Alright, I'm not sure if there is some sort of language barrier going on here or if you're genuinely confusing terminology, but let me clarify a few things so that you can correctly refer to these things in the future...
I have a pt who diagnosis with fever of unkown origin.
should probably be: I have a patient with a diagnosis OF fever of unknown origin. (even though the symptoms you list with the chief complaint, specifically the diarrhea, can arguably be considered evidence of an infection process) but we don't have to fight the medical diagnosis, at least not now, lets focus on the other elements related to a nursing diagnosis/care plan.
for my nursing intervention i have are
1, infection r/t disease process as evidence by temp 101.9 and pt received with antibiotics.
2, risk for electrolyte imbalance r/t diarrhea
The items that you have listed are referred to as nursing diagnoses
, which even then aren't constructed 100% correct, but they are not nursing interventions. A nursing intervention
is what you, as a nurse, DO to treat the patient. Nursing interventions are the implementation of actions that are outlined in a nursing care plan
, which is generated after a nursing diagnosis is made. Nursing diagnoses are developed after conducting a nursing assessment
. I'll go more into why your listed diagnoses are incorrect later on in this post.
With all that being said, I can try and help you brain storm other possible nursing diagnoses to consider, but the summary you've given about this patient is really limited (this means you need a more comprehensive patient assessment in order be able to apply multiple diagnoses to this patient)
I'll try to outline my thinking process for you to maybe apply in your future of development of nursing dx's and care plans...but again, this is a really constricted scenario given the lack of information about the patient. 1. What I know:
Patient is moderately feverish (101.9) suffering from diarrhea (for an unknown amount of time, unless you have that information handy), being treated with a course of antibiotics.
Normally during this first step, I've usually got a lot of information from a thorough patient assessment to draw from. A thorough patient assessment will allow for you to draw information about not just the physical symptoms the patient is presenting, but also about non-physical conditions that would be beneficial to address in a nursing care plan, things like: ability to cope with stress/illness, support system, learning/language barriers, medical/physical history that could relate to the current condition, etc. Before sitting down to write a care plan, make sure you've done as thorough of an assessment as you could. Sometimes this isn't possible due to time constraints and patient presenting unresponsive, in these isolated incidence, just get as much of an assessment done as you can, develop some nursing diagnoses and a plan of care, and re-assess and revise it when an opportunity to better assess the patient arises. 2. Relate what was listed above to the systems that will be effected, the actual problems present that can be associated with the current condition, and potential problems that can arise from the information given that should be prepared for or prevented.
Fever/hyperthermia: an increase in body temperature. Usually in response to infection or disease, but sometimes related to medications, teething, autoimmune disorders, some cancers, or endocrinological malfunction. do I have any information from my assessment to support any of the listed causes of fever that I have just made?
No, not really, only the exact temperature to support me calling this fever a fever. Not really important though because we aren't aiming to make a MEDICAL diagnosis, we just want information that could be used to support any nursing diagnoses we may eventually come up with relating to the objective finding. Getting this kind of information in most cases would require a medical history, lab results, and other information only available through directly asking the patient. Moving on. What do I know about the systemic effect of a fever?
Given the massive amount of information I could list here, I won't go into great detail, but just know that part of narrowing down (or sometimes expanding) your options for applicable nursing dx, considering the systemic effect of reported symptoms or history could include or eliminate options from the list of possible dx. In this case, the most obvious effects of a fever involve increasing the body's consumption of resources/energy by way of an increased metabolism, so I take this info and I run with it.. -->increased metabolic processes lead to an increase of waste products-->waste products have to be eliminated-->elimination of this kind, for the most part, involves the kidneys. Increased metabolism also requires fuel from natural stores (water, glucose, blood cells), which is transported via a vascular system undergoing stress of the increased demand.
