Priority nursing diagnoses

  1. 0
    good morning everyone!

    i was in the icu during clinicals over the weekend and had a gentleman with renal failure, dm ii, dehydration, hyperkalemia (in the 7's!!!). when i came in on sunday, he looked awful. bp was 72/40, pallor, etc. i called the doc and he ordered a stat troponin. it came back as 5.45 (the day before it was <0.10). it turns out that he was having an acute mi.

    many of my nursing interventions revolved around keeping him calm and as pain free as possible. we couldn't push morphine or give nitro d/t his bp being so low.

    the careplans i had completed went completely out the window because they were no longer applicable because of his deteriorating state. i am re-writing them and have the following:

    priority #1: decreased cardiac output due to altered contractility; hyperkalemia associated with cardiomegaly, renal failure and acute mi.

    priority #2: imbalanced fluid and electrolytes due to hyperkalemia and hypocalcemia associated with chronic renal failure.

    priority #3: fear and anxiety due to symptoms being experienced with mi and being transferred to an unfamiliar environment associated with mi.

    do you feel that these are in the correct order? i did every single intervention i could do increase his cardiac output and try to correct his imbalanced fluid and electrolytes. but, i barely left his side other than to get meds and items to improve comfort. we are not permitted to use acute pain as a nursing diagnosis (it's the rule at my college because they feel we should be concentrating on more "difficult" diagnoses).

    if anyone would mind looking them over and provide feedback, please let me know (hint, hint daytonite).

    thanks so much,
    dani
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  4. 15 Comments so far...

  5. 3
    yes, they are in the correct order.

    i do have a problem with the way your nursing diagnostic statements are worded. are you supposed to have 3-part nursing diagnoses? or, just the nursing diagnosis itself and nothing more? is this the way you have been instructed to write your nursing diagnostic statement? did you use a nanda reference?
    decreased cardiac output due to altered contractility; hyperkalemia associated with cardiomegaly, renal failure and acute mi.
    you could only use the medical diagnoses of cardiomegaly, renal failure and acute mi if you include them with the related factor as "secondary to" the related factor (also "due to"). hyperkalemia is a symptom. i would have written this as:
    decreased cardiac output related to altered contractility secondary to (or due to) cardiomegaly, renal failure and acute mi as evidenced by [what are your supporting signs and symptoms, or defining characteristics? hyperkalemia is not one of them as it belongs with your next diagnosis.] [color=#3366ff]decreased cardiac output
    imbalanced fluid and electrolytes due to hyperkalemia and hypocalcemia associated with chronic renal failure
    there is no actual nanda diagnosis of imbalanced fluid and electrolytes. however, if this is one that your nursing program has allowed be sure your patient has the signs and symptoms (defining characteristics) of it. also, what is the underlying etiology of the fluid and electrolyte imbalance? look at the related factors of excess and deficient fluid volume as a guideline ([color=#3366ff]excess fluid volume and [color=#3366ff]deficient fluid volume). they are generally fluid volume loss or intake, failure of regulatory mechanisms, or renal dysfunction is also another one. so, i would tend to word this as:
    imbalanced fluid and electrolytes related to failure of regulatory mechanisms secondary to (or due to) chronic renal failure as evidenced by [hyperkalemia and hypocalcemia and any other supporting signs and symptoms, or defining characteristics?] i would list the actual potassium and calcium levels as well as any signs and symptoms of these conditions that the patient had.
    fear and anxiety due to symptoms being experienced with mi and being transferred to an unfamiliar environment associated with mi
    you've combined two nursing diagnoses together. these could be separated since fear (fear) is one nursing diagnosis and anxiety (anxiety) is another. "experiencing an mi" and "being transferred to an unfamiliar environment" are symptoms, or defining characteristics that you would have picked up during your assessment of the patient and belong in the aeb (as evidenced by) part of your diagnostic statement. these are the things that your nursing interventions would address. your actual related factors (etiologies) of the fear and anxiety have to do with things like learned responses, being separated from support systems during stressful situations, situational crisis, a change in health status, etc. if you have a nursing diagnosis book read the list of related factors under the diagnoses of fear and anxiety to see what i am talking about. otherwise, you will find a listing of them in the two links i've give you above to the ackley/ladwig care plan constructor website nursing diagnosis pages. i would suggest you separate those into two nursing diagnoses. you can include interventions for pain under either one of these two diagnoses.
    anxiety related to situational crisis secondary to experiencing an mi as evidenced by [look at the defining characteristics listed for anxiety]

