help with nursing diagnoses...please!!!

[mollysaunt]

Hi all,

First time poster. I'm having trouble crafting and prioritizing the 4 nurses diagnoses needed for my concept map.

Here is a little bit about my patient (only cared for him during 1 shift): he is a 6 week old, ex-31 week preterm infant. His prior medical history includes -- Neonatal Abstinence Syndrome (NAS) , chronic lung disease of prematurity (bronchopulmonary dysplasia), anemia of neonatal prematurity (AOP), patent ductus arteriosus (PDA).

His withdrawal taper ended several weeks ago.

He is mainly at the hospital for oxygen supplementation and optimization of his nutrition.. He is on 0.5L high flow nasal cannula and PO feeds 3x/day and via NGT 3x day.. a big problem for him is that his sats drop to 93-94% (goal is to keep at >98%) and he can get tachypneic when he is feeding if the caregiver/nurse doesn't use pacing/give him breaks. His vitals were normal and he took all of his food volumes in my shift.

Here are the only real "abnormals" from which to glean some sort of diagnosis (most of his assessment seems within normal range, vitals ok, breath sounds clear, no murmurs, I/Os are adequate, cap refill

I have to come up with 4 nursing diagnoses in 4 different areas (respiratory, neuro, etc). So far, I have..

1. Ineffective breathing pattern related to pulmonary immaturity as evidenced by intermittent tachypnea and retractions, inability to maintain effective breathing pattern without supplemental oxygen, and decreased oxygen saturation when feeding without pacing.

----- I was debating between "ineffective breathing" and "impaired gas exchange r/t alveolar-capillary membrane changes as evidenced by intermittent tachypnea, retractions, decreased hematocrit and reticulocyte count"...but went with ineffective breathing as I am only permitted to have one respiratory diagnosis.

2. Imbalanced nutrition: less than body requirements r/t increased caloric needs unable to be met secondary to disease process as evidenced by increased work of breathing during feeding, and decreased total protein, albumin, and hematocrit laboratory values.

----- for priority dx #2 I am torn as to how to account for his skin mottling (I get it may be related to being a NAS baby and poor perfusion).. so I was considering

"Ineffective peripheral tissue perfusion" related to altered oxygen-carrying capacity as evidenced by skin mottling and decreased hematocrit and reticulocyte count.... However, I have not seen much mention in my research of bronchopulmonary dysplasia infants having problems with tissue perfusion... so I am stumped...is it correct to attribute his mottling to ineffective peripheral tissue perfusion?

3. the diagnosis books seem to recommend "excess fluid volume" but I am not seeing the evidence to support that dx with this pt.. but, of course, I could be very wrong.

4. Possibly Impaired Infant Feeding, Disorganized Infant Behavior or Activity Intolerance (he has respiratory distress when feeding from time to time)... he could be at risk for delayed growth and development

Hopefully, this is somewhat comprehensible. Any help you guys can provide would be very much appreciated!! I am (obviously) confused and sort of torn as to how to prioritize my dx..and whether to even use "ineffective peripheral perfusion" or "excess fluid volume" at all...Thank you.. if you made it all the way to end of this post. :)

[Esme12, ASN, BSN, RN]

What does a PDA cause?

A patent ductus arteriosus may cause:

• Poor eating, poor growth – due to easy fatigability brought about by decreased blood oxygenation. Continuous shunting of blood causes pulmonary hypertension then congestion of the right ventricle leading to decreased efficiency in pumping blood towards the lungs for oxygenation.
  
• Enlarged heart – right ventricular hypertrophy – due to continuous shunting of blood that causes pulmonary hypertension then congestion of the right ventricle because of backflow of blood from the lungs
  
• Tachycardia or other arrhythmia – due to compensation of the heart brought about by the inability to efficiently pump blood out to the lungs.
  
• Cyanosis – pressure in the pulmonary artery equals or even exceeds that of the aorta. Either the diastolic portion of the murmur or the complete murmur may disappear due to flow reversal (reverse shunting PDA). With this, blood then bypasses the lungs therefore there is no oxygenation of the blood leading to cyanosis.
  
• Persistent fast breathing or breathlessness – compensation to increase oxygen supply to the body due to decreased oxygenation
  
• Easy fatigability – due to decreased blood oxygenation. Continuous shunting of blood causes pulmonary hypertension then congestion of the right ventricle leading to decreased efficiency in pumping blood towards the lungs for oxygenation.
  
• Frequent respiratory infections (eg, colds, pneumonia) – due to decreased blood oxygenation leading to decreased functioning of the immune system to resist infection and of the respiratory system to expel offending microorganisms
  

You are in the ball park and your baby fits these. Always think ABC's and Maslows when deciding priority.

Here is what I think applies...

1. Decreased Cardiac Output related to malformations of the heart.
   
2. Impaired Gas Exchange related to pulmonary congestion.
   
3. Activity Intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.
   
4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to the tissues.
   
5. Imbalanced Nutrition Less than Body related to fatigue at mealtime and increased caloric needs.
   
6. Risk for Infection related to decreased health status.
   

[mollysaunt]

Thanks for the detailed reply, Esme12…much appreciated.

[nurseprnRN, BSN, RN]

You don't "pick" or "choose" or ""craft" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristic)(s)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2012-2014 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

[Esme12, ASN, BSN, RN]

Thanks for the detailed reply, Esme12…much appreciated.

You started the post with good info....just needed tweeking....I hope it helped.

[mollysaunt]

Very much so...lots to learn which is why your help is so valued.

[mollysaunt]

I will definitely order these from Amazon..thank you!

[Esme12, ASN, BSN, RN]

They will save your sanity!