Help with Nx Dx!! Sepsis

Your teacher may be looking for something specific, but you could use Excess fluid volume r/t effects of sepsis AEB 4+ pitting edema over entire body.

I don't know if that's right, though. It's been awhile since I had to write those. I really don't think they are very useful.

Skin integrity would be an issue with this patient. Sepsis of a comatose patient with +4 generalized pitting edema. Can not move to relieve pressure or tell you about pain or areas of discomfort.

Take everything you know about this patient and put it together. What are her vital signs? Labs? History? Family support? Physical assessment?

Fluid Volume Excess, High Risk for Alteration in Skin Integrity, Risk for Alteration in Perfusion.

Sepsis is a medical diagnosis and really is no help in formulating a nursing diagnosis except for what the patient's responses are to it. Since she is in a vegetative state then she must be a total care patient. She must have many self-care deficits. How is she being fed, her elimination managed, and her mobility taken care of? These are nursing problems that are turned into nursing diagnoses once assessed. What are the symptoms of her sepsis? Can the reason for her 4+ pitting edema be determined? What other medical problems does she have that might explain the edema? What medications is she receiving and why? Were each of her body systems assessed and was anything abnormal other than the pitting edema and that she does not speak or communicate (I assume)?

Diagnosing is based upon the signs and symptoms that the patient has. Each nursing diagnosis has its own definition, a list of defining characteristics (signs and symptoms) and related factors (etiologies). Just as a doctor takes a history, does a physical examination and performs tests before determining the person's medical diagnoses, we nurses do something very similar. To diagnose, we must:

• perform a health history (review of systems) - this information can be found in the patient's chart
• perform a physical exam
• assess the patient's ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
• review the pathophysiology, signs and symptoms and complications of their medical condition - this information will be found in textbooks and on the Internet
• review the signs, symptoms and side effects of the medications the patient is being given

Then, you list out the abnormal data. That data becomes the signs and symptoms, or AEBs, for the nursing diagnoses that you will find and use for the care plan. The information you learn from all this will also help you determine the related factors for the nursing diagnoses you will chose. Until you do this preliminary work, it is inappropriate to start diagnosing the patient.

See http://allnurses.com/general-nursing-student/help-care-plans-286986.html - Help with Care Plans for information and examples on using the nursing process to construct care plans.