    fear related to being hospitalized secondary to experiencing an mi as evidenced by [look at the defining characteristics listed for fear] - are you sure this is what you want the diagnosis of fear to reflect? most people who have had an mi fear having another mi and dying. there is a specific diagnosis for this: death anxiety
    hope that helps. if you still have questions, just ask.
    surviveslu, fathernurse2b, and Eirene like this.
  6. 0
    Daytonite, thank you so much for your help. It all makes sense to me now. I seem to always get messed up on the wording in the core of the nursing diagnoses.

    I do have one other question. In my nursing plan book, it states "Risk for imbalanced fluid and electrolytes" (Ulrich/Canale) is a nursing diagnosis (not imbalanced as I orginally wrote). Could that diagnosis still be applied to this nursing care plan since it is an actual problem and not an "at risk" problem?

    "Risk for Imbalanced Fluid and Electrolytes related to failure of regulatory mechanisms due to chronic renal failure as evidenced by hyperkalemia (7.9 mEq/L) and hypocalcemia (6.5 mg/dl)."
    Thank you so much for your help.

    Always, Dani
    Last edit by Eirene on Oct 30, '07 : Reason: scatterbrained writing
  7. 1
    the construction of the 3-part nursing diagnostic statement follows this format:
    p (problem) - e (etiology) - s (symptoms)
    where
    p is the nursing diagnosis - e is the nanda related factor - s is/are the nanda defining characteristics
    and you can also write
    p (nursing diagnosis) secondary to a medical diagnosis to help clarify the underlying etiology if you like, but it is not always necessary - e (related factor) - s (defining characteristics)
    this is why you need a nursing diagnosis reference to help you in putting these statements together as well as making sure that you have the right symptoms going with the right nursing diagnosis. a doctor doesn't erroneously call hematuria, cloudy and foul smelling urine, and a urine dip stick that is positive for bacteria a bladder obstruction. it is a urinary tract infection and it can be verified by checking a resource that lists the symptoms of a uti. you want to do the same when you choose a nursing diagnosis. check a nursing diagnosis reference book to see that the nursing diagnosis you want to use lists some of the same symptoms that your patient has (which you found during your assessment). that's the beauty of what the nanda taxonomy has done for us. want to know what the symptoms of dehydration are? look at the defining characteristics that nanda has listed under deficient fluid volume.

    you can't use a "risk for" diagnosis for an actual problem. a "risk for" diagnosis is an anticipated problem that doesn't exist but is expected to potentially occur. the risk factor (there are no related factors) for risk for imbalanced fluid volume is "scheduled for major invasive procedures". it's definition is "at risk for a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid. this refers to body fluid loss, gain, or both." (page 93, nanda-i nursing diagnoses: definitions & classification 2007-2008). that doesn't fit the profile of your patient. are you asking if you can just remove the risk for part of the diagnostic statement and use imbalanced fluid volume as your nursing diagnosis? i suppose you could, but what would you use as your defining characteristics and related factors? there are already two nursing diagnoses that cover actual fluid volume problems: deficient fluid volume and excess fluid volume. you can't have both existing at the same time! you'll either have one or the other.

