In desperate need of help on NANDA

  1. For a big project we have to write assessments, problems, interventions, rationale and evaluations on 4 nanda's and one knowledge deficit. since being students we cant give real care plans here its all made up anyways. the ones my teacher gave me are on a PT whom had a L Total hip replacement. my nanda's are

    Risk for infection R/T Total hip replacement
    Pain R/T Post op condition AEB Pt stating "my leg hurts"
    Impared gas exchange R/T COPD AEB 02 sat @ 86%

    Impared physical mobility R/T Total hip replacement AEB abduction pillow and fall risk precaution

    Knowledge dificit R/T Diabetes AEB glucose 236

    Can someone please help me with what assessments you would find that would support these nanda's, some problems the patient would experience, interventions you could do to help the patient and why you would do it and an expected outcomes? im completly lost and dont know where to turn. any help is appreciated. thank you.
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    Joined: Mar '09; Posts: 1


  3. by   Daytonite
    for this big project to write a care plan on a patient who has had a hip replacement i recommend that you follow the steps of the nursing process. i post this outline for writing a care plan using the nursing process in a lot of posts. if you search the allnurses threads you will find this and you will find how i apply it on this thread: - help with care plans
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) [font=arial unicode ms]
      • 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) with the disease
      • 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 disease or condition 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.
      • use: - medical disease information/treatment/procedures/test reference websites
    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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
      • always sequence actual nursing problems before potential (risk for) or anticipated problems
        • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
      •'s_hierarchy_of_needs - maslow's hierarchy of needs
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements: see post #157 on thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    a nursing diagnostic statement follows this format:

    p (problem) - e (etiology) - s (symptoms)

    • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    • etiology - also called the related factor by nanda, this is what is causing the problem and resulting in the symptoms. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
    • symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
    when doing a case study of a nonexistent patient there is some assessment activity that obviously can't be done since no real patient exists. so, abnormal assessment data must be compiled from what is expected to happen and complications of medical therapies should be addressed.

    step 1 assessment - the first thing you do is find information about this surgery. a hip replacement is a surgical treatment for a medical problem or a trauma that has happened to the patient. so, the reason for this surgical treatment should be established before you go any further. this kind of surgery is usually elective and planned in advance. it is called a hip arthroplasty and you should read about it on these websites so you know what the patient goes through and what recovery involves:
    in addition, these patients undergo major anesthesia so they are surgical patients that require monitoring after surgery for postoperative complications of anesthesia. those are (you can find these in the section of your nursing textbook about the general surigical patient):

    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (paralytic ileus)
    after reading those websites, looking at the list of postop surgical complications and checking your textbook for information about surgical patient care, you should be able to begin starting a list of the kind of symptoms this hip replacement patient might have and what things the nurse should monitor this patient for. you monitor for breathing problems, but you must break those down into the signs and symptoms of those problems.

    step #2 determination of the patient's problem(s)/nursing diagnosis - now you turn that list of symptoms into diagnoses. use a nursing diagnosis reference to help you. i want to address the problems with the diagnoses you listed. then, you need to begin your care planning process again--from the beginning. your nursing diagnoses need to be re-written.


    sequenced in proper priority:

    • impaired gas exchange r/t copd aeb 02 sat @ 86%
      • refer to a nursing diagnosis reference. this diagnosis is about oxygen not being exchanged in the alveoli of the lungs. copd is not a good enough reason to explain why oxygen and carbon dioxide are not being exchanged in the alveoli of this patient's lungs. see post #4 of this thread: where i explain the related factors of this diagnosis
      • i might accept an o2 sat of 86% but if you look at the defining characteristics of this diagnosis and the symptoms of hypoxia that you want to monitor for, there are better choices you could use. see impaired gas exchange
    • impaired physical mobility r/t aeb abduction pillow and fall risk precaution
      • a total hip replacement is really not why the patient has difficulty moving. it is because the bone has been impaired.
      • an abduction pillow is an intervention an a medical intervention at that so it cannot serve as a symptom, or evidence of this nursing problem of impaired physical mobility
      • a fall risk precaution is a nursing intervention so it cannot serve as a symptom, or evidence of this nursing problem of impaired physical mobility
    • pain r/t post op condition aeb pt stating "my leg hurts"
      • pain, if you read the nanda definition (see acute pain), states that it is from actual or potential damage. so, while the patient's pain is due to surgery it cannot be stated as post op condition. the damage is due to the cutting of tissues with a scalpel and other instruments and the manual manipulation of the tissues as well. this induces the inflammatory response (redness, heat, swelling and pain). and that is the underlying pathophysiology that is involved. it is good enough to say "surgical invasion", "surgery", or something similar.
      • pain is assessed thus:
        • where the pain is located
        • how long it lasts
        • how often it occurs
        • a description of it (sharp, dull, stabbing, aching, burning, throbbing)
          • have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
        • what triggers the pain
        • what relieves the pain
        • observe their physical responses
          • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
          • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
          • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
    • knowledge deficit r/t diabetes aeb glucose 236
      • the definition of this diagnosis (the problem) is: absence or deficiency of cognitive information related to a specific topic.
      • you haven't named the specific topic. with postop surgical patients there are a lot of choices for a topic. they need a lot of discharge teaching relating to
        • their medical disease
        • their diet
        • allowed physical activity (physical therapy in this case)
        • medications they need to take
        • any treatments and tests they need to be doing after discharge
        • referrals to any outside agencies or support groups
        • follow up appointments with doctors have been made and patient understands
        • teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient
      • again, the related factor must explain what the cause of the problem is and it cannot be stated as a medical disease. this problem, an absence or deficiency of cognitive information (a lack of information) is not because a patient has diabetes. diabetes doesn't cause someone to be ignorant of facts. this is what causes knowledge deficits:
        • cognitive limitation (in other words, not the brightest light bulb)
        • information misinterpretation
        • lack of exposure (to information sources, never given the information in the first place)
        • lack of interest in learning (apathy)
        • lack of recall (bad memory)
        • unfamiliarity with information resources (doesn't know where to look)
      • now that you know more about what this diagnosis means, can you see that glucose 236 is not an appropriate symptom of this problem? an appropriate aeb item here would be, for example, patient observed not using walker correctly to ambulate or a statement by the patient such as "i don't understand why i need to continue taking this new medication when i go home?"
    • risk for infection r/t total hip replacement
      • the risk for an infection is not because the hip has been replaced; it is because tissue has been invaded and an opportunity created for bacteria to be introduced into the body. that merely needs to be stated concisely.
      • interventions for these "risk for", or potential, problems are
        • strategies to prevent the problem from happening in the first place
        • monitoring for the specific signs and symptoms of this problem
            • sepsis is infection accompanied by an acute inflammatory reaction with systemic manifestations associated with release into the bloodstream of numerous endogenous mediators of inflammation. the inflammatory reaction typically manifests with 2 or more of the following
              • temperature > 38 c or < 36 c
              • heart rate > 90 beats/min
              • respiratory rate > 20 breaths/min or paco2 < 32 mm hg
              • wbc count > 12,000 cells/μl or < 4000 cells/μl, or > 10% immature form

            • severe sepsis is sepsis accompanied by signs of failure of at least one organ. cardiovascular failure is typically manifested by hypotension, respiratory failure by hypoxemia, renal failure by oliguria, and hematologic failure by coagulopathy

            • septic shock is severe sepsis with organ hypoperfusion and hypotension that are poorly responsive to initial fluid resuscitation

            • with sepsis, the patient typically has fever, tachycardia, and tachypnea; bp remains normal. other signs of the causative infection are generally present. as severe sepsis or septic shock develops, the first sign may be confusion or decreased alertness. bp generally falls, yet the skin is paradoxically warm. oliguria (< 0.5 ml/kg/h) is likely to be present. later, extremities become cool and pale, with peripheral cyanosis and mottling. organ failure causes additional symptoms and signs specific to the organ involved.
        • reporting any symptoms that do occur to the doctor or other concerned professional