NR 226 Week 8 Nursing Diagnosis Reflection Example

Reflection: "Related to Pneumonia," the Line I Wrote in Week 3, and the Cough at 1100 That Showed Me What Was Wrong With It

Student Name

College of Nursing, Chamberlain University

NR 226: Fundamentals: Patient Care

Instructor Name

Month Day, Year

Reflection: "Related to Pneumonia," the Line I Wrote in Week 3, and the Cough at 1100 That Showed Me What Was Wrong With It

1. The Original Line, Quoted

In my first draft of the Week 3 nursing diagnosis exercise for Mr. W., the 81-year-old man with pneumonia I followed through this course, my first statement read: "Ineffective airway clearance related to pneumonia as evidenced by crackles, cough and sputum."

Under it, in the first draft of the care plan, I wrote the goal "Patient will have improved breathing by discharge," and the first intervention was "Administer antibiotics as ordered." Those three lines went together, and all three had the same problem.

2. The Error, Named Specifically

The cause I named was the disease. Pneumonia is the reason Mr. W. had secretions, but it is not something nursing treats; the antibiotics, ordered by the provider, treat it. A nursing diagnosis whose cause is a disease leads straight to a nursing intervention that is really a medical one, which is exactly what happened: my first intervention was to give the antibiotic. Giving it is a nursing task, but it is not a nursing intervention for this diagnosis, because it does not act on anything a nurse decides.

The goal had a second, separate error. "Improved breathing by discharge" had nothing in it anyone could check at the end of a shift. It did not say improved from what, to what, measured how. Nobody could ever have written "goal not met" against it, which means it could not tell anyone whether the plan was working.

3. The Replacement, Written Out

The final version kept the label and changed everything after it. The cause became his cough, which was too weak, and his secretions, which were too thick: two things a nurse can work on. The evidence stayed in the assessment's own terms, the crackles at the right base, the scant thick sputum and a breathing rate of 24. The goal was rewritten to be judged at 1500 on the same day, with three parts anyone could check: whether he brought up secretions with each coached session, whether his breathing rate had come down to 22 or less, and whether his saturation was holding at 92% or more without needing more than 2 liters of oxygen. The first intervention became coaching him to breathe deeply and cough, every two hours while awake and sitting upright, with a drink offered every hour to loosen what he was trying to clear.

Each part of the replacement now points at the same thing: a cough that nursing can strengthen and secretions that nursing can thin. The label follows the NANDA International classification (Herdman et al., 2021), but the improvement was not in the label, which stayed the same. It was in the cause, which changed the goal and the interventions that followed from it.

4. The Moment That Exposed It

My instructor's feedback on the draft said, "What can you do about pneumonia?" I rewrote the statement, but I did not fully understand why until the Week 6 case. At 1100, when Mr. W.'s saturation fell to 89%, I sat him up and coached him to cough, and he brought up a large plug of sputum and his saturation rose to 93% within five minutes. Nothing about his pneumonia had changed in those five minutes. What changed was his cough. That was the moment the difference between the disease and the nursing cause stopped being a rule about how to write diagnoses and became something I had seen work.

If my plan had still said "related to pneumonia" with "administer antibiotics" underneath, it would have given me nothing to do at 1100 except wait for the next dose.

5. Inexperience, Left Visible

I do not want to write this as though the problem is solved. In my Week 4 care plan I still struggled to write the skin goal in a way that could be checked within one shift, because a pressure injury does not heal in eight hours. My solution, that the wound would be no larger and that no new areas of redness would appear, is checkable, but it measures the absence of harm rather than progress, and I am not sure that is the best a shift-length goal can do. I also used the word "improved" twice more in my first draft of the discharge plan before catching it. The habit of writing vague goals is weaker, but it is still there, and I now read every goal I write and ask whether a tired nurse at 1900 could mark it met or not met.

There is one more gap I can see now. My plans for Mr. W. treated his reluctance to call for help as a teaching problem, solved by telling him that calling is expected. I am not sure that telling is enough for a man who has spent 81 years not wanting to be a bother. The plan measured whether he called, which was right, but I did not plan what to do if he still did not. A more experienced nurse might have arranged hourly rounding at night so that the question of calling rarely came up. I did not think of that until after he went home.

6. What I Carry Forward

What I take into the next course is a test I can apply to any diagnosis: if the cause I have named would still be true after the nurse has done everything nursing can do, it is the wrong cause. Pneumonia would still be true after the best coughing coaching in the world. A weak cough would not. That test would have caught my Week 3 draft before my instructor did.

7. A Note on How the Parts Fit

Looking at the six weeks together, the line I quoted at the start was not an isolated error. The same pattern, naming what is wrong with a patient rather than what nursing can change, appeared in my first drafts of the concept map, where I began with the diagnosis at the center, and in my first discharge plan, which opened with a paragraph explaining pneumonia. In each case the fix was the same move: put the patient and the nursing cause at the center, and let the disease sit in the background as the reason the nursing problems exist. The fact that one move fixed three assignments is the best evidence I have that I understood the error rather than just correcting one line.

References

Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). NANDA International nursing diagnoses: Definitions and classification 2021-2023 (12th ed.). Thieme.