[Daytonite]

Originally Posted by multicollinearity

Has anyone heard of a diagnosis of "high risk for impaired skin integrity"?

Nope. However, a facility, employer or nursing program is free to mandate that any specific nursing diagnoses be used as long as they define them. NANDA isn't the only game in town and doesn't have a corner on the market.

[mkcrturner]

ok, I am truly stuck.

I am doing a HUGE care plan.
Pt is 38 y.o. F with AIDS, HEP C, MRSA in a wound from an IND to a cyst that has gone from anterior hip to the iliac crest with osteomyelitis (FUN dressing change..)

she was admitted with vaginal bleed and green frothy discharge. Medical DX = Trichomonas vaginalis.
For the life of me I am STUCK on a NANDA diagnosis.
Our care plan is broken into each system, under elimination i have the following

ELIMINATION
Intake for shift = 2254
Output for shift = Voids x5, BM x1
Urine characteristics/Problems voiding; Foley (Y or N)= Amber, cloudy, sediment, strong odor
Hx of kidney or bladder disease = Renal insuffiency
BM/Stool pattern/last BM= Daily, 4/12 @ 11:30
Hx of hemorrhoids or bleeding= Admitted with vaginal bleeding, green frothy discharge.
Diuretics= 40 mg Lasix daily
BUN= 7
Creatinine= 0.6


We are supposed to highlight anything that is abnormal, then if there is any abnormality we need to include a nursing diagnosis for that section.

I am STUCK on this area. Please help......

TIA~ Kelly

[Daytonite]

Originally Posted by mkcrturner

ok, I am truly stuck.

I am doing a HUGE care plan.
Pt is 38 y.o. F with AIDS, HEP C, MRSA in a wound from an IND to a cyst that has gone from anterior hip to the iliac crest with osteomyelitis (FUN dressing change..)

she was admitted with vaginal bleed and green frothy discharge. Medical DX = Trichomonas vaginalis.
For the life of me I am STUCK on a NANDA diagnosis.
Our care plan is broken into each system, under elimination i have the following

ELIMINATION
Intake for shift = 2254
Output for shift = Voids x5, BM x1
Urine characteristics/Problems voiding; Foley (Y or N)= Amber, cloudy, sediment, strong odor
Hx of kidney or bladder disease = Renal insuffiency
BM/Stool pattern/last BM= Daily, 4/12 @ 11:30
Hx of hemorrhoids or bleeding= Admitted with vaginal bleeding, green frothy discharge.
Diuretics= 40 mg Lasix daily
BUN= 7
Creatinine= 0.6


We are supposed to highlight anything that is abnormal, then if there is any abnormality we need to include a nursing diagnosis for that section.

I am STUCK on this area. Please help......

TIA~ Kelly

I think that what you were to do was highlight any symptoms that were abnormal. Why? Because you can only base nursing diagnoses, goals and nursing interventions on abnormal data (symptoms) that the patient has. Think about it. A doctor does a workup on a patient that includes a review of systems and history, a physical exam and a battery of tests. The doctor bases his diagnosis on the symptoms he has observed during these activities. Nursing diagnosis is no different except that the criteria that is used to classify each nursing problem is somewhat different than for a medical diagnosis. To help us, NANDA has published the nursing diagnosis taxonomy that lists defining characteristics, a fancy NANDA term for symptoms, for each diagnosis. Because each of the nursing diagnoses covers a wide range of situations, their defining characteristics can be quite broad in scope. Nonetheless, it is most helpful to have a nursing diagnosis reference or a care plan book that includes the NANDA taxonomy for each nursing diagnosis it uses. Start checking the NANDA taxonomy information for each diagnosis you choose to make sure you are diagnosing correctly. The more you work with diagnosing, the more comfortable you get with it.

Did you look up information about Trichomonas vaginalis (trichomoniasis)? That is something you should do as part of your assessment activity. You would have discovered that symptoms of this condition usually include severe itching, vaginal edema and excoriation, dysuria, and urinary frequency. I know, I had this many years ago; the itching and pain were unbelievable. So, I would ask you if you missed assessing this in this patient. With these symptoms you could use the nursing diagnoses of Acute Pain and Impaired Urinary Elimination (http://allnurses.com/forums/f205/i-m...ns-293100.html)

However, the abnormal data for Elimination you collected is:

• cloudy amber urine with sediment and a strong odor
• vaginal bleeding
• green frothy vaginal discharge.
• BUN= 7 (this is indicative of the kidney disease)

This abnormal data is what you have to work with in looking for defining characteristics of nursing diagnoses that would apply here. That only allows you to use:

• Risk for Infection R/T inadequate immunity, spread of pathogen from genital tract and presence of existing kidney disease [the infection the patient is at risk for is a UTI so that is what you focus on - http://allnurses.com/forums/2751313-post8.html]

Renal insuffiency and 40 mg Lasix daily are not symptoms. Renal insufficiency is a medical diagnosis; 40 mg of Lasix daily is a treatment.

[mkcrturner]

Thanks Daytonite.

