STUDY GUIDE 1.1: NURSING DIAGNOSTIC STATEMENTS AND COMPREHENSIVE PLANS OF CARE

STUDY GUIDE 1.1: NURSING DIAGNOSTIC STATEMENTS AND COMPREHENSIVE PLANS OF CARE WHAT IS A NURSING DIAGNOSIS? A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems / life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. (Carpenito-Moyet, 2010, p.10). There are five types of nursing diagnoses recognized actual, risk, possible, wellness, and syndrome. And, one COLLABORATIVE diagnosis which nurses intervene either as a primary provider or in collaboration with medicine. Actual An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. Defining characteristics are signs and symptoms that, when seen together, represent the nursing diagnosis. (Carpenito-Moyet, 2010, p.13) Problem r/t etiology e/b Risk and High-Risk Diagnoses A risk or / and high risk diagnoses is defined as a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. (Carpenito-Moyet, 2010, p. 14) A risk diagnosis is one that is likely to develop if you do not intervene to prevent it. It is diagnoses by the presence of risk factors rather than defining characteristics. The patient does not have any defining characteristics of the diagnosis if signs and symptoms were present, the diagnosis is actual, not risk. Problem r/t risk factors Possible Nursing Diagnosis Possible nursing diagnoses are statements that describe a suspected problem requiring additional data (Carpenito-Moyet, 2010, p. 14). It can also be thought of as a tentative position similar to the rule-out statement healthcare provider s use. Problem r/t data that leads the nurse to suspect the diagnosis Wellness Diagnoses A wellness diagnoses is described as a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. (Carpenito-Moyet, 2010, p. 17). Two cues should be present to use a wellness diagnosis: a desire for increased wellness and effective present status or function. Wellness diagnoses are especially useful for healthy clients, such as school children or new parents, who require teaching for health promotion, disease prevention, and personal growth. These types of diagnostic statements do not contain related factors, but rather contain the label only. Readiness for enhanced Syndrome Diagnoses The Syndrome diagnoses comprise a cluster of predicted actual or high risk nursing diagnoses related to a certain event of situation. (Carpenito-Moyet, 2010, p. 18). This type of diagnostic statements only contain the label (no related to or m/b). NANDA has five syndrome diagnoses: Rape Trauma Syndrome, Disuse Syndrome, Post-Trauma Syndrome, and Impaired Environmental Interpretation Syndrome. Revised 01 /17/ 2012 /cmg 1 P a g e

COLLABORATIVE PROBLEMS Collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of the events. (Carpenito-Moyet, 2010, p. 24) This does not mean that ALL physiologic complications are collaborative problems. Carpenito-Moyet (2010) clearly makes the distinction if the nurse can prevent the onset of the complication or provide the primary treatment for it, then the diagnosis is a nursing diagnosis. Collaborative problems are complications from a disease, test, or treatment that nurses cannot treat independently. Nurses focus mainly on monitoring and preventing such problems. All collaborative problems begin with the diagnostic label Risk for Complication of (RC of). The RC diagnosis alerts the nurse that the client is either experiencing or is at high risk to experience the problem. When writing collaborative problems, students are required to word the collaborative problem so that it reflects the specific cause (s) for the problem noted. Risk for complication of Hyperglycemia r/t.steroid therapy TPN Surgery DIFFERENTIATING NURSING DIAGNOSES FROM COLLABORATIVE PROBLEMS According to Carpenito-Moyet (2010), both nursing diagnoses (ND) and Risk for complications (RC) involve the five steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Each, however, requires a different approach for the nurse. Assessment and diagnosis ND: Data collection to identify signs and symptoms of actual diagnoses or risk factors for high risk diagnoses. RC: Assessment focuses on determining physiologic stability or risk for instability. The nurse identifies a RC when certain situations increase the client s vulnerability for, or the client has experienced a complication. RC s are usually associated with a specific pathology or treatment. Ask yourself if the nurse can monitor the condition. sometimes this is a medical diagnosis, but not always. Revised 01 /17/ 2012 /cmg 2 P a g e

Goals ND: Client centered goals Client goals are statements describing a measurable behavior of the client, family, or group that denotes a favorable status after the delivery of nursing care. They serve as the criteria for measuring the effectiveness of a plan of care. Essential components of goals include: long term vs. short term, measurable behavior, specific in content and (what the client is to do, experience, or learn) and time of achievement (by discharge, continued, by date), attainable (based on age, condition, mental status, and motivation), and Individualized to the client. RC: Nurse centered goals Nursing goals are statements describing measurable actions that denote the nurse s accountability for the situation or diagnosis. This accountability includes monitoring for physiologic instability; consulting standing orders and protocols and/or a physician to obtain orders for appropriate interventions, performing specific actions to manage and to reduce the severity of an event or situation, and evaluating the client responses. The nurse centered goals can be written as: The nurse will manage and minimize complications of the problem The nurse will monitor to detect early signs/symptoms of the problem, and collaboratively intervene to stabilize the client The nurse will monitor for and manage changes in status In addition to the nurse centered goals, students will need to include a list of the Indicators used as monitoring criteria. Interventions ND: Nurse prescribed. The nurse independently prescribes the primary treatment for goal achievement. (ie. Monitor and evaluate status, promote higher-level of wellness, reduce or eliminate contributing factors of the diagnosis) RC: Nurse prescribed and physician prescribed (delegated). The nurse confers with a physician and implements physician prescriptions, in addition to nurse prescribed nursing interventions. Collaborative interventions should include monitoring for changes in status, managing changes in status with nurse-prescribed and physician prescribed interventions, and evaluating clients response. **Frequently, nurses are responsible for planning the interventions, but not actually implementing the care. This is where the nurse must manage the care of the client using skills such as delegation, assertion, and regular evaluation. Revised 01 /17/ 2012 /cmg 3 P a g e

