurable (3 ways), had a target date (by 05/01/05), and used a behavioral verb (will state).

You should not say the patient will state 3 ways to treat hypoglycemia and will know signs and symptoms of hypoglycemia by ...Because that is addressing two responses. And using the word 'know' is not very measurable. You can not prove they "know" or they "understand" something.

a few Behavioral verbs to use:

A good explanation....

VickyRN

Asst. Admin
What I have been teaching my students is much along these lines, but I go a little further and teach the "pattern of reversal" method.
#1. The student obtains objective/ subjective assessment data.
#2. From this assessment data, the student formulates high priority nursing diagnoses (in PES format - problem, etiology, and signs/ symptoms). Make sure the nursing dx are current and NANDA-approved. (Every few years or so, NANDA changes the wording on their diagnoses ever-so-slightly.) Write the nursing diagnosis based on the major/ minor defining characteristics. This is the nursing diagnosis stem.
#3. Next, write the "related to" portion of the nursing diagnosis. The "related to" (etiology) part of the nursing diagnosis phrase is very important, because this makes the nursing diagnosis unique and precise to the individual client situation. The "related to" statement directs the independent and collaborative nursing interventions and gives direction for client care.
#4. The student writes the client goal, by reversing the nursing diagnosis stem. Nursing diagnoses are written in negative language, such as "Decreased Cardiac Output," "Imbalanced Nutrition: Less Than Body Requirements," or "Ineffective Individual Coping." For the client goal, the stem is simply written in reverse, "The client will demonstrate increased cardiac output...." or "The client will cope effectively..."
The nursing diagnosis stem points to the goal and ultimate client outcome.
The goal is simply the nursing diagnosis stem written positively (in reverse) in measurable terms, with a time element ("by end of student nurse's shift on...," "by hospital discharge," "throughout hospital stay," etc.). Make sure, as Angie pointed out, that measurable verbs are used.
The "related to" (etiology) points to the nursing interventions. In other words, the nursing interventions for "Decreased cardiac output r/t atrial tachydysrhythmia" must be directed not towards the "Decreased cardiac output" stem, but towards assisting with the "atrial tachydysrhythmia" etiology instead. Remember, each intervention must be accompanied by a scientific rationale.
The outcome is simpy the final evaluation of the achievement of the earlier stated client goal AFTER the nursing interventions have been performed. (This is the difference between the goal and outcome). You are adding an element of judgment to the earlier stated goal (i.e., achievement or non-achievement). To do this, the student must evaluate the client's progress/ lack of progress towards the expected outcome. A new set of assessment data are gathered to "back up" the claim of achievement of/ non-achievement of client goal. Hence, the "circular" nature of the nursing process. So, you would state one of three choices:
Goal met
Goal not met
Unable to evaluate goal due to lack of time
For all three, the student will need to give "AEB" data. For the last one, the student should state, "Unable to evaluate goal, due to lack of time. However, if I were present at time of discharge (or other designated date), I would state 'Goal Met" if the following outcome criteria were achieved:..." Then give the outcome criteria that would satisfactorily meet this goal.

nurseprnRN, BSN, RN · Mar 30, 2014

I am not faulting you for not being able to figure this out, because it doesn't sound as if your faculty is doing a very good job of helping you close the loop on assessment, diagnosis, and planning. 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. :) A little background first, and then we'll look at your particular nursing diagnostic challenge.

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." Or, "You've got anemia. I wonder what your CBC would show if we drew one?" :)

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??? :) Amazon.com: Nursing Diagnoses: Definitions and Classification 2012-14 (9780470654828): NANDA International: Books

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.

OK, now.

Here are some possible Nsg Dx I'm thinking of, but I'm not sure if I'm on the right track:
1. Disturbed Body Image r/t loss of leg function,
2. Death Anxiety r/t uncertainty of prognosis
3. Readiness for Enhanced Knowledge r/t medical treatment
4. Anxiety r/t change in health status
5. Risk for adverse effects of medication (high BUN levels may be caused by adverse effects of antibiotic Cefepime...not sure if this is a nsg dx or a medical dx)
6. Pain r/t injury in L arm

1. "Disturbed body image" is defined as "Confusion in mental picture of one's physical self." This has very definite related (causative) factors and defining characteristics, and "loss of legs" isn't one of them. You cannot make this stuff up even if it sounds reasonable to you, and your faculty should really know better than to tell you to make it up (Unbelieveable, really) (Did she REALLY say that, "Make it up!"?). All registered nurses must use the NANDA-I 2012-2014 list of approved and validated nursing diagnoses, related/causative factors, and defining characteristics to make a nursing diagnosis.