Your fresh eyes helped alot. This careplan is hard to explain. But the middle pages have the areas broken up. And if there is one thing wrong/different/unusual/abnormal we need a NANDA dx for it. It gets confusing if your patient has a huge list of symptoms.
ie- generalized weakness and pain (2 different areas) could both have a dx of "activity intolerance"

This pt had stuff in every section and I was finding myself repeating or getting lost.
LOL about the Lasix and renal insuffiency failure....if you only knew how many times I questioned that- to myself of course...to quote my instructor "do you take Lasix? then it is not a normal thing..." She wants EVERYTHING to be highlighted so she can spot it easily. <shrug> she is grading me so I do it her way. Even if Lasix was the only thing in there and all else was ok, this instructor would want a diagnosis r/t the fact this patient takes Lasix.
"I love nursing school, I love nursing school..... " hehehehe

THANKS VERY VERY much for giving me a fresh view and the thought process that I needed to complete this LENGTHY careplan without repeating a million times.

[Daytonite]

Originally Posted by mkcrturner

This careplan is hard to explain. But the middle pages have the areas broken up. And if there is one thing wrong/different/unusual/abnormal we need a NANDA dx for it. It gets confusing if your patient has a huge list of symptoms.
ie- generalized weakness and pain (2 different areas) could both have a dx of "activity intolerance"

Got it. The wording you use to describe the symptoms can solve part of that. And it's true that some symptoms can be used as evidence for more than one nursing diagnosis. If the shoe fits, do it. And, yes, it can sometimes be frustrating to tie every single abnormal assessment data item to a nursing diagnosis. That again, may fall back to wording of the symptom. That's the frustration of being in school. You won't have to do that on the job--I promise.

[annmarierichard]

I must write a care plan. I need two nursing and 1 psychosocial diagnosis. I was wondering, is deficient knowledge about gestational pregnancy a nursing diagnosis or a psych one? Please advise.. thanks so much for whatever input I can get.
annmarierichard

[Daytonite]

Originally Posted by annmarierichard

I must write a care plan. I need two nursing and 1 psychosocial diagnosis. I was wondering, is deficient knowledge about gestational pregnancy a nursing diagnosis or a psych one? Please advise.. thanks so much for whatever input I can get.
annmarierichard

I think what you are meaning to say is that you need two nursing diagnoses that address the patient's physiological response to their condition and one nursing diagnosis that addresses their psychological response to their condition. Yes, according to NANDA Deficient Knowledge (specify) is classified as a psychosocial nursing diagnosis. There is a listing of all the psychosocial diagnoses on post #145 of this thread: http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)

[FriendlyGhost87]

Okay, so right now I am doing my first care plan ever...and I'm confused which way to go with it....it's probably going to be an easy one for you guys but I just wanted to make sure I'm going in the right direction with it, so here it goes...!

A client who is 73 was admitted with pneumonia and a history of ALS. She recently developed an upper respiratory infection that won't go away. She has coarse breath sounds bilaterally and a weak, ineffective cough. She has patchy infiltrates in RML, RLL, and LLL. Her O2 sat is 91-92% with O2 therapy (2L/min/NC)-------all of these things lead me to choose ineffective airway clearance...BUT

this client has difficulties with chewing and swallowing, therefore losing 10% of her body weight in the past month (from 120 down to 108) The reason this part makes me want to choose this is the lab results. Her HgB and Albumin are both low. I know the HgB could be d/t low oxygen levels, but the O2 sat level she's at isn't TOO low...it's not an ideal percentage but it's above 90%... so the other possible diagnosis I could see is Imbalanced Nutrition: Less than body requirements.

I guess I just want to know if I'm going in the right direction here with this one!! Thanks for any and all help!

[Daytonite]

Originally Posted by FriendlyGhost87

Okay, so right now I am doing my first care plan ever...and I'm confused which way to go with it....it's probably going to be an easy one for you guys but I just wanted to make sure I'm going in the right direction with it, so here it goes...!

A client who is 73 was admitted with pneumonia and a history of ALS. She recently developed an upper respiratory infection that won't go away. She has coarse breath sounds bilaterally and a weak, ineffective cough. She has patchy infiltrates in RML, RLL, and LLL. Her O2 sat is 91-92% with O2 therapy (2L/min/NC)-------all of these things lead me to choose ineffective airway clearance...BUT

this client has difficulties with chewing and swallowing, therefore losing 10% of her body weight in the past month (from 120 down to 108) The reason this part makes me want to choose this is the lab results. Her HgB and Albumin are both low. I know the HgB could be d/t low oxygen levels, but the O2 sat level she's at isn't TOO low...it's not an ideal percentage but it's above 90%... so the other possible diagnosis I could see is Imbalanced Nutrition: Less than body requirements.

I guess I just want to know if I'm going in the right direction here with this one!! Thanks for any and all help!