---kinda getting my point? Do this step with as many elements of the patient assessment you believe are the most pertinent to both the short term and long term goals of care of the patient (the goals can change anywhere throughout this process). This thinking process is what lays the foundation of choosing nursing dx's from the big list. This step obviously takes the longest, especially if you're in need of critical thinking practice or if you need to review pathophysiology.
In this case, I would consider the systemic effect of diarrhea, and then I might consider the psychosocial implications of these symptoms (like stress, embarrassment, inability to go to work...). If I had any information from a medical history, specific medication list, or other physical complaints, I'd consider them in relation to the "big picture". Remember, everything listed and considered should take into consideration not just treating the disease process but the entire patient...that's what nursing is after all, a holistic approach.
Be sure to consider risks and complications that could present throughout the case. This serves to consider preventative measures to enact, or to prepare a plan to respond. This information is particularly helpful in patient teaching.
This step is really the meat of critical thinking. It's taking knowledge that you know from studying nursing theory, combining it with the facts of the patient situation/ailment and the assessment you've done, and translating it into appropriate diagnosis and plan of care. It requires abstract thinking, objective evaluation, and consideration of both real and potential factors.
3. Scour the big list of NANDA approved nursing dx's. You can only apply them to this patient if you're able to defend it with facts from the brainstorming you did in step 2
This step should follow a format similar to this:
[Nursing Dx worded as a NANDA statement] related to
[the medical diagnosis (careful, be sure this symptom is undoubtedly related to it, or it's not accepted as an appropriate defense) and the major OBJECTIVE signs and symptoms] as evidenced by
[subjective symptoms (patient behavior, pt's reports, and other non quantifiable data you've collected in the assessment)]
if your nursing dx/NANDA statement is "at risk for ____" this means you are diagnosing a potential problem. Potential problems don't exist yet, therefore there can't be evidence of the problem yet. Do not include the "as evidenced by" portion of the format above for at "at risk for___" NANDA statements.After you practice developing care plans more, you'll realize that most "at risk for" diagnoses are incredibly difficult to expand into a thorough plan of care and therefore should not be prioritized. Keep this in mind in your future of nursing, actual problems will ALWAYS be higher on the list of priorities than potential (a.k.a "at risk for") problems. Your plan of care should first and foremost address actual, current patient problems.
On to the list:
These are the dx's I find most applicable to the given patient scenario it would probably include more if there was more pt information provided...
- At risk for ineffective tissue perfusion r/t hyperthermia.
- at risk for compromised human dignity r/t diarrhea as evidenced by inability to control the urge to defecate before reaching the restroom. (this dx would only work if you could prove in your assessment that the patient had no control of his bowels and was also embarrassed by it)
- Bowel Incontinence r/t GI upset as evidenced by multiple episodes of uncontrollable diarrhea. (again, this dx can only be made if you have the assessment data to support that his episodes of diarrhea are uncontrollable, and you can't relate this symptom to the fever because there isn't evidence supporting a direct relation. No assumptions allowed in nursing dx).
- Diarrhea r/t frequent bowel movements of loose stool as evidenced by patient chief complaint.
- At risk for electrolyte imbalance r/t diarrhea (claiming an actual electrolyte imbalance problem would require patient labs like a CBC/Chem 10 panel, to quote as "as evidenced by")
- at risk for fluid volume deficit r/t diarrhea (not an actual problem until vital signs, labs, and physical s/s can prove it)
- at risk for fluid imbalance r/t fever
- at risk for acute confusion r/t fever
- Impaired comfort r/t diarrhea as evidenced by patients report that "[INSERT QUOTE ABOUT THE DISCOMFORT BROUGHT ON BY DIARRHEA EPISODES]"
-Imbalanced body temperature r/t diagnosis of fever of an unknown origin as evidenced by temperature reading of 101.9
- Hyperthermia r/t temperature of 101.9 as evidenced by patient reports of heat flashes and chills.