The one that I can see most applicable given your assessment data (and congrats-- you seem to have done more nursing assessment than 90% of the students who post here) would be "... related to injury (T8 ASIA-A (look that up-- it'll help) ), as evidenced by feelings that reflect an altered view of his body ("I am ashamed and embarrassed because I can't move my legs.") "

2. "Death anxiety" is defined (page 356) as "vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one's existence." Related factors do include, "uncertainty of prognosis," so now to complete your diagnostic statement, you have to say what defining characteristics he meets for that. "Reports negative thoughts related to death and dying" would certainly fit the bill ("I don't know if I'll ever make it out of the hospital alive," and others.)

3. "Readiness for enhanced knowledge" is defined (p. 272) as, "A pattern of cognitive information related to a specific topic, or its acquisition, that is sufficient for meeting health-related goals and can be strengthened." There is no "related to" to make this diagnosis, but there are specific defining characteristics, none of which is "medical treatment." Again, you can't make this up. You have to choose from the definitive list in NANDA-I 2012-2014. Your choices there are: Behaviors congruent with expressed knowledge, describes previous experiences pertaining to the topic, explains knowledge on the topic, and/or expresses an interest in learning. You would say, "Readiness for enhanced knowledge, as evidenced by expressing an interest in learning about pressure ulcer avoidance (or whatever)."

4. "Anxiety" (page 344) has a long list of defining characteristics in the behavioral, affective, physiological, sympathetic, parasympathetic, and cognitive realms. You pick 'em for this patient, to describe the ones he exhibits which caused you to make this diagnosis. Related factors are many, and I am sure you could pick at least one of those too. "Change in health status" is certainly one.

5. "Risk for adverse effects of medication" does not exist in NANDA-I with the specific exception of adverse reaction to iodinated contrast material (page 461) and allergy (page 465). If it's not iodinated contrast he's getting (with a history of adverse reaction to it in the past), or a known allergy to medications, there is no way for you to make this diagnosis because it doesn't exist.

It may well be possible for you to find another diagnosis wherein the related cause is the effects of medications, for example, dehydration or electrolyte imbalance in one of the nursing diagnoses that address decreased circulation or arrhythmias, but you need specific evidence that this is a possibility in this patient.

6."Pain" is almost always safe, "related to injury (specify-- what happened to his arm?) as evidenced by reports of discomfort when he .... "

I encourage you to get the book (2-day free delivery, for heaven's sake-- order it this afternoon and have it Tuesday, or instant for your Kindle or iPad) and check out the entire list at the beginning of each section, then see what is needed to make the diagnosis under each and see what fits your guy. Esme has given you a really good list that would apply.

And for god's sakes, don't make them up. :) If she wonders where you got the language, tell her you wanted to check the original sources cited in your textbook, got the current edition, and found it useful !!!

lwandel · Mar 30, 2014

Good LORD y'all are amazing!!! Thank you so very much for responding with so much information. It really is so very helpful!

GrnTea- just to clarify, for the dx of Disturbed Body Image should be: "Disturbed Body Image r/t injury"? Or would the full "Disturbed Body Image r/t Injury AEB feelings that reflect and altered view of his body"?

I have tried to use AEB's in my previous nsg dx statements, but she marks them out and tells me

that they need to be rephrased as AEB's for my Goal. But I may have been using them incorrectly. For example, on my last care plan I used "Deficient knowledge r/t wound care AEB numerous infected wounds". My instructor crossed out "AEB numerous infected wounds" and told me to list it under my Goals/Outcomes as a AEB. I'm just confused. lol

nurseprnRN, BSN, RN · Mar 30, 2014

Good LORD y'all are amazing!!! Thank you so very much for responding with so much information. It really is so very helpful!
GrnTea- just to clarify, for the dx of Disturbed Body Image should be: "Disturbed Body Image r/t injury"? Or would the full "Disturbed Body Image r/t Injury AEB feelings that reflect and altered view of his body"?
I have tried to use AEB's in my previous nsg dx statements, but she marks them out and tells me
that they need to be rephrased as AEB's for my Goal. But I may have been using them incorrectly. For example, on my last care plan I used "Deficient knowledge r/t wound care AEB numerous infected wounds". My instructor crossed out "AEB numerous infected wounds" and told me to list it under my Goals/Outcomes as a AEB. I'm just confused. lol

"Disturbed Body Image r/t Injury (T8 ASIA A, complete), AEB feelings that reflect an altered view of his body ("I am ashamed and ...")" Be sure you know the ASIA scale (it's short and sweet) before you turn that in. :) http://www.asia-spinalinjury.org/elearning/ISNCSCI_Exam_Sheet_r4.pdf

I am not sure I understand what you mean as evidence for your diagnosis being used as a goal. Perhaps she means that (for example) a short-term or long-term goal might be, "Patient makes positive statements about his abilities / new abilities learned in OT, as evidenced by statements such as, 'I am doing really well at XYZ now.' " That reflects a positive change.

"Deficient knowledge" is not caused by wound care. Remember, "related to" means "caused by" or "because of." Wound care does not cause deficient knowledge. What did you mean to communicate here? You felt that he had open wounds, now infected, because he didn't know how to avoid them? That would have a different cause (what?) and result in a different nursing diagnosis, wouldn't it? Sounds like something to look into ... let me know what you find out about that. Hint: check around things like skin integrity, knowledge deficiency, self-care, coping...

lwandel · Mar 30, 2014

I know that I didn't post the cues for it earlier, but what about a Nsg Dx of Stress Overload r/t fear about finances, divorce, and fear of losing girlfriend.

He is currently going thru a divorce, stated "my soon-to-be ex-wife is causing me a lot of stress right now”.

Worried about relationship with girlfriend. Stated “we were only together for 8 weeks before my accident. I hope she doesn’t leave me, but I couldn’t blame her if she did. I’ve put her through enough”.

Stated “I’m worried about my finances since I’ve been in the hospital for so long”.

nurseprnRN, BSN, RN · Mar 30, 2014

Definition: "Excessive amounts and types of demands that require action."

No "related to" = "fear" in this diagnosis. What else do you see in that list that might fit him? Remember, you can't make it up! What are the approved "related factors" for this diagnosis? One or more of them might well work, but "fear" isn't on the list.

What action do you / does he see is required?

(gotta check out for the night-- see you tomorrow)

lwandel · Mar 30, 2014

Let me see if I have this one right:

Nsg Dx: Disturbed Body Image r/t Injury (T8 AISA A, Complete) AEB feelings that reflect an altered view of body.

Goal: By discharge, patient will Incorporate changes caused by injury into self-concept without negating self-esteem AEB

1. Patient will state "even though I'm in a wheelchair, I don't feel like a freak".

2. Patient will state "I am not ashamed or embarrased anymore about being a paraplegic".

Intervention:

1. "Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body or lifestyle."

Rationale: "The influence of emotion-focused coping (venting emotions and mental disengagement) on distress following disfiguring injury was associated with less body image disturbance" (Ackley, et al, 2011, p. 174).

2. "Provide patient with a list of appropriate community resources" (Support, Challenge, Inspire in Dallas, TX and Fort Worth Area Spinal Cord Injury Support Group)

Rationale: "Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning" (Ackley, et al, 2011, p. 174).

3. "Collaborate with hospital counselor/psychiatrist to provide counseling about body changes, and include ways for patient to cope with reactions from others".

Rationale: "To prepare patient for reentry into social settings" (Monahan, et al, 2011, p. 730).

Esme12, ASN, BSN, RN · Mar 30, 2014

A wife and a girlfriend...then became a paraplegic? yes he has stress overload.... but look at your definitions.

stress overload: Excessive amounts and types of demands that require action

Defining Characteristics

Demonstrates increased feelings of anger; demonstrates increased feelings of impatience; reports a feeling of pressure; reports a feeling of tension; reports difficulty in functioning; reports excessive situational stress (e.g., rates stress level as 7 or above on a 10-point scale); reports increased feelings of anger; reports increased feelings of impatience; reports negative impact from stress (e.g., physical symptoms, psychological distress, feeling of being sick or of going to get sick); reports problems with decision-making

Related Factors (r/t)

Inadequate resources (e.g., financial, social, education/knowledge level); intense stressors (e.g., family violence, chronic illness, terminal illness); multiple coexisting stressors (e.g., environmental threats/demands, physical threats/demands, social threats/demands); repeated stressors (e.g., family violence, chronic illness, terminal Illness)

Where does your patient fit into these? Fear is not one of the characteristics of this diagnosis

lwandel · Mar 30, 2014