risk for impaired skin integrity - page 2

We are starting clincial Monday (nsg101) and have to go in with a generic risk for impaired skin integrity. the outcomes I can think of are 1. maintain clean and intact skin 2. vital signs WNL... Read More

  1. Visit  Magriff3 profile page
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    There are some great books on INterventions and problems..look into it..I found awesome ones....at Barnes Nobles etc.
    GAstudentNurse likes this.
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  3. Visit  GAstudentNurse profile page
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    Thank you!!
  4. Visit  GAstudentNurse profile page
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    Wow......thank you so much for such great information. It is much appreciated!
  5. Visit  GAstudentNurse profile page
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    Hello and thanks in advance to anyone that responds. I have a patient diagnosed with Crohn's, Failure to Thrive. She has lost weight (30lbs) in a short amount of time. In my interview and assessment of her, she informed me of also being very depressed and proceeded to talk of her late husband and how life just isn't the same. I feel like I need to choose Imbalanced Nutrition: Less than Body Requirements, but am also thinking of Depression. Can I use depression as AEB? I certainly feel that along with Crohn's, it is affecting her nutritional status. She is also exhibiting unsteady gait. Labs (albumin decreased, RBC, WBC, Hbg, Hct also decreased) She is on a medication for Cachexia as well. She has a history of recent falls. Can I tie all of that into one careplan for Imbalanced nutrition or would I need to separate? Ex: Imbalanced Nutrition: LTBR R/T Crohn's, Failure to Thrive AEB:

    1. Recent weight loss of 30lbs 2. Decreased Albumin, RBC, WBC, Hcg, Hct 3. Verbal acknowledgement of having no appetite 4. Unsteady gait (directly related to poor nutrtion??) 5. Depression (which affects appetite???)

    I also have another one due on a patient with a Trach. I am choosing, "Ineffective Airway R/T COPD, ARDS AEB:

    1. Bilaterally Diminished breath sounds 2. Non-productive cough 3. Increased RR (26) 4. Artificial Airway (???)

    Thanks again for any advice. I'm hoping something is going to CLICK soon and I won't have such difficulty with these anymore! Again, much thanks!
    Last edit by GAstudentNurse on Mar 10, '09 : Reason: I wasn't finished
  6. Visit  Daytonite profile page
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    Quote from gastudentnurse
    hello and thanks in advance to anyone that responds. i have a patient diagnosed with crohn's, failure to thrive. she has lost weight (30lbs) in a short amount of time. in my interview and assessment of her, she informed me of also being very depressed and proceeded to talk of her late husband and how life just isn't the same. i feel like i need to choose imbalanced nutrition: less than body requirements, but am also thinking of depression. can i use depression as aeb? i certainly feel that along with crohn's, it is affecting her nutritional status. she is also exhibiting unsteady gait. labs (albumin decreased, rbc, wbc, hbg, hct also decreased) she is on a medication for cachexia as well. she has a history of recent falls. can i tie all of that into one careplan for imbalanced nutrition or would i need to separate? ex: imbalanced nutrition: ltbr r/t crohn's, failure to thrive aeb:

    1. recent weight loss of 30lbs 2. decreased albumin, rbc, wbc, hcg, hct 3. verbal acknowledgement of having no appetite 4. unsteady gait (directly related to poor nutrtion??) 5. depression (which affects appetite???)

    i also have another one due on a patient with a trach. i am choosing, "ineffective airway r/t copd, ards aeb:

    1. bilaterally diminished breath sounds 2. non-productive cough 3. increased rr (26) 4. artificial airway (???)

    thanks again for any advice. i'm hoping something is going to click soon and i won't have such difficulty with these anymore! again, much thanks!
    i understand your dilemma. let me first say that i am not being mean, but when you say "i feel like i need to choose. . ." it tells me that you are not using rational thinking processes. diagnosis is a rational process. there is nothing intuitive about it. it is quite scientific. no crystal balls or tarot cards involved.

    how a doctor diagnoses: (1) they take a history of the patient's past health problems, usually systematically by body systems (this is called a review of systems, or ros). (2) they do a physical examination. (3) they will order tests that target what are going to help them identify what the problem might be. (4) they put all the data that they collected together and determine what disease or condition the patient has. a medical diagnosis has very specific signs and symptoms. they look through the data they have collected to see if those are present.

    how a (student) nurse diagnoses: (1) we assess the patient: assessment for us nurses consists of:
    • a health history (review of systems)
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications they are taking
    (2) we list out all the abnormal data this have collected from the assessment that the patient has. (3) we use a nursing diagnosis reference to match this abnormal data with the defining characteristics (this is nanda language for signs and symptoms) of the different nursing diagnoses in order to correctly pick the diagnoses for the nursing problems that the patient has.

    care planning is actually the seeking out and identification of the patient's nursing problems and then developing strategies to do something (provide help) for them. we use the nursing process, which is nothing more than a tool to help us do that. when you assess the patient as the first step of the nursing process, you are, in effect, searching for evidence of the existence of nursing problems. this is all very logical and rational. when these elements are present there is no intuition involved. the problems are there as is the evidence proving them. there is no guesswork.