- At risk for impaired skin integrity r/t diarrhea (this, like many of the other "at risk"s listed above can be converted into actual problems [so you can drop the "at risk" at the beginning] if you can use collected data/evidence to support the presence of the subject. In this case, if you assessed the perineum/anus/butt as being red, swollen, tender to the touch, chapped, bleeding, etc, then you have evidence to support the presence of an actual skin integrity problem.)
- Ineffective thermoregulation r/t fever as evidenced by patient reports of "chills".
As you can see a couple of these are repetitive, but that's only because I was only given 2 symptoms and an active therapy to work with while considering the list of dx's. Because you have no further assessment data provided, a lot of them have to remain "at risk" problems until you can provide data that supports the presence of the actual problem (vital signs, lab work, history, pt complaints, etc)
Where you went wrong on your initial list is on your number 1: "infection r/t disease process as evidence by temp 101.9 and patient received with antibiotics". You made some common fundamental errors.
First, you cannot claim that there is an actual problem of infection. Nothing in the patient summary you provided supports that claim, especially not the medical diagnosis you reported was made as: "fever of unknown origin". Claiming infection would be an example of you using the symptoms (fever and diarrhea) to diagnose a medical condition
. While it isn't necessarily wrong to associate the presence of fever and diarrhea as probable indicators of an infection process, the correlation of these symptoms to that conclusion is not in your scope of practice as a nurse
This infection claim would need to remain an at-risk diagnosis until a medical diagnosis or positive lab culture confirms a bacterial colonization (which would be an infection with or without the need for a doctor to confirm it as a diagnosis).
Secondly, even if we were to ignore the fact that the infection claim was invalid, relating it to a "disease process" does nothing to provide evidence of the claim. Mostly because an infection IS a disease process. A disease process is also not an objective finding (unless it is specifically named by a doctor officially making a medical diagnosis).
Lastly, and probably the biggest thing wrong with the entire statement is the fact that you included "patient received with antibiotics" (which I'm sure is meant to read "pt treated with antibiotics") as evidence. You cannot use a treatment/therapy as evidence to the claimed PRESENCE of a problem
especially in the form of a prescription of antibiotics being evidence of the presence of infection, most simply because if you just look at the issue rationally, the wrong drugs get prescribed all the time, or drugs sometimes get prescribed for off-label purposes, simply possessing a prescription for any drug doesn't definitively mean you have the ailment said drug is meant to treat...but I guess that's really not the point. In nursing care plans, you really don't use the prescribed therapies to a problem as evidence to the existence of problem itself ever. It wouldn't make much sense.
In this specific case, the only useful way we could use the information regarding the patient being prescribed an antibiotic in relation to a nursing care plan would be to associate it with a RISK of infection r/t prescribed antibiotic therapy...the rationale behind this would be reasoning like: the risk antibiotic therapy poses on hospitalized patients for c-diff, the risk of a super infection from bacterial resistance or opportunistic infection exposure. The beauty of nursing diagnoses is that if you collect enough information from your patient, you could potentially qualify SEVERAL NANDAS. The key is having the information/data to back up any claim you make, especially if you're going to attempt to claim an issue as an active on-going problem, and always remember that we aren't doctors, we, as nurses, can't diagnose medical conditions/diseases, but we can come really really close.
I know this was a really really really long post, but I remember how frustrated I was in nursing school with trying to construct quality nursing care plans. If this helps you, great. If it doesn't, maybe someone else will benefit from some of the explanations. If you have any problems with formulating the rest of the care plan, let me know (I promise I won't be as long winded), after you make solid diagnoses, the plan of care is easy to blow through, at that point it's just listing the steps you'd take to solve or prevent the actual or potential problems (and in some cases citing literature to back you up, yaknow, evidence based practice), and then explaining how you would evaluate if you were successful in doing it...it all comes back to the basics of the nursing process. Have fun! I promise it will get easier to do this the more you are assigned to do it, and it doesnt mean they ever become less annoying to complete.