Nursing Diagnosis for Pt. w/ CVA & UTI

DidiRN · Nov 16, 2013

Moved to Nursing Assistance Forum

virgolove34 · Nov 16, 2013

If it were my patient, I would focus on the recent stroke and elevated troponin levels. Elevated troponin levels are often correlated with myocardial damage. Was her CK-MB elevated as well? When you have myocardial damage, the heart doesn't contract efficiently and tissue perfusion decreases. When organs aren't getting perfused well, they start losing their function. So if the brain isn't getting perfusion, you're at great risk for stroke. I think focusing on the perfusion is more higher priority than the UTI. My fundamentals teacher always said, ask yourself "what can kill you first?"

lwhatley · Nov 16, 2013

First and foremost, and this is mostly because I read virgolove34's response before starting this reply, remain in your scope of practice at all times. As a nurse you are never allowed to make a medical diagnosis, but it's a common error when first learning how to develop a care plan, especially in complicated cases. There are grey areas to this rule, but in terms of this case, you do not have the authority to associate troponin conclusively with any degree of myocardial damage, but for arguments sake, lets say you could, just to bring me to my next point...even if you had the authority to conclusively diagnose some myocardial damage r/t elevated trop, to then go on to assert that the myocardial damage-->contractility decrease-->tissue perfusion decrease-->function loss/stroke warning...well...as much as admire the thought process involved in the example, in terms of it's appropriateness or relevance to nursing care plan development? Well, it's wayyyy to giant of a stretch filled with assumptions to become a priority focus, but I'll get to that in a sec.

Let's dive in to your case...

"My 78yr old Pt. came to hospital for recurrent dizziness, confusion and unstable blood pressure"

Great, right away we have a chief complaint, and while I'm sure you did a complete assessment with far more comprehensive information, the remaining information gives me at least a hint of the symptoms she is actively presenting with (dizziness, confusion, hypo/hyper BP). All of these symptoms, assuming the pt is reporting currently suffering from them, are active ACTUAL PROBLEMS (this is important later).

"Work up indicated UTI of course, but also revealed signs of a CVA(stroke). It says that it happened a few months ago. She also has elevated troponin level."

Even better, we've thrown a medical diagnosis into the ring (UTI). Keep in mind that the only way we can officially refer to this as a UTI in our care plan is if an M.D officially submitted it to the chart as a diagnosis. If not, we're only allowed to play with the elements of the work up that pointed in the direction of a UTI (ua+culture). This is frustrating for a lot of care plan writers because nurses are perfectly capable of drawing the same medical conclusion as a doc given the facts surrounding the presentation, but again, this all goes back to the scope of practice issue. We don't have the authority to interpret lab results in order to definitively diagnose a medical condition.

In the interest of idea flow, let's assume this UTI fact is an official medical dx submitted by the doc, meaning we get to refer to it as such if we want to use it later in the evidence/etiology portions of our plan. Next: signs of a recent CVA, bummer. I'm assuming these signs came from the interpretation of the results of an imaging study like a CT, which in the interest of our care plan, is an example of objective data. I know the buzzword "CVA/stroke" is what is making you question your priority belief system, but hear me out...

Strokes are bad-news-bears no doubt, but here's the thing, unless patients present to you actively suffering the effects of a stroke with all those beautiful s/s they beat into you at your BLS course, there's not much you can do about it at that second but take steps to prevent a recurrence in the future. In this case, there's literally nothing you can do, at that moment, to treat those signs of an approximately 2 month old stroke. That event and those CT results, in terms of how they can contribute to your current care plan development, are now only data to consider citing when supporting claims of mainly at-risk problems, since that past stroke is really only a sign that she is now susceptible to recurrent strokes in her future if we don't do some serious behavior modification, pt education, and maybe even some prophylactic medication prescriptions. The point I'm really trying to make here right now is that this CT result/evidence of result stroke we've stumbled upon is NOT an ACTIVE problem, and therefore, fails to make it to the top of the priority list...more on that in a sec.

