Another nursing diagnosis post (sepsis)

[guavaturtle]

Hello to all the nursing students and nurses smarter than me (seems like everyone these days)...I'm writing my care plan and my NANDA seems too....undetailed? Here's a quick lowdown on my patient.

72 year old man with reoccurring UTIs. Upon admission exhibited weakness, fever @101, BP 140/95 and pulse ox 86%. (his WBC count was within normal range) Urine samples were "cloudy" with evidence of WBCs and blood.

I figured that since there is a potential for urosepsis stemming from his UTI/indwelling catheter, would it be lame just to say ...

Risk for infection (sepsis) r/t UTI/indwelling catheter?

I wasn't sure if I should write any a.e.b, even though I could stick in (fever,chills, low O2 sat). Wasn't sure if it belonged there....because he technically doesn't "have the infection yet"

I also chose risk for infection because well.....he already has a UTI, but I found it important to make sure that infection did not spread into the bloodstream, given his vital signs and medical history of cancer and diabetes...which makes him increasingly at risk to sepsis.

Any recommendations or slaps in the face would be greatly appreciated, thanks a ton!

[guavaturtle]

Bump?

[ckh23, BSN, RN]

I would use something else because he is not at a risk anymore because he does have an infection and actually meets the criteria for sepsis. You could use something like Impaired gas exchange aeb by pox 86% r/t infection.

[Rhody34]

If you're doing a "risk for" diagnosis- you wouldnt have r/t or aeb... You would have Risk for Infection: Risk Factors: and then would list the risks. This is true for all risk for diagnoses. But I agree witht he previous poster- he's not at risk- he has an infection. Make a problem list- then choose the priority to make your Nursing Diagnosis. Utilize your books- then post what youve come up with. Good luