help with a NANDA label

Gravysgal · Apr 24, 2008 04:24 AM

I have to do 5 care plans on my patient,
She was admitted to the hospital with N/V and a temp of 102.4
Diagnosised with a UTI and Leukocytosis

I have managed to come up with 4 NANDA labels and need a little assistance with my 5th one.

She is currently raising her 3 year old grandson (pt is 53)
what would be an appropriate NANADA label that would address
this?

I was thinking of
Role performance, altered
but my book doesnt correlate to her situation.

Any input will be GREATLY appreciated!!

*Daytonite* · Apr 24, 2008, 06:18 AM

I have to do 5 care plans on my patient

Do you mean 5 nursing diagnoses? A care plan "allows a nurse to identify a patient's problems and select interventions that will help solve or minimize these problems" (page 3, Nursing Care Planning Made Incredibly Easy) and is a "statement of the goals and objectives of the nursing care [to be] provided for the patient and the activities or tasks required to accomplish the plan, including the criteria to be used to evaluate the effectiveness and appropriateness of the plan" (page 1487, Taber's Cyclopedic Medical Dictionary, 18th edition).

A nursing diagnosis is a patient problem that is identified by the nurse after assessing the patient and comparing the findings to what is considered to be normal.

She is currently raising her 3 year old grandson (pt is 53)
what would be an appropriate NANDA label that would address
this?

Nursing diagnoses are ALWAYS based upon the symptoms (abnormal data) your patient is having. For nursing diagnosing, the symptoms we look for are not only the same ones the doctors focus on, but also include patients responses to their diseases and conditions as well as their ability to perform their ADLs. This information comes from your assessment of the patient. Every nursing diagnosis has a list of signs and symptoms (NANDA calls them defining characteristics) and before you assign any nursing diagnosis to a patient you should check a nursing diagnosis reference to make sure that a diagnosis you are contemplating using has one or more of your patient's symptoms, or defining characteristics, listed for it. You should also double check the definition of the nursing diagnosis to make sure it is indeed the correct problem that the patient has.

You've listed no data in relation to this situation so it would be very difficult to advise you what nursing diagnoses might be appropriate to use.

With my years of med/surg experience, and reading the brief history you provided of the UTI, leukocytosis, nausea and fever. . .I wouldn't even touch a psychosocial problem related to her grandson unless this patient is making a lot of comments about her relationship with (and more likely, away from) her grandson being a situational crisis causing manifested emotional or behavioral responses. Especially, if you haven't done any psych nursing principles and assessment yet. She has plenty of physiological things going on that you should be able to come up with 5 diagnoses. People with UTIs are hospitalized for treatment that can only be done in the hospital, otherwise they are allowed to be at home on oral antibiotics. Your assessment of the patient should include:
most importantly
a physical assessment of the patient

assessment of the patient's ability and any assistance they need to accomplish their ADLs (activities of daily living)

data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians

knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical diseases or conditions that the patient has. This includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. If this information is not known, then you need to research and find it. You can use the links on this thread to help you:
http://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - Medical Disease Information/Treatment/Procedures/Test Reference Websites

Symptoms of a UTI include:

bladder pain
hematuria
fever
cloudy, foul smelling urine

There is testing that can be done to determine the organism involved and voiding cystourethrography or urography may be done as well as ultra sound. The patient needs education about:

what a UTI is, how it is diagnosed and treated
what tests are being done and the preparation required for them
why completing a prescribed course of antibiotics is important
what drugs they are being given, why, and possible side effects
the correct way to wipe herself after voiding (from front to back)

Complications of UTI are:

damage to the urinary track lining
infection of adjacent organs and structures
sepsis (http://allnurses.com/forums/f205/pathophysiology-uti-septicemia-268443.html)

All of the above have the potential basis to become nursing problems (nursing diagnoses). You might want to see this thread from about a month ago on dysuria (http://allnurses.com/forums/f205/i-m...ns-293100.html) which can be an accompanying symptom of a UTI. In particular, look at the interventions listed on post #13 for this diagnosis of Impaired Urinary Elimination.

Gravysgal · Apr 24, 2008, 06:43 AM

sorry to have not included enough info,

I have to do 5 different nursing diagnosis, including a care plan for each.
The thing is we are 1st semester students, but are on an acute care floor. So I only get the pt for one clinical day.

She was admitted to the hospital the previous night with a fever of 102.4, N/V

Lab results indicated she had a UTI and Leukcytosis
otherwise she was a very healthy lady.

She mentioned concern about her grandson, and the fact that he was staying with his mother while she was in the hospital.
and stated that the daughter never watched after him.

thanks Daytonite!