    what we, as nurses, are concerned with is the patient's response to what is happening to them. that is a very important concept to keep in mind. you patient may have crohn's disease, but what we are concerned with is her response to it. what physical and psychological responses have come about because of what this change in the anatomy & physiology to her body has done to her? let the doctor worry about treating the actually changes in the anatomy & physiology. our concern as nurses is:
    • carrying out the doctors treatment orders
    • treating the patient's response to the disease
    • assisting her in performing her adls as modified by her disease
    the 3-part nursing diagnostic statement is constructed following this formula:

    p (problem) - e (etiology, or cause--cannot be a medical diagnosis)- s (symptoms)
    you are proposing a diagnosis of: imbalanced nutrition: less than body requirements r/t crohn's, failure to thrive aeb:

    1. recent weight loss of 30lbs 2. decreased albumin, rbc, wbc, hcg, hct 3. verbal acknowledgement of having no appetite 4. unsteady gait (directly related to poor nutrtion??) 5. depression (which affects appetite???)
    the reason students need to be looking up the pathophysiology, signs and symptoms and complications of their patient's medical conditions (in this case, crohn's disease, failure to thrive and i would also suggest you do some investigation of cachexia) is to learn about these conditions. you are looking to find why each of her symptoms occurred.

    the r/t part of the diagnostic statement contains your related factors, or the underlying cause of the nursing problem (nursing diagnosis). it cannot be a medical diagnosis. a medical diagnosis can be re-written in generic medical terminology, and this is another reason why you need to know the pathophysiology of these medical diseases. if there is depression (a psychological condition) going on you need to research its effect on eating with patients.

    aebs (as evidenced by) are the proof of intake of nutrients insufficient to meet metabolic needs, the definition of this diagnosis. so, by diagnosing her with imbalanced nutrition: less than body requirements you are saying that she isn't taking in enough nutrients and the proof of this is a 30 pound weight loss, a bunch of screwed up labwork, and the patient's own statement that she has no appetite (i would make that more specific, such as she states "she does not feel like eating"). is an unsteady gait really related to not taking in enough nutrients? when you see someone with an unsteady gait is your first thought that they have a nutrition problem? i don't. depression is a medical diagnosis. like unsteady gait, it is not evidence of not eating enough.

    does she have diarrhea? does she have any abdominal pain or cramping because of the crohn's? diarrhea in people who have crohn's is one of the related factors of this diagnosis. why? the food is propelled through their gi track so fast that nutrients have no time to be absorbed.

    your diagnostic statement should look something like this: imbalanced nutrition: less than body requirements r/t altered ability to ingest and absorb food secondary to crohn's disease aeb 30 pound weight loss in ___ days, decreased albumin, rbc, wbc, hgb, hct and patient's statement that "i have no appetite."
    this patient also has
    • impaired physical mobility r/t nutritional status aeb unsteady gait
    • chronic sorrow r/t death of husband aeb sadness and statement that "life just isn't the same."
    • risk for falls r/t history of previous falling and unsteady gait [note: if she has diarrhea because of her crohn's disease, the diarrhea is also a risk factor for risk for falls]
    i also have another one due on a patient with a trach. i am choosing, "ineffective airway r/t copd, ards aeb:

    1. bilaterally diminished breath sounds 2. non-productive cough 3. increased rr (26) 4. artificial airway (???)
    not being mean here, but ineffective airway is not an official nanda diagnosis and it really isn't telling us what the problem is. again, look up the pathophysiology, signs and symptoms and complications of copd and ards. copd is a general term for a group of 4 respiratory diseases. was the patient diagnosed with at least one of them? a tracheostomy is a medical (doctor's) intervention for a medical problem and cannot serve as evidence of a nursing problem. however, as a nurse, you should look up the complications of a tracheostomy and be prepared to observe for them and be able to treat them if they occur.

    bilateral diminished breath sounds, a non-productive cough and an increased respiratory rate are symptoms of ineffective airway clearance. the cause, or related factor for this is the presence of an artificial airway (the trach) and excessive mucus (???) or perhaps retained secretions (???). knowing nothing else about this patient makes it hard to know why the ineffective airway clearance would be happening.

    you could write this diagnostic statement as: ineffective airway clearance r/t presence of a tracheostomy tube aeb bilateral diminished breath sounds, a non-productive cough and an increased respiratory rate.
    you can find information about crohn's, ards, copd and ards on these websites:
  7. Visit  GAstudentNurse profile page
    0
    Daytonite, wow.......thanks for such great indepth information and for your honesty! Both goes a long way! I tried today to utilize your "plumber" scenario to help me! Thanks again!

    Can I ask a question? Was it always this easy for you?
    Last edit by GAstudentNurse on Mar 10, '09 : Reason: misspelling
  8. Visit  Daytonite profile page
    1
    Quote from GAstudentNurse
    Daytonite, wow.......thanks for such great indepth information and for your honesty! Both goes a long way! I tried today to utilize your "plumber" scenario to help me! Thanks again!

    Can I ask a question? Was it always this easy for you?
    No, which is why I am so passionate about helping you guys.
    mandajeanice likes this.


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