You are always going to look at what was abnormal about your assessment of your patient because those are the clues (evidence) of their nursing problems. The coarse breath sounds bilaterally, weak, ineffective cough, and patchy infiltrates in RML, RLL, and LLL are defining characteristics (symptoms) of Ineffective Airway Clearance. The underlying pathology is partly because of bacterial invasion and partly because of the neuromuscular dysfunction of the ALS. I was wondering what this patient's O2 sats were before getting O2. Without O2 there is probably Impaired Gas Exchange due to a ventilation perfusion imbalance caused by the debris and exudate of the inflammatory process of the pneumonia that is going on in the alveoli of the lung. These two nursing diagnoses often go hand-in-hand when there is pneumonia. There are other defining characteristics (symptoms) of impaired oxygenation beside low O2 levels. They will be listed on this webpage: Impaired Gas exchange

In ALS (amyotrophic lateral sclerosis) the patient's motor neurons progressively fail to work due to loss of myelin while their mental functioning remains intact. There is usually asymmetrical weakness of one limb, fatigue and cramping in the affected muscles. Weakness progresses to the muscles of the arms, legs and trunk. Eventually the patient will have difficulty talking, chewing, swallowing, and breathing. They can become SOB and drool. Complications include lung infections, respiratory failure, immobility, aspiration and physical injuries.

Your assessment found difficulty with chewing and swallowing, loss of 10% of her body weight in the past month, and that HgB and Albumin are both low. If you look in a lab reference book, you will find that low hemoglobin levels are due to things like anemias, hemorrhage, nutritional deficiencies and chronic diseases (http://www.labtestsonline.org/unders...obin/test.html). Oxygenation would be affected if she were anemic. Albumin, which is a blood protein (now we're into fluids and electrolytes), is low when there is malnutrition and inflammation (http://www.labtestsonline.org/unders...umin/test.html). I think you are going in the right direction with Imbalanced Nutrition: Less than body requirements. Undoubtedly, the related factor is her inability to ingest food (because of her swallowing difficulties she probably gets fatigued and just doesn't have the energy to eat enough at meals or maybe she gets muscle spasms in the muscles of mastication when chewing) and your evidence supporting this is problems chewing, loss of 10% of her body weight in the past month and the low HgB and Albumin.

However, her problem with swallowing can go to one or both of these diagnoses on a care plan: Impaired Swallowing (Impaired Swallowing).and a potential Risk of Aspiration (Risk for Aspiration). The underlying cause is what is happening to her physiologically from the ALS.

You were going in the right direction, just not noticing all the scenery!

[FriendlyGhost87]

Originally Posted by Daytonite

You are always going to look at what was abnormal about your assessment of your patient because those are the clues (evidence) of their nursing problems. The coarse breath sounds bilaterally, weak, ineffective cough, and patchy infiltrates in RML, RLL, and LLL are defining characteristics (symptoms) of Ineffective Airway Clearance. The underlying pathology is partly because of bacterial invasion and partly because of the neuromuscular dysfunction of the ALS. I was wondering what this patient's O2 sats were before getting O2. Without O2 there is probably Impaired Gas Exchange due to a ventilation perfusion imbalance caused by the debris and exudate of the inflammatory process of the pneumonia that is going on in the alveoli of the lung. These two nursing diagnoses often go hand-in-hand when there is pneumonia. There are other defining characteristics (symptoms) of impaired oxygenation beside low O2 levels. They will be listed on this webpage: Impaired Gas exchange

In ALS (amyotrophic lateral sclerosis) the patient's motor neurons progressively fail to work due to loss of myelin while their mental functioning remains intact. There is usually asymmetrical weakness of one limb, fatigue and cramping in the affected muscles. Weakness progresses to the muscles of the arms, legs and trunk. Eventually the patient will have difficulty talking, chewing, swallowing, and breathing. They can become SOB and drool. Complications include lung infections, respiratory failure, immobility, aspiration and physical injuries.

Your assessment found difficulty with chewing and swallowing, loss of 10% of her body weight in the past month, and that HgB and Albumin are both low. If you look in a lab reference book, you will find that low hemoglobin levels are due to things like anemias, hemorrhage, nutritional deficiencies and chronic diseases (http://www.labtestsonline.org/unders...obin/test.html). Oxygenation would be affected if she were anemic. Albumin, which is a blood protein (now we're into fluids and electrolytes), is low when there is malnutrition and inflammation (http://www.labtestsonline.org/unders...umin/test.html). I think you are going in the right direction with Imbalanced Nutrition: Less than body requirements. Undoubtedly, the related factor is her inability to ingest food (because of her swallowing difficulties she probably gets fatigued and just doesn't have the energy to eat enough at meals or maybe she gets muscle spasms in the muscles of mastication when chewing) and your evidence supporting this is problems chewing, loss of 10% of her body weight in the past month and the low HgB and Albumin.

However, her problem with swallowing can go to one or both of these diagnoses on a care plan: Impaired Swallowing (Impaired Swallowing).and a potential Risk of Aspiration (Risk for Aspiration). The underlying cause is what is happening to her physiologically from the ALS.

You were going in the right direction, just not noticing all the scenery!

Thanks for helping out!! It cleared up some confusion I was having for sure, and also taught me a lot!!!