Evaluations DID YOUR PLAN / INTERVENTIONS WORK??? It is vital for the nurse to perform an ongoing evaluation while caring for patients. Equally important, is the evaluation of the patient s status after care has been provided. This is essential to determine if the stated interventions have been effective, or not. And, if the stated goal was realistic / or appropriate, or not. ND: RC: Review the goals or outcome criteria for each nursing diagnosis. Did the client demonstrate or state the activity defined in the goal? If yes, then document the achievement on your plan. If not, and the client needs more time, change the target date. If time is not the issue, evaluate why the client did not achieve the goal. Was the goal not realistic, not the appropriate priority, of not acceptable to the client? The nurse evaluates collaborative problems by: 1) reviewing the nursing goals for the collaborative problem 2) Assessing the client s status 3) Comparing the data to established norms (indicators); 4) Judging if the data fall within acceptable ranges.; 5) Concluding if the client is stable, improved, unimproved, or worse. Is your client stable or improved? If yes, continue to monitor the client and to provide interventions indicated. If not, has there been a dramatic change (eg. Elevated blood pressure and decreased urinary output)? Have you notified the physician or advanced practice nurse? Have you increased your monitoring of client? Communicate your evaluations of the status of collaborative problems to your clinical faculty and to the nurse assigned to your client. Additionally, you must address: if stated goal (s) were achieved Describe any progress the client has made toward the stated goals. Evaluate effectiveness of nursing interventions (related to the goal). List suggested revisions to the interventions that might improve goal achievement Revised 01 /17/ 2012 /cmg 4 P a g e

EXAMPLE OF A COLLABORATIVE PROBLEM RC of Dysrhythmias r/t Hypokalemia Temporary transvenous pacemaker Anemia COPD CHF Cardiomegaly Medications: Lasix Bumex Goal: The nurse will manage and minimize dysrhythmic episodes. Indicators: Calm, alert, oriented SPO2 > 95% Breath sounds clear NSR No life threatening dysrhythmias No chest pain K+ >4.0 meq/l Hgb > 9 Interventions Monitor for signs and symptoms of dysrhythmias Abnormal rate, rhythm Palpitations, chest pain, syncope, fatigue Decreased SpO2 or SaO2 ECG changes Hypotension Evaluate electrolytes at the beginning of the shift and prn, initiating potassium and magnesium protocols directed by the MD. Initiate appropriate dysrhythmic protocols. (be specific based on individual client, ie. VT/VF) Follow Hgb levels, transfuse with one unit PRBC s to maintain Hgb >9 as directed by MD. Revised 01 /17/ 2012 /cmg 5 P a g e

LIST OF COLLABORATIVE PROBLEMS Carpenito-Moyet (2010) identifies 52 collaborative problems, grouped under nine generic collaborative problem categories. Although this is not a definitive list, the collaborative problems were selected due to their high incidence or morbidity. Risk for Cardiac / Vascular Dysfunction Risk for Respiratory Dysfunction RC of Bleeding RC of Hypoxemia RC of Decreased Cardiac Output RC of Atelectasis RC of Dysrhythmias RC of Pneumonia RC of Pulmonary Edema RC of Tracheobronchial Constriction RC of Deep Vein Thrombosis RC of Pneumothorax RC of Hypovolemia RC of Compartmental Syndrome Risk for Renal/Urinary Dysfunction RC of Pulmonary Embolism RC of Acute Urinary Retention RC of Renal Insufficiency RC of Renal Calculi Risk for Metabolic /Immune /Hematopoietic Dysfunction Risk for Neurological / Sensory Dysfunction RC of Hypo/Hyperglycemia RC of Allergic Reaction RC of Negative Nitrogen Balance RC of Increased Intracranial Pressure RC of Electrolyte imbalance RC of Seizures RC of Sepsis RC of Increased Intraocular Pressure RC of Acidosis (Metabolic, Respiratory) RC of Neuroleptic Malignant Syndrome RC of Alkalosis (Metabolic, Respiratory) RC of Alcohol Withdrawal RC of Thrombocytopenia RC of Opportunistic Infections Risk for Muscular / Skeletal Dysfunction RC of Sickling Crisis RC of Pathologic Fractures RC of Joint Dislocation Risk for GI / Hepatic/Biliary Dysfunction Risk for Reproductive Dysfunction RC of Paralytic Ileus RC of Joint Dislocation Prenatal Bleeding RC of GI Bleeding RC of Joint Dislocation Preterm Labor RC of Hepatic Dysfunction RC of Joint Dislocation Pregnancy-Associated Hypertension RC of Hyperbilirubinemia RC of Joint Dislocation Nonreassuring Fetal Status RC of Joint Dislocation Postpartum Hemorrhage Risk for Medication Therapy Adverse Effects RC of Anticoagulant Therapy Adverse Effects RC of Antidepressant Therapy Adverse Effects RC of Antianxiety Therapy Adverse Effects RC of Antiarrhythmic Therapy Adverse Effects RC of Adrenocorticosteroid Therapy Adverse Effects RC of Antipsychotic Therapy Adverse Effects RC of Antineoplastic Therapy Adverse Effects RC of Antihypertensive Therapy Adverse Effects RC of Anticonvulsant Therapy Adverse Effects RC of β-adrenergic Blocker Therapy Adverse Effects RC of Calcium Channel Blocker Therapy Adverse Effects RC of Angiotensin-Converting Enzyme Inhibitor Therapy Adverse Effects Revised 01 /17/ 2012 /cmg 6 P a g e