Nursing Diagnosis: Deficient Knowledge Application of NANDA, NOC, NIC

Nursing Diagnosis: Deficient Knowledge
Suzanne Skowronski and Gail B. Ladwig

NANDA Definition: Absence or deficiency of cognitive information related to a specific topic

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors: Lack of exposure; lack of recall; information misinterpretation; cognitive limitation; lack of interest in learning; unfamiliarity with information resources

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Knowledge of: Diet
·         Disease Process
·         Energy Conservation
·         Health Behaviors
·         Health Resources
·         Infection Control
·         Medication
·         Personal Safety
·         Prescribed Activity
·         Substance Use Control
·         Treatment Procedure(s)
·         Treatment Regimen
Client Outcomes
·         Explains disease state, recognizes need for medications, understands treatments
·         Explains how to incorporate new health regimen into lifestyle
·         States an ability to deal with health situation and remain in control of life
·         Demonstrates how to perform procedure(s) satisfactorily
·         Lists resources that can be used for more information or support after discharge
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Teaching: Disease Process
·         Teaching: Individual
·         Teaching: Infant Care
Nursing Interventions and Rationales
·         Observe client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, no existing pain, emotional readiness, absence of language or cultural barriers). Education in self-care must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age (Bohny, 1997).
·         Assess barriers to learning (e.g., perceived change in lifestyle, financial concerns, cultural patterns, lack of acceptance by peers or coworkers). The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
·         Determine client's previous knowledge of or skills related to his or her diagnosis and the influence on willingness to learn. New information is assimilated into previous assumptions and facts and may involve negotiating, transforming, or stalling.
·         Involve clients in writing specific outcomes for the teaching session, such as identifying what is most important to learn from their viewpoint and lifestyle. Objectives put the content into focus, provide a forum for evaluation outcomes, and ensure continuity. Client involvement improves compliance with health regimen and makes teaching and learning a partnership.
·         When teaching, build on client's literacy skills. In patients with low literacy skills, materials should be short and have culturally sensitive illustrations (Mayeaux et al, 1996). The National Adult Literacy Survey reported that 44 million Americans could not read or write well enough to meet the needs of everyday living and working (Quirk, 2000).
·         Present material that is most significant to client first, such as how to give injections or change dressings; present additional material once client's most pressing educational needs have been met. Information building begins with explaining simple concepts and moves on to explanations of complex application situations.
·         Determine client's understanding of common medical terminology, such as "empty stomach," "emesis," and "palpation." Clients are expected to read and understand labels on medicine containers, appointment slips, and informed consents, yet an estimated 40 million adults are functionally illiterate (Williams et al, 1995).
·         Evaluate the readability of the material in pamphlets or written instructions. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability and comprehension of instruction, poor communication, and increased physical limitations (Hayes, 1998).
·         Use visual aids such as diagrams, pictures, videotapes, audiotapes, and interactive Internet web sites. Verbal reinforcement of personalized, written instructions appears to be the best tested intervention. Computer-generated, personalized instructions improved adherence when compared with handwritten instructions (Hayes, 1998). This evidence-based study suggested leaflets as a useful resource for information provision (Kubba, 2000).
·         Provide preadmission self-instruction materials to prepare client for postoperative exercises. Providing clients with preadmission information about exercises has been shown to increase positive feelings and the ability to perform prescribed exercises (Rice et al, 1992).
·         Identify the primary family support person; be aware of that person's ability to learn and incorporate needed changes.
·         Assess willingness of family to incorporate new information, immunizations, medical/dental care, and diet/behavior modifications in support of the client. Attention needs to be directed at family adjustment factors. For example, women recovering from alcohol abuse are at risk for relapse if their spouse continues to drink alcohol (Murphy, 1993), and modification of eating patterns plus social and partnership support have had more success than modification alone (Keller et al, 1997).
·         Help client identify community resources for continuing information and support. Learning occurs through imitation, so persons who are currently involved in lifestyle changes can help the client anticipate adjustment issues. Community resources can offer financial and educational support. For example, role modeling and skill training have been used to monitor symptoms and solve asthma problems (Bartholomew et al, 2000).
·         Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations. Presenting information along with with examples of how to apply the information has been found more successful than providing information alone in a home care setting (Duffy, 1997).
·         Adapt the teaching process for the physical constraints of the aging process (e.g., speak clearly, use a variety of audio-visual-psychomotor methods, provide examples, and allow time for client to repeat and review). Adults are capable of learning at any age. Age modifies but does not inhibit learning (Dellasega et al, 1994). Older adults need practice to use new technology (Westerman, Davies, 2000).
·         Ensure that the client uses necessary reading aids (e.g., glasses, magnifying lenses, large-print text) or hearing aids. Visual and hearing deficits require amplification or clarification of sensory input.
·         Use printed material, videotapes, lists, diagrams, and Internet addresses that the client can refer to at another time. These methods provide a reference that can be used in a less stressful setting, decreasing barriers to learning. This study demonstrated the effectiveness of printed material and a web-based format for education. The web-based format demonstrated two additional benefits when compared with printed material: increased social support and decreased anxiety (Scherrer et al, 2000).
·         Assess client's previous knowledge and resistance or blocks to incorporating new information into the current lifestyle. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
·         Repeat and reinforce information during several brief sessions. Understanding past information is essential to acquiring new knowledge. Brief sessions focus attention on essential information.
·         Discuss healthy lifestyle changes that promote wellness for the older adult. It is never too late to stop smoking, lose weight, or modify dietary intake of fats and alcohol. Quality vs. quantity of life may be the key issue in teaching self-care health habits (Walker, 1992).
·         Evaluate readability of the material. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability, comprehension of instruction, poor communication, and increased physical limitations (Hayes, 1998).
·         Consider health education programs using television and newspapers. There was a significant increase in stroke knowledge (52% more likely to know a risk factor and 35% know a symptom, p = 0.032) following this health education program as demonstrated through a telephone pretest and posttest (Becker et al, 2001).
·         Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).
·         Assess for the influence of cultural beliefs, norms, and values on the client's knowledge base. The client's knowledge base may be influenced by cultural perceptions (Leininger, 1996).
·         Use a neutral indirect style when addressing areas where improvement is needed when working with Native American clients. Using indirect statements such as "I had a client who tried 'X' and it seemed to work very well" will help avoid resentment from the client (Seiderman et al, 1996).
·         Validate the client's feelings and concerns related to previous learning experiences. Validation lets the client know the nurse has heard and understands what was said. (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
·         Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect and lack of caring have special significance for individuals of color (D'Avanzo et al, 2001).
Home Care Interventions
·         NOTE: Because home care is an intermittent model of care having a goal of safety and optimal wellness of the client between visits, the importance of teaching (by nurse) and learning (by client) should not be understated. All of the previously mentioned interventions are applicable to the home setting.
·         Select a space and time for teaching in which client and/or caregiver can focus on information to be learned. The home setting provides many distractions that may impair the ability of the client to learn.
·         Consider the complexity of material or behaviors to be learned. Adjust care plan and respective teaching and learning experiences accordingly to build client confidence in ability to learn (and change). Confidence in ability to learn and change is part of readiness to learn.
·         Assess for specific areas of learning that have the potential for strong emotional responses by the client or family/caregiver. Allow time for expression of feelings and encourage acceptance of need for learning. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior. Clinicians should develop interventions that increase benefits and decrease barriers (Fenn, 1998).
·         Document client's and caregivers' responses to learning. Clear documentation supports continuity in the learning experience

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