Help with nursing Diagnosis for an unconcious, dieing, comfort care patient

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    I have a dieing, unconcious, comfort care patient. The family has just DC peg tube feedings. She has a fever, she is on morphine via peg tube. We are gradually decreasing o2 via nasal cannula. I am having a difficult time picking 3 nursing diagnosis for this patient. I have never worked with a dieing pt. before. My main concerns are keeping her comfortable although she is unconcious, decreasing her fever and support the family in the grieving process. Any suggestions would be great. Thanks.
  2. 7 Comments so far...

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    An unconscious, dying patient still may have pain management and comfort issues, correct. You are completely correct that the family is part of your care. So. When you looked in your NANDA-I 2012-2014, the current edition, which every nursing student should have even if the faculty forgot to put it on your bookstore list and is available with free 2-day shipping from Amazon, what nursing diagnoses did you see listed that might apply? When you looked at them, what defining characteristics did you assess in your patient/family, so you know you have the right diagnoses? Hint: Look in the sections on Coping/Stress, Life Principles, and Comfort. I promise you there are several there.

    Oh, you don't have that book? How do you identify nursing diagnoses normally? If you have found something in some of your textbooks, what are they? Tell us what you have so far-- we don't do your homework for you, though we are very happy to point you in the right direction.

    Well, if you aren't in the path of this big storm we have coming in here in New England... you can have the book by Saturday night if you order it right now. Otherwise, maybe Monday. Get it now! (This is the right direction )
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    What I have so far is Risk for Pain/discomfort related to end of life status, 2nd Hyperthermia r/t pneumonia, 3rd, Grieving r/t impending death of loved one. Let me know what you think of these. Thanks.
    GrnTea likes this.
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    Risk for dehydration related to withholding food\water and fever. Interventions-antipyretics, frequent mouth care, and infusioning IV fluids
    Risk for pressure area related to lack of movement. Intervention- frequent position changes and pressure matress
    Risk for contracture related to lack of movement. Interventions-rom
    That's all I can think of
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    Quote from mertzk
    What I have so far is Risk for Pain/discomfort related to end of life status, 2nd Hyperthermia r/t pneumonia, 3rd, Grieving r/t impending death of loved one. Let me know what you think of these. Thanks.
    Your care plan is all about the patient.......Here is what I know.....Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use
    Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.
    From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
    What care plan book do you use?

    Now tell me bout your patient....What do you think they need? How would you know that? What are your vital signs? What is your assessment?
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    This is hospice, so no IV fluids as these actually increase discomfort as body organs shut down; fluids by mouth as wanted, but don't push them as the patient might not want them anyway. (This is not "withholding" food and water.) Dehydration is good at this point.
    KelRN215 likes this.
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    Quote from mertzk
    I have a dieing, unconcious, comfort care patient. The family has just DC peg tube feedings. She has a fever, she is on morphine via peg tube. We are gradually decreasing o2 via nasal cannula. I am having a difficult time picking 3 nursing diagnosis for this patient. I have never worked with a dieing pt. before. My main concerns are keeping her comfortable although she is unconcious, decreasing her fever and support the family in the grieving process. Any suggestions would be great. Thanks.
    So you have a dying, comfort care patient who is unconscious .....tell me what you see....what does she NEED, what is your assessment...what is the physical assessment.

    Care plans are all about the assessment....there isn't really enough information here to help you. You state the patient is febrile....so you have Hyperthermia related to...what. She is on morphine....so she has pain...related to why. So she has impaired mobility. How is her family....are they aware of the dying process....are they prepared?

    If this was your grandma what would you want done for her.....
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    Quote from pinkessence_58467
    Risk for dehydration related to withholding food\water and fever. Interventions-antipyretics, frequent mouth care, and infusioning IV fluids
    Risk for pressure area related to lack of movement. Intervention- frequent position changes and pressure matress
    Risk for contracture related to lack of movement. Interventions-rom
    That's all I can think of
    I see what you're saying here, however it sounds like this patient is actively dying, and is comfort care only. Review pathophys in the dying client- generally the need/desire for food and fluids decrease or disappear completely because the person simply doesn't need these things any more. Body systems are shutting down and no longer require energy to build new tissue. Plus peristalsis is decreased so it takes things considerably longer to exit the body as well. IV therapy, even fluids would be inappropriate for a comfort care client too. The only medications that should be given are things to promote comfort and are generally given PO or SL, usually painkillers (morphine especially because it decreases anxiety). IV, IM and SQ are all UNcomfortable procedures and are typically not used in comfort care clients. (insulin is often withheld in the last few days of life too because of the pain associated with fingersticks and injections)
    Turining Q2H is important as you do not want pressure ulcers to form, however is a patient that is actively dying going to develop contractures before they pass? Probably not.
    I think the OP is correct in her original dx of comfort measures, family support and grieving.


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