Question about Nanda dx

Esme12, ASN, BSN, RN · Apr 13, 2014

Care plans are all about the patient assessment.

Here is my standard speech.....

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.

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 from our Daytonite

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.

Another member GrnTea say this best......

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.

Now before I can help you I need your assessment of the patient. Is this your only diagnosis?

takingcare19 · Apr 13, 2014

Here are some other data:

IV right hand which wasn't infusing solutions.

Neuropathy pain was rated at 4/10, then later in the afternoon after scheduled pain meds at 2/10.

Foley cath since 2/19

He was admitted for his pressure ulcer on his sacrum. He also happened to have an ulcer on each heal that he says he has been fighting "for a long time"

His left hand is fixed in a partially closed position, but he told me OT was working with him.

He said he lost all strength in his legs since he was hospitalized.

He also told me he has no idea when he could go back to his nursing home, he is just there for ride.

He is also on 20 medications, 6 of which I noticed had adverse affects on the liver.

So my other 2 dx are:

Risk for infection r/t foley catheter.

Risk for impaired liver function r/t polypharmacy of potentially liver damaging drugs

takingcare19 · Apr 13, 2014

Oh, and abnormal labs are:

low RBC

low h&h

high RDW

Esme12, ASN, BSN, RN · Apr 13, 2014

YOUR assessment. What did you see? what did you hear? What were the vitals? Was his skin intact? Is he confused AEB I'm here for a ride? What care plan resource are you looking at for your ND definitions?

If this was your family member what do they NEED? What would you like the staff to pay attention to?

You are in the typical problem of nursing students of choosing a diagnosis and trying to fit your patient into it.

Esme12, ASN, BSN, RN · Apr 13, 2014

Why has he been in bed for 2 months? What are his other co-morbidity?

Neuropathy pain was rated at 4/10, then later in the afternoon after scheduled pain meds at 2/10.
Foley cath since 2/19
He was admitted for his pressure ulcer on his sacrum. He also happened to have an ulcer on each heal that he says he has been fighting "for a long time"
His left hand is fixed in a partially closed position, but he told me OT was working with him.
He said he lost all strength in his legs since he was hospitalized.
He also told me he has no idea when he could go back to his nursing home, he is just there for ride.
He is also on 20 medications, 6 of which I noticed had adverse affects on the liver.

So your patient has pain.

Your patient has Impaired Comfort.

Your patient has Impaired Tissue Integrity

Your patient has Impaired Skin Integrity

Now look up in your NANDA resource what the definitions are and how they apply to your patient....then tel me what you think your diagnosis should be.

takingcare19 · Apr 13, 2014

Well, for the life of me, I can't find where his vitals are! *sigh* (Half the time I can't even find my own head!) But, I do remember there wasn't anything abnormal about them. He is on room air. He never c/o pain, but when asked about his peripheral pain, he rated 4/10. He was asleep every time I walked in the room, except for when he was eating and he woke up easily enough. His mood was appropriate, he never showed too much emotion regarding anything, although he took a while to open up to me. He was oriented x3 and alert. Speech clear. Regular respirations. No c/o diarrhea or constipation. No c/o n/v. Urine was clear and yellow. I didn't note any swelling in his legs, feet. Minus where his wound bandages were, his skin appeared intact. He had just had a flap for his sacrum ulcer with 2 jackson pratt drains, which I assessed and found small amounts of red drainage. His IV was intact, no s/s of infiltration. No c/o pain.

He never had a want or need from me or a complaint to tell me! He was very shy but sweet to talk to. I found he battled depression from his 2 previous marriages ending. That 7 years ago, he had to go on disability from his job and moved to a nursing home.

takingcare19 · Apr 13, 2014

I considered impaired comfort level r/t pain, but my teacher says to be careful about pain as if it is manageable by medications, it isn't a dx.

Would risk for infection r/t foley and IV be appropriate? I know I had run by risk for infection r/t foley to my teacher and she had seemed to like that one.

He said he had lost strength at his nursing home and was in a wheelchair, and then brought to this hospital b/c of an odorous sacrum ulcer. He had mentioned he lost strength in his legs and I asked about physical therapy and he told me they came to his room and worked with him there.

Is this tissue integrity r/t bed bound? I try to stay away from wounds; my teacher has told us if it is already being addressed by the wound care nurse, then it is not a dx.

I've just gone my semester thinking I am making progress and am just beat down. I haven't grasped this yet and I'd love to blow my teacher away. =]

takingcare19 · Apr 13, 2014

I am using Ackley and also Myers. I didn't feel he was confused. He was just very complacent about being there. He didn't express excitement to go home. He didn't express frustration for being there for so long. He just was.

If this was my family member, I would be concerned about infection and his strength. But again, strength seems more of therapy rather than me.

Esme12, ASN, BSN, RN · Apr 13, 2014

Well according to NANDA impaired comfort is ....Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and sociocultural dimensions

Defining Characteristics

Anxiety; crying; disturbed sleep pattern; fear; illness-related symptoms; inability to relax; insufficient resources (e.g., financial, social support); irritability; moaning; noxious environmental stimuli; reports being uncomfortable; reports being cold; reports being hot; reports distressing symptoms; reports hunger; reports itching; reports lack of ease or contentment in situation; restlessness

I like to nap a lot, it makes the day go by faster."
Has been in a room in bed for almost 2 months.
Regarding his girlfriend, stated, "She can't visit, she is in a nursing home and health wise worse off than I am."
Children, grand kids and girlfriend all live in [in a town more than 1 hour away].
Stated "I'm really shy, but the more we talk, the more I open up"
Expressed uncomfortable feelings regarding when "people speak down to me. I'm 6'1", I'm not used to it, I'm usually the one looking down while standing in conversation. I feel anxious sometimes."

This man has been alone in a room in bed for almost 2 months, talked about his family but never mentioned if they visited, sleeps all day, requests his door be kept shut all the time, and keeps the TV turned up super loud.

I disagree with your instructor for you could use chronic pain but she is the boss. I slo disagree that if it is being cared for it isn't a concern His heel brakdown will continue to be a problem as long as he is in bed and needs constant intervention to prevent worsening.

If his had is contracted has he had a CVA? How does he do with ADLs does he need help?

So he has had a fresh surgical procedure?

He had just had a flap for his sacrum ulcer with 2 jackson pratt drains, which I assessed and found small amounts of red drainage.

Sure he has risk for infection....and that is a good risk for diagnosis. but is this all this patient needs? I think with a fresh surgical procedure and 2 drains pain would still be an issue and a new one. Did you do drsg changes? how did the suture line look?

Esme12, ASN, BSN, RN · Apr 13, 2014

I use Ackley as well.....He has also mentioned anxiety. Maybe Deficient Diversional Activity. Hopelessness. He definitely has Impaired physical Mobility.

Powerlessness.

Impaired skin integrity...Altered epidermis and/or dermis

Defining Characteristics

Destruction of skin layers; disruption of skin surface; invasion of body structures

Related Factors (r/t)

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

takingcare19 · Apr 14, 2014

Risk for infection r/t Foley catheter aeb prolonged insertion.

Patient remains free of infection aeb:

1. Normal vital signs

2. Absence of discharge or pain at insertion site.

3. Absence of cloudy or blood tinged urine.

Interventions:

1. Maintain asepsis for catheter care.

2. Observe and report signs of infection at insertion site.

3. Assess temperature, report if higher than 100.5 F

4. Request urinalysis to be ordered if signs of infection noted.

Risk for impaired liver function r/t polypharmacy of potentially liver damaging drugs.

Patient will retain normal liver function aeb:

1. Have normal liver enzymes, serum, urinary bilirubin levels, wbc, rbc.

2. Be free of jaundice, pruritus, bruising, petechiae, gastrointestinal bleeding, hemorrhage.

3. Be oriented to time, place, person.

4. Be free of cardiovascular and/or renal compromise: fluid retention, peripheral edema, ascites, decreased urinary output, changes in BUN and creatinine levels.

5. Be free of abdominal tenderness/pain and have normal colored stool.

Interventions:

1. Watch for signs of liver dysfunction: jaundice of eyes or skin, pruritus, gastrointenstial bleeding, infections, increasing abdominal girth, fluid overload, sob, mental status changes, changes in color of stool, changes in urinary function con current with increased serum and urinary bilirubin levels.

2. Evaluate liver function test.

3. Monitor for signs of emorrhage, especially in upper GI tract.

4. Monitor for signs of electrolyte and acid-base imbalances, especially hyperkalemia, hypoglycemia, and metbolic acidosis.

Impaired (or altered?) comfort r/t peripheral neuropathy aeb c/o pain at 4/10.

Patient's level of pain decreases aeb:

1. Provide evidence for improved comfort compared to baseline.

2. Perceived level of pain is at an acceptable level for patient.

3. Identify strategies to improve and/or maintain acceptable comfort level.

Interventions:

1. Assess current level of comfort.

2. Enhance feelings of trust between patient and health care provider.

3. Assist patient to understand how to rate their current state of holistic comfort, utilizing institution's preferred method of documentation.

4. Provide distraction techniques such as music, tv, or games.

5. Encourage early mobilization and provide routine position changes to decrease physical discomforts associated with bed rest.

Question about Nanda dx

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