Back to the labs we go. Elevated troponin, uhOh, what's that mean? Wait, don't answer that, that would be asking you to diagnose a condition by interpreting the lab value, let's rephrase: What body processes might contribute to the elevation of troponin, and what does that mean for my patient in the here and now in terms of nursing care to consider? See there? Just because I can't officially diagnose, doesn't mean I can't use my extensive knowledge of physiology to ride the diagnosis line like a tight rope. But before we jump on the "omg she is either having or has had a heart attack! Save the cardiac tissue!" bandwagon (talkin' to you virgolove34), take a breath and really think about the implications of the value. Our reflex reaction to troponin is of course to think our patient now qualifies for an M.I merit badge to wear with honor, and it's a good gut reflex to have, but go deeper. You may have to refer to your reference materials for this one, but 1. do you recall how long a troponin result remains elevated before trending back to normal? (psst 2 weeks) 2. What other conditions could possibly contribute to troponin elevation? (this one requires a little more heart nerdiness than the average nursing student cares to attain) Beyond it's helpful abilities to normally point towards an M.I dx, troponin can be elevated by anything that causes myocardial damage of any kind to any degree; so CHF, pericarditis, endocarditis, lymes disease, autoimmune diseases....the list goes on a little bit more than that, but I don't really feel like referencing my notes right now, but you get my point.

Even with all that information about what could be raisin' the trop lvl and potentially how long it's been since the trop took to climbing the ladder, we have to again remind ourselves that we are developing a nursing care plan for that patient that walked in complaining of dizziness, confusion, and unstable blood pressure as her actively bothersome problems to address. While it's important to understand what those diagnostic results could mean for her in regards to medical diagnoses and potential future care since we as nurses and doctors play on the same team, in regards to a nursing care plan, our priority will always be active, actual problems before potential problems.

So what's it all lead up to!?

Should my first diagnosis focus on the symptoms from the UTI(Impaired Urinary Elimination) or (Risk for Acute Confusion) or the the stroke(Ineffective Tissue Perfusion:Cerebral) although it happened a while ago?

So after all of that previously stated information, lets see if we can agree on a priority dx together given the key elements I emphasized earlier..

1. actual active problems trump potential problems (risks in the future)....which if we review how we broke down each of the biggest problems we're debating (including virgolove's guess), means we'll be eliminating the ineffective tissue perfusion: cerebral, the risk for acute confusion (but actually we're eliminating that because it's an incorrect statement given the pt's case), and anything else related to perfusion deficits until further notice.

So what we're left with is an actual medical diagnosis of a UTI, which means our patient is actively suffering from an infection. This is an actual, active problem. Would it be reasonable, in a 78 year old woman, to assume that some of her presenting symptomology might, in fact, be related to this infectious process? (we don't really HAVE to draw definitive conclusions, but it's helpful when writing up the list of applicable nursing dx what chunks of evidence help to defend what dx's...). and what happens to infections when left untreated? Septic shock.

Prioritizing one active problem does not mean we say "screw the rest"! Care plans have multiple diagnoses involved for that very reason, our goal is to look at the patient as a whole. So while I have spent this time fighting for the prioritization of a nursing dx r/t a response to an active UTI infection, because while virgolover has got a point about perfusion problems killing you faster than a UTI, she fails to consider the fact that the UTI, as an active problem, has more probability of turning perfusion into an actual problem by way of urosepsis, yaknow, septic shock? Attention to all applicable nursing dx's is required in order to deliver the best nursing care possible to our patient, so it's incredibly important to recall the other potential pathological processes that may very well be developing to become a problem, but we just can't assume they are full blown problems yet because we don't have the facts to back it up...so basically, my vote is for:

- At risk for shock r/t UTI as evidenced by acute onset of focal neurological deficits with fluctuating blood pressures.

but given those same references neuro def's and even stretching to include that past incidence of CVA, you could make a damn good case for an at risk for injury (or at risk for falls) r/t dizziness with history of recent CVA as evidenced by acute confusion...

in the event that you have any other cardiac related symptoms, history, or dx left unlisted from your assessment, you could easily make a case for a problem with decreased cardiac output or ineffective peripheral tissue perfusion or even fluid volume deficit...but that's only if you can better support either a CHF/HF cause (which requires formal dx to refer to it) or a dehydration element, all of which have the potential to invoke those presenting symptoms listed....

But now i'm getting tired and I feel like no one has even read this far.

Have fun with your care plan, you really won't be doing them much outside of nursing school. :-)

Esme12, ASN, BSN, RN · Nov 16, 2013

Welcome to AN! The largest online nursing community!

What semester are you?

You are falling into the same trick bag that all students fall into.....picking you diagnosis and trying to fit the patient into it......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.

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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.

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

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
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.

Now......Tell me about your patient.......What do they need? What do they c/o? What is your assessment? What is your patient saying? 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.

Esme12, ASN, BSN, RN · Nov 16, 2013

To start........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/care map: ADPIE.

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Ok real life application paraphrased from our Beloved Daytonite.....

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it..............a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated.

What you have just done is.......

Step #1 of the nursing process--performed an assessment. You determine that you have a flat tire.

You have just done.....

Step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do i do?" You are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. .......Good thing you took that class in how to do simple maintenance and repairs on a car!

You have just done.....

Step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work.

You have just done.....

Step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive....... Good....... Everything seems fine. The spare tire seems to be ok and off you go and on your way. You have just done

Step #5 of the nursing process--evaluation (determined if your goal was met).

Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

critical thinking involves knowing:

the proper sequence of steps in the nursing process
the normal anatomy and physiology of the human body
how the normal anatomy and physiology are changed by the medical and disease process that are going on
the normal medical treatment that the doctor(s) are likely to order to treat the medical and disease process going on
the nursing interventions that you have learned for the things that support the medical and disease process that is going on
making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are

check out this thread as well https://allnurses.com/nursing-student-assistance/care-plan-nursing-887917.html

Esme12, ASN, BSN, RN · Nov 16, 2013

Hello, My 78yr old Pt. came to hospital for recurrent dizziness, confusion and unstable blood pressure. Work up indicated UTI of course, but also revealed signs of a CVA(stroke). It says that it happened a few months ago. She also has elevated troponin level. Should my first diagnosis focus on the symptoms from the UTI(Impaired Urinary Elimination) or (Risk for Acute Confusion) or the the stroke(Ineffective Tissue Perfusion:Cerebral) although it happened a while ago? Any help would be appreciated.

You have told me your patients medical presentation/diagnosis.......now tell me your assessment of your patient

TCCD2016 · Nov 17, 2013

I haven't started classes yet, but am learning just from reading these replies. This site is so good.

nurseprnRN, BSN, RN · Nov 22, 2013

Prioritizing is something you'll be learning all the way along. However: Never let anyone tell you that a risk-for nursing diagnosis is somehow less "real" or less "actual." When one of a nurse's first obligations is to maintain patient safety, the reason for that becomes clear. Your NANDA-I 2012-2014, which you should have by now even if your faculty forgot to put it on the bookstore list, has a whole section devoted to safety nursing diagnoses, and most of them begin "risk for..." I challenge anyone to tell me a valid reason why, say, "risk for aspiration" isn't a more serious diagnosis than "constipation." (Think Maslow's hierarchy of needs if you need to think about this some more.)

There is, however, an actual nursing diagnosis, "Risk for shock." Risk factors for this nursing diagnosis (at least one of which you must identify in your assessment, which includes chart material/medical diagnosis) include hypotension, hypovolemia, hypoxemia, hypoxia, infection, sepsis, and systemic inflammatory response syndrome. Your patient is reported to have a urinary tract infection. You get to decide whether her symptoms are serious enough that shock is a more foreseeable occurrence than anything else, thus making it your priority.

(Also never let anyone tell you that you cannot use a medical diagnosis as a related/causative factor for the defining characteristics to make a nursing diagnosis, Not true at all, but you have to use the ones approved in NANDA-I 2012-2014 all the way anyhow. $29 at Amazon, free 2-day delivery for students. Never get screwed up on this sort of thing again.)

However, as for the rest of it. There are three confusion-related nursing diagnoses: Acute confusion, chronic confusion, and risk for confusion. Your patient isn't at risk for confusion, she IS confused, according to your original description. Therefore you look at the defining characteristics listed for each of the other two, and determine which is your patient's problem, and look at the related factors (causative factors) to see which apply. What can you foresee as problems developing if her confusion isn't properly managed? Is that happening right now? How will you reevaluate her response to your nursing interventions? Now you're planning.