MAKING A NURSING DIAGNOSIS

Guiding Steps

RationaleHello All – In the one-minute papers you wrote at the end of our last class, many of you expressed your need to have some more experience making a nursing diagnosis.

In this slidecast, I provide some step-by-step directions for making a nursing diagnosis. Have the two Handouts, Nursing Diagnosis Worksheet AND Functional Health Patters & Associated Nursing Diagnoses, with you as you review this slidecast. Complete the assignment per the instructions provided. Thanks – Dr. Nickerson

Case IllustrationAlice is a tired and nervous looking 19 year old, college freshman, and a single, first-time. Her son, Alex, was born two weeks ago. Alex’s father moved out 6 months ago and has no interest in being a father. She now lives alone in a one-bedroom apartment with Alex; her Mom, Dad, and younger sister live in a neighboring town.

She has been trying to breast-feed Alex, but Alice says he is a restless baby who “can’t seem to comfort himself,” so Alice isn’t getting much sleep. He likes cuddling with her, and she has been so tired that she tried nursing him while lying on her side. Although he relaxes more when she does this, she isn’t able to fall asleep with him lying next to her. As soon as she tries to move, he awakens.

At Alex’s first well-baby visit, Alice complains that she hasn’t slept for more than a half hour since he was born. Her fatigue is making her tense and grumpy, and he doesn’t seem satisfied after a feeding. Your assessment of Alex’ weight indicate that he has lost 6 ounces since discharge. When you tell her, she begins to cry.

Making inferences -

Some of my tentative inferences from the data available . . .• Alice’s is young and inexperienced and possibly some

immature.

• She probably doesn’t know much about parenting and breastfeeding given her age, maturity level, and limited experience.

• All of the above plus her fatigue are affecting her problem-solving ability.

• Alice has a compromised support system and that is the reason for her exhaustion.

• Alex’s agitation is the result of poor let-down of milk in the nursing mother and hunger in the baby.

This concept map i l lustrates my

thinking so far . . .

FACTORS AFFECTING COPING

19 y. o.

First baby

1st nursing experience

FACTORS AFFECTING INFANT FEEDING

Alex does not “self-comfort”

Alice is tense & grumpy

Alex is not satisfied after feeding and isn’t sleeping well either

FACTORS AFFECTING ABILITY TO SLEEP & REST

C/O little sleep since birth

Looks tired and nervous

Little immediate social support; no relief from infant care

FACTORS AFFECTING PARENTING ROLE

Little caregiving experience; novice in the maternal role

Limited social support and mentoring

Some rationales for my choices -• Decision-making, problem-solving, and overall coping generally

improve with age and experience.

• Baby’s have different dispositions; some are not able to “self-comfort.”

• Every woman can lactate; some have difficulty to “letting down” milk; impaired milk “let-down” reduces the volume of feeding and impairs milk production.

• Maternal factors that affect the let-down reflex include personality, nutrition, fatigue, confidence, anxiety, experience.

• Infant factors that affect the effectiveness of breastfeeding include disposition, mouth placement, fatigue, hunger.

Functional Health Patterns I believe are at risk . . .

Sleep/Rest Pattern

• The pattern involving a person's of the quality and adequacy of sleep, rest, and relaxation

practices.

Coping/Stress Tolerance Pattern

• The pattern of a person's perception of stress and on his or her coping strategies including

the following: Ability to manage stress, knowledge of stress tolerance, sources of support,

number of stressful life events in last year.

Role/Relationship Pattern

• The pattern of a person's roles in the world and relationships with others, satisfaction with

roles, role strain, or dysfunctional relationships, and satisfaction with relationships and

responsibilities.

Self-perception/Self-concept

• The pattern of a person's attitudes toward self, including identity, body image, and sense of

self-worth, level of self-esteem and response to threats to his or her self-concept, attitudes

about self, sense of worth, perception of abilities, emotional patterns, body image, identity.

Do you see preferable alternative FHPs and/or NDs?

• Review the alternatives listed on the handout, “Functional Health Patterns (FHP) & Associated Nursing Diagnoses (ND).”

• Using your own logic and understanding of the language used in defining the FHPs and NDs listed there, ask yourself whether some other statement names Hannah’s problem more clearly and effectively than my selections did.

• Note your suggestions on the back of your assignment and be prepared to defend them in class.

Which is/are the most important Nursing Diagnosis (-es)?

QUESTIONS TO CONSIDER . . .

• Is any one threatening to life or safety of Alice or Alex?

• Which “related to” factors are amenable to change?

• Which factors does Hannah believe are the most important?

• Which factors d you believe are most important?

Naming the problem – ordinary language:

Tentative Nursing Diagnoses please fill in the blanks . . .

• Sleep deprivation, related to possible ineffective breastfeeding and anxiety, manifested by C/O fatigue, restless, cranky infant.

• Ineffective individual coping, related to fatigue, limited social support, and possibly inexperience and compromised maternal role acquisition, manifested by__________________________________

• Ineffective breast-feeding, related to _________________, manifested by __________________________________.

• Caregiver role strain, related to related to __________________, manifested by ________________________________.

Sample Nursing Diagnosis

Your turn -

• Consider the case scenario on the following slide (also on your ND Worksheet).

• Imitate the process I demonstrated for identifying compromised Functional Health Patterns and then selecting a Nursing Diagnosis for at least on of them

• Use your Nursing Diagnosis (ND) Worksheet to document the steps you take.

• Bring the ND Worksheet to class on Wednesday, November 14 to finish this assignment.

The Case of Hannah Hannah is a 33 year old widow whose husband, Samuel, died two weeks ago. He had sustained a gunshot wound in a drive-by shooting, spent two weeks on life support after having been shot, but was “brain dead.” Several of his organs were “harvested” for organ transplant . Hannah and Sam were high school sweethearts and had been married for 10 years at the time of his death; they had no children. Hannah was a “stay-at-home” wife; her closest friend is her cousin, Ivy. She works as an administrative assistant for an insurance company. Hannah and her cousin have been Christians since childhood. Both Hannah’s and Ivy’s parents are dead.

All of her life, Hannah and Sam had enjoyed “good health” in every respect, but Sam’s relatively sudden death was a huge shock to Hannah. Ivy calls a Family Practice Clinic where you are working as a triage nurse.” She tells you her concerns that Hannah “isn‘t the same” since Sam’s death - that Hannah is moody and distant, and seems “lifeless” herself. Iv

Hannah

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Choose Affected Functional Health Patterns

Naming problems in ordinary language:

Use the example in the previous slide to name possible problems you see in each functional health pattern in your own words:

On the basis of your assessment, select 1-2 Nursing Diagnoses associated with the affected FHPs:

1. ND: ____________ related to_________ manifested by_______________

2. ND: ____________ related to_________ manifested by_______________

3. ND: ____________ related to_________ manifested by_______________

4. ND: ____________ related to_________ manifested by_______________