nursing diagnosis on my patient w/c diff

nurseprnRN, BSN, RN · Jan 21, 2013

I think you have gotten off to a excellent start. Your risk of dehydration is r/t to his diarrhea, though-- there are lots of infections that don't dehydrate ya :)

Yes, you can use more than one nursing diagnosis for one key assessment. Imagine: Can you have more than one nursing problem related to confusion? What else besides risk of injury? Acute and chronic confusion are also nursing diagnoses. Since your other "key diagnoses" appear to be medical diagnoses, I am assuming this is what your faculty wants, although it annoys me because it makes people assume that there is a list somewhere of medical diagnoses with a related list of nursing diagnoses, and this is beyond wrong. For the moment, however, let's recommend that you find some medical diagnosis that accounts for his nursing diagnosis of confusion (acute or chronic? specify).

Or, are you asking if you can have more than one cause for your nursing diagnosis of risk for injury? Of course-- amputation, opioids, and confusion can all increase his risk of injury. I'll bet that if he has had toes off already he is either a mountain climber who lost digits to frostbite, diabetic, or he passed out dead drunk and his dog ate them ::eeeww:: Ahem. Odds favor the diabetes :) ...and this is yet another risk factor for injury (why? what kind?).

I always strongly suggest that students get the NANDA-I 2012-2014 (most current issue) so they have the approved nursing diagnoses with the defining characteristics for each (these are the required elements, nonnegotiable) and the related factors (these are the possible reasons the defining characteristics are present). Free 2-day shipping from Amazon for students. You'll have it by Thursday. :)

Esme12, ASN, BSN, RN · Jan 22, 2013

This is my first care plan that I have made for my patient with c-diff. He was admitted to the hospital w/the medical diagnosis of dehydration, fall, syncope, & syncopal episode. He also has a history of great toe & little toe amputation on his right foot. I have to come up with 5 different key problems & nursing diagnosis. While taking care of him, I did notice that he had diarrhea, is on normal saline 1000 mL, infusing at 75 mL/hr. Iv looked great & all. So far, what I have come up with is 1)key problem of amputation w/a nursing diagnosis of impaired physical mobility; 2)key problem pain w/nursing diagnosis of pain, acute; 3)key diagnosis of c-diff w/a nursing diagnosis of risk of dehydration r/t infectious diseases, & 4) (which doesn't really fit to me) key diagnosis confusion w/a nursing diagnosis of injury, risk for. Do these seem plausible? My next question is, can I use the same key assessment twice, if I have a different nursing diagnosis for it each time? If not, do you have any suggestions for me? Uggh, I am so confused!

Is this your first care plan ever????

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

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.

Esme12, ASN, BSN, RN · Jan 22, 2013

ok.....now looking at your data.....What do we know?

patient with c-diff. He was admitted to the hospital w/the medical diagnosis of dehydration, fall, syncope, & syncopal episode. He also has a history of great toe & little toe amputation on his right foot. I have to come up with 5 different key problems & nursing diagnosis. While taking care of him, I did notice that he had diarrhea, is on normal saline 1000 mL, infusing at 75 mL/hr. Iv looked great & all. So far, what I have come up with is 1)key problem of amputation w/a nursing diagnosis of impaired physical mobility; 2)key problem pain w/nursing diagnosis of pain, acute; 3)key diagnosis of c-diff w/a nursing diagnosis of risk of dehydration r/t infectious diseases, & 4) (which doesn't really fit to me) key diagnosis confusion w/a nursing diagnosis of injury, risk for.

Now remember, FIRST.... what is YOUR assessment of the patient....not the patients medical diagnosis. What are their vital signs...What co-morbidities (other diseases) do the have? How do they other disease processes affect this patient now? hat 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.

Care plans are the recipe card for the patients care....what do you need to do now to help that patient be well. ....You NEED to have a care plan book....which one do you have? As I stated before I use....Ackley: Nursing Diagnosis Handbook, 9th Edition and...Gulanick: Nursing Care Plans, 7th Edition. It is also important to have a NANDA I reference....Nanda list as contributed by vickirn (assistant administrator) nursing diagnoses 2012 - 2014.pdf‎

Now tell me about your patient...what are they complaining of...What do they NEED....

If your patient was admitted with diarrhea and Syncope/Syncopal episode/Fall. Can diarrhea cause Syncope? What is dehydration? What are the signs of dehydration? What would be reflected in the vital signs of a dehydrated patient? Can being dehydrated cause you to pass out?

Your pateints pressing problem is that the patient has C-diff....What exactly is C-diff.....CDC - Clostridium difficile Infection - HAI. What are the complications or C-diff? http://www.mayoclinic.com/health/c-difficile/DS00736

So C-diff causes diarrhea....

NANDA I describes diarrhea as....the Passage of loose, unformed stools with t

Defining Characteristics

Abdominal pain; at least three loose liquid stools per day; cramping; hyperactive bowel sounds; urgency....

Related Factors (r/t)

Psychological: Anxiety; high stress levels

Situational: Adverse effects of medications; alcohol abuse; contaminants; travel; laxative abuse; radiation; toxins; tube feedings

Physiological: Infectious processes; inflammation; irritation; malabsorption; protozoal, gastrointestinal disorders

Therefore....your patient has a key diagnosis of Diarrhea R/T (related to) C-diff infection AEB (as evidenced by) passage of loose, unformed, foul smelling stools.

What else is important to your patient....that they got so dizzy that they passed out and fell. Can someone become so dehydrated that they pass out? What is dehydration? A lack of fluid in the body.

Your patient has Deficient Fluid volume .....

NANDA I defines deficient volume as....Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level.....which has

Defining Characteristics as......Changes in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness.....

caused by/Related Factors (r/t) Active fluid volume loss; failure of regulatory mechanisms

The patient has deficient fluid volume R/T diarrhea caused by C-diff (infectious agent) AEB syncope and .....what evidence do you have...what is the urine output what are the vital signs...what is your assessment.

You choose Impaired physical Mobility.......why do they have impaired physical mobility? How would being dizzy/syncopal have to do with their ability to move about safely? What does NANDA I say about impaired physical mobility....

NANDA-I Definition.

A limitation in independent, purposeful physical movement of the body or of one or more extremities

Defining Characteristics:

Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements

Related Factors (r/t)

Activity intolerance; altered cellular metabolism; anxiety; body mass index above 75th age-appropriate percentile; cognitive impairment; contractures; cultural beliefs regarding age-appropriate activity; deconditioning; decreased endurance; depressive mood state; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding value of physical activity; developmental delay; discomfort; disuse; joint stiffness; lack of environmental supports (e.g., physical or social); limited cardiovascular endurance; loss of integrity of bone structures; malnutrition; medications; musculoskeletal impairment; neuromuscular impairment; pain; prescribed movement restrictions; reluctance to initiate movement; sedentary lifestyle; sensoriperceptual impairments......Which of these fit your patient?

According to your assessment....What do you need to address next? pain? Confusion? Is this patients confusion acute or chronic?

Do you see where this is going? I was able to get all this information from what you provided, which wasn't a complete assessment/information. Which is what a care plan is supposed to do.....What do you think is next?

Esme12, ASN, BSN, RN · Jan 22, 2013

Waht will also help is using good information collection sheets........here are a few.

mtpmedsurg.doc

1 patient float.doc‎

5 pt. shift.doc‎

finalgraduateshiftreport.doc‎

horshiftsheet.doc‎

report sheet.doc‎

day sheet 2 doc.doc

‎critical thinking flow sheet for nursing students

student clinical report sheet for one patient

I made some for nursing students and some other an members have made these for others(daytonite).....adapt them way you want. i hope they help