[srg4784]

I understand how to do nursing process and care plans, but this week our instructor handed us a paragraph and to make one from there. My problem is I have never done one with an "actual diagnosis" in our example the client HAS a UTI. So I can't say "risk for infection...etc"

But what about .... "risk for cystitis...risk for urge urinary incontinence" I just need some help with a Dx to get me started.

[Daytonite]

All nursing diagnoses stem from abnormal symptoms that the patient is having. The clue to the patient's symptoms in this exercise the instructor has given you is: UTI (Urinary Tract Infection). You need to exercise some critical thinking here. Now, this is a medical diagnosis. However, each medical diagnosis also has symptoms. And, it is perfectly kosher for you to use and apply the symptoms that make up a medical condition to formulate your nursing diagnosis for the same patient. So, I went to Family Practice Notebook, one of my favorite sites for getting quick, concise signs and symptoms of medical diseases, and came up with these signs and symptoms of a UTI (http://www.fpnotebook.com/URO17.htm):

• dysuria (painful, burning urination)
• urinary frequency
• urinary urgency
• suprapubic pain (after voiding)
• hematuria (blood in the urine)

The next order of business is to look these symptoms over and see if any of them can be grouped into one or more nursing diagnoses. Sure enough, this is what I come up with (using official NANDA nursing diagnoses which I verified in my copy of Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International):

• Impaired Urinary Elimination R/T urinary tract infection AEB dysuria, urgency and frequency
• Risk for Deficient Fluid Volume R/T loss of blood through the urinary tract

The remainder of my care plan will have outcomes, nursing interventions and rationales that address the problems of dysuria, urgency and frequency under the diagnosis of Impaired Urinary Elimination. Under the Risk for Deficient Fluid Volume my nursing outcomes, interventions and rationales will have to do with the hematuria. Remember that any diagnoses beginning with the words "Risk for" are anticipatory problems and don't really exist yet. So, they must be listed last.

I just want to point out to you that there is no nursing diagnosis of cystitis in the NANDA nursing diagnosis classification, so that would be an invalid nursing diagnosis to use. Risk for Urge Urinary Incontinence is a valid NANDA nursing diagnosis, but the "related to" factors, or causes for it, include the effects of medications, detrusor muscle hyperreflexia or instability, involuntary sphincter relaxation, ineffective toileting habits or small bladder capacity. Unfortunately, with the scanty information that was given in the scenario and the known symptoms of a UTI, I would not jump to any of those conclusions just to use that diagnosis.

[Daytonite]

I just want to clarify that in my above post and taking the symptoms of the medical diagnosis of a UTI and using those same symptoms to formulate two nursing diagnoses that I was using still following the nursing process. The first step in the nursing process is assessment. That includes obtaining the patient's health and medical history as well as performing a physical examination. In this particularly case, the only assessment data that was available is what the instructor gave. So, that is all there was to work with. Obviously, if this were an actual patient, there would have been more opportunity to explore medical records, interview the patient and observe and examine the patient as well.

To summarize, in writing any care plan, you always follow the nursing process:

• assess the patient and collect data
• develop nursing diagnoses that are based on symptoms (problems) identified during the assessment [NOTE: a symptom is a objective observation or a subjective perception of the patient]
• plan the patient's care which includes writing outcomes and nursing interventions
• implement the care plan
• evaluate your plan of care

I found a website that is devoted to the nursing process and critical thinking the other day. I had run across it before when surfing the 'net and failed to do that. It may help define these steps for you as well. It's not a good idea to try to back into a nursing diagnosis by looking at the patient's medical problems and try to figure out a nursing diagnosis. You are still going to be forced to look at the symptoms and problems the patient has in order to support the use of that diagnosis. It's much more efficient to have the data already and go "shopping" for a nursing diagnosis. I cannot stress enough how important it is to scrutinize your patient's charts when you are in the clinical area. Look at H&P's, surgical reports, procedure reports, lab results, x-ray results, pathology results, evaluations by dietary, physical therapy and respiratory therapy as well as the nursing admission assessment form and any nursing transfer sheets (if the patient came from a nursing home). They all contain data that may be helpful to you. They may clue you in to something you might have missed during the time you spent with the patient. You can never have too much data. And, your data collection never stops. It is always ongoing. As a seasoned nurse, I can tell you that from many years of experience.

http://home.cogeco.ca/~nursingprocess/index.htm - this is a beautiful site that defines and explains a bit of what the nursing process is. You can also click on the links at the left side of the webpage to go to various subjects included within the nursing process to find out more about them.

[srg4784]

Thank you soooo much, I used "Impaired Urinary Elimination r/t UTI" and I did another one for "Knowledge deficit r/t UTI" We should get them back tomorrow so I'll let you know how it goes. I've received sat. on all of them thus far just didn't know how to start when a medical diagnosis was given. This week is COPD so at least I have some idea of where to start now so again, thank you !!

[Daytonite]

You are very welcome! Good luck with your future care plan writing!

[hopecandles]

Just my 2 scents here are some diagnosis to consider for your COPD pt.
Gas exchange, impaired r/t low V/Q ratio
Activity intolerance r/t imbalance between oxygen demand and requirement.
Infection, risk for decreased lung defenses

Don't just use these blanketly though. Look at how they will apply to your patient, and how you, as a nurse, can either help reverse, or prevent the complications.
i.e. activity intolerance... are they panting when they get up, do their sat's drop, etc...
what you can do as a nurse...group activities and allow for frequent rest periods, apply oxygen

Good Luck