nursing diagnosis relating to a pt with sepsis and cellulitis

vagray · Jul 18, 2013

sorry, a few nursing diagnosis** and i have to work one up to include interventions, outcomes, etc

nurseprnRN, BSN, RN · Jul 18, 2013

What do you have so far? You know that nursing dx come from assessment, and you can find them in the NANDA-I. You match your assessment findings with the defining characteristics for a given diagnosis, and you're all set. To use a medical example, if your patient has a low hematocrit, your diagnosis is anemia.

Where is your nursing assessment of her condition? Doing it by systems-- neuro, cardiac, pulmonary, integumentary, psychosocial-- is a good way to help organize your thoughts.

See, you are falling into the classic nursing student trap of trying to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $24 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

So... since we don't do your homework for you, tell us what you have already and we'll be pleased to help you.

vagray · Jul 18, 2013

So far, I have impaired skin integrity related to effects of cellulitis aeb draining blister on left calf, sore under left knee, erythema and warm to touch from left knee to left ankle.

Infection related to cellulitis aeb wbc of 32, heart rate of 110, rr of 28

ineffective tissue perfusion r/t ?? aeb decreased urinary output, low BP, HR of 110..

decreased cardiac output r/t bacterial infection/sepsis aeb low BP, low urinary output, high HR, hgb 10.5

I understand that infection is not a NANDA dx, however our instructor said we could use it if we can prove it..

Sun0408, ASN, RN · Jul 18, 2013

Sounds just like a pt we got in early tuesday morning.

Esme12, ASN, BSN, RN · Jul 18, 2013

Hello, I have to complete a careplan for a patient who was admitted to the ICU with left lower extremity cellulitis with sepsis. upon admission her BP was 93/32, temp 99.1, pulse 110. her weight is 339.6. she was complaining of left posterior knee pain from a small sore that had purulent drainage, her left leg is warm to touch, 2+ pitting edema, and erythema from the knee to ankle. she was given IV vancomycin 1 g x 3 and the next day her BUN was up to 37 and Creatanine to 4.2, her white count topped out at 32. her urine out put on her first day was 10ml with over 3000 input, but was increased the next two days. i worked with her on her 3rd hospital day and her leg swelling had decreased (now to the 2+) and was still warm and red. she had also developed two golf ball size blisters on her left calf which ended up fusing together and later in the day began to leak yellow, clear, non odorous fluid. by the afternoon, another blister had developed underneath the other. her BP was between 113/57 an d162/66, her o2 was 92% on 2 L via NC. Due to her heavy weight, her breathing is labored and she grunted on expiration and stated she had been for years. her RR was 28. towards the end of my shift, her breathing changed and she wound up being intubated and shipped out in critical condition. I still have to form a careplan and need help coming up with a few. Any help would be great! THanks!

Out of all of this information you see infection and skin impairment for your nursing diagnosis....... What about this story should concern you. If this was your loved one what would you want taken care of first what would concern you? what semester are you? What care plan book do you use?

This patient has impaired renal function.....with intake far greater than output...does a urine out put of 10ml alarm you? what should the minimal urine output be to show adequate renal perfusion? HINT it's 30cc/hr..........with the fluid overload are you sure that her tachypnea at rest and low O2 sat was from her weight and not fluid overload? What was her baseline O2 sat? Clearly...this patient was in resp distress that required intubation...grunting on expiration is a compensatory measure to increase positive end pressure (peep) to increase oxygenation? what did he lungs sound like what was her assessment.

care plans are all about the assessment.....of the patient. I know you have to start somewhere but it is so difficult to "get the picture" from a bunch of typed words.

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.

So in the future.........What is your assessment? What are the vital signs? What is your patient saying?. 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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.

check out this thread....https://allnurses.com/nursing-student...085-page2.html

Critical Thinking Flow Sheet for Nursing Students.doc

nurseprnRN, BSN, RN · Jul 19, 2013

So far, I have impaired skin integrity related to effects of cellulitis aeb draining blister on left calf, sore under left knee, erythema and warm to touch from left knee to left ankle.
Infection related to cellulitis aeb wbc of 32, heart rate of 110, rr of 28
ineffective tissue perfusion r/t ?? aeb decreased urinary output, low BP, HR of 110..
decreased cardiac output r/t bacterial infection/sepsis aeb low BP, low urinary output, high HR, hgb 10.5
I understand that infection is not a NANDA dx, however our instructor said we could use it if we can prove it..

Good ideas, except for the infection part. Your instructor is wrong about that, or, to be charitable, perhaps you misunderstood her. The point of NANDA-I is to have scientifically-validated nursing diagnoses. "Infection" is not a nursing diagnosis, it's a medical diagnosis. It is "proven" by all the things we know-- elevated white count, positive cultures, etc. Those are medical diagnostic criteria. Sure, we know them and recognize them, but still, "infection" is not a nursing diagnosis. Pull out your NANDA-I and show it to her. Infection can certainly be a related factor to a nursing diagnosis, though.

As to the ineffective tissue perfusion, you're right about that. How does that happen in sepsis? Why can someone have a fast heart rate but not get much in the way of BP out of it, when you and I would crank up our BPs a lot if we had faster heart rates? So... if she has that effect from her sepsis, what happens to the kidneys (and everything else)?

What does a hgb of 10.5 tell you about oxygen-carrying capacity? If someone has a hematocrit of 20 and an SpO2 of 99%, how does that compare to someone with a hct of 40 and a SpO2 of 99%? Which one carries more O2 to the cells?