    also, with "risk for" diagnoses, you can't have defining characteristics. why? because the defining characteristics are actual symptoms that a patient has. you determined this from your assessment. but these are anticipated problems so no symptoms of any problem exist yet! to use the diagnosis you are proposing, the only way you can write it, for example, is
    risk for imbalanced fluid volume related to open heart surgery to be done tomorrow
    Eirene likes this.
  8. 0
    daytonite, again-- thank you so much for your time. i wish i knew you so i could give you a big hug for helping me.

    i think the problem lies with me and the way my nursing school requires our careplan format. from what a previous instructor told me, we're using the old 1980's format on that long sheet of paper. do you know what i'm talking about? not many other nursing schools from other colleges do. we don't use nic and noc outcomes. i think that's why i'm so darn confused.

    i know understand why i cannot use the "risk for" diagnosis.

    i do have one more question according to my patient. he had all of these issues, but was admitted with renal failure, dehydration, and hypokalemia. his was intake was way more than his output and he was retaining fluid somewhere because he constantly gained weight. there was no edema on assessment and his skin turgor was poor. no symptoms of ascites. where in the world was his fluid going? i know his i and o's were accurate because he had a catheter in. that's why i'm so stumped on what nursing diagnosis to use; fluid volume deficit or fluid volume excess? i'm so darn frustrated with this.

    thank you so very much. i sincerely appreciate all of your help.
  9. 3
    don't chastise yourself. this concept is not easy to grasp. i really didn't understand it fully until well after i had graduated and was doing care plans at a workplace.

    think of the care plan format as just that--a way to present it. it is still the problem solving process. the actual format is just the physical way it is presented. there are care maps (concept maps) which are picture boxes. there are critical pathways which are the nursing interventions presented in a day-by-day event format. and, there is a kind of traditional chart where you have columns of information. they all incorporate the basics of the nursing process. the first 3 steps (assessment, problem determination, planning) are the most important because those are the guts of your care plan.

    nic and noc are fancy names that a bunch of professors over at the university of iowa came up with. they are doing research on them and getting their phds in the process. nics and nocs (i love saying that out loud!) are nothing more than lists of interventions and outcomes (goals) that they came up with and that they have been able to cross match with the nanda nursing diagnoses. these people work hand-in-hand with nanda. one of their reasons for doing this, get this, is to code and store these things in computers so they can be easily retrieved. have you heard the expression "canned care plan"? well, that is what these things were partly developed for. it is also partially because advanced care nurses and other ancillary healthcare practitioners have to have a way to bill for their services which are done by computer, and also because the healthcare industry as a whole is moving toward reducing the patient medical record to electronic storage--no more paper records are their goal--and they decided long ago that they wanted a systematized way to store the nursing care plan. that is part of the reason that nanda came into existence. shoving this stuff down working nurses throats just happened as facilities became computerized. when nursing instructors saw the rationale behind the use of nursing diagnosis it started to catch on in educational circles. when i went to school back in the 70s our care plans didn't use nursing diagnoses. we just listed patient problems that we found during our assessments. some smarty pants realized that some of the symptoms grouped together and could be lumped together with similar interventions. thus, a diagnostic label could be slapped onto them--thus, nanda stepped in. since i have also been a medical coder (coding medical diagnoses from doctor's discharge summaries for payment of medical bills) i think that what nanda is trying to do is eliminate the problems that medical coders have had with the coding of medical diagnoses. you see, there really is no taxonomy of medical diagnoses like nanda has created for nursing diagnoses. in a way, nanda has made nursing diagnosing pretty cut and dry. you merely have to know what your patient's symptoms are and check them against a nanda reference. bingo! you've got your diagnosis. it's not that easy in the medical diagnosis world. then coding medical diagnoses can be a nightmare because a doctor can use a medical diagnosis and put all kinds of other symptoms in his documentation that have coders scratching their heads. their problem is they have to have a valid medical diagnosis to match the procedures and supplies that are used or the insurance companies won't pay for the stuff.

    if you truly want a bit of a cheat and want to see the nics and nocs, there are complete listings of them in these publications:
    • nursing interventions classification (nic), by joanne mccloskey mccloskey dochterman, gloria m. bulechek, gloria m. bulechek. cost is $49.95.
    • nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean maas. cost is $49.95.
    otherwise, your nursing textbooks should have nursing interventions in them. outcomes are really quite rational. they are the opposite of your problems and symptoms with specific measurements on them as well as time limits. to formulate them you have to know some of the underlying pathophysiology and how the body heals and corrects it's imbalances to know how fast you can expect an intervention to work.

    renal patients are funny ducks. when they have dialysis the techs usually pull off water during a treatment. these people don't usually make any urine, so the water goes into the intracellular spaces. yes, it is a fluid volume excess. you won't often see the usual outward signs. the fluid is pulled off in two days with the next treatment. but, look at their electrolytes. the swelling of the tissues is also very subtle. it's more of an anasarca (all over the body) and it's hard to notice if you've never seen the patient in their normal state. so, ask the patient next time, have you noticed places in your body where you are swelling since you've been on dialysis, and where are they? weight gain is a symptom that is valid in order to use the nursing diagnosis of excess fluid volume and you have that symptom. you need to understand that you don't need to have all the defining characteristics that are listed under a nursing diagnosis. as long as the patient meets the criteria for the definition of the diagnosis and has one or more of the symptoms and at least one of the related factors, you are good to go in using it. some of the nursing diagnoses are kind of broad in their scope of use, but not all. one that is not is decreased cardiac output. the airway ones are not either.

    i used to work on a renal unit and i started asking the long term renal failure patients about their lives and got some interesting answers. most of them told me that they often were nauseated and that they never felt well or they never felt normal like they did before they went into full blown failure. that was a eye opener to me who was healthy all my life. it was a great learning experience. when we had rf patients who got very confused or obtunded i would ask their relatives what the person had been like before the rf and the stories i heard would have made you cry. these chronic diseases bring people down in the worst way sometimes. what i learned is not to be fooled by a patient seeming to act normally. we do things by routine. i have learned over the years to take time to sit and talk with people who are willing to talk about how their chronic disease has affected their lives. you will be amazed at what you hear. and, now, i find myself in that situation every day as my health declines. not many healthcare workers are really interested in listening to what i'm trying to tell them. i "look" fine to them. inside i feel like a mess. a lot of nurses just don't "get" that. and, this is what nurses are supposed to be doing--attending to people's adl problems. that's what we do. but many forget that in the excitement of carrying out medical orders. we nurses are about the person and how they function in their environment, not the medical orders. that's where we differ from medicine.

    sorry for the lecture. hope i answered your question satisfactorily.
    gayleraff, grenada, and Eirene like this.
  10. 0
    daytonite,

    i am so sorry that i didn't thank you sooner. with your help, i passed my careplans with flying colors and the course with an a! i only have 2 quarters left to go.

    i loved your lecture. because you share your stories, i feel that i am going to be a better nurse.

    always,
    dani
  11. 0
    Woo Hoo! We Ohioans rock! Good for you!

    Hope you aren't snowed in yet. It's cold out here in LA too in case you might think the west coast weather is better. The leaves have turned colors and are falling off some of the trees that aren't semi-cactus. We just don't get the snow. We will, however, get winter rain.

    Enjoy your holiday break.
  12. 0
    When do you use 'secondary to' after related to in a nursing diagnosis?
    Thanks for clarification!
  13. 0
    Quote from Jaxs
    When do you use 'secondary to' after related to in a nursing diagnosis?
    Thanks for clarification!
    When you want to place a medical diagnosis in a nursing diagnostic statement to help clarify on the etiology of the nursing problem. For example, Impaired Gas Exchange R/T ventilation perfusion balance secondary to viral pneumonia AEB abnormal blood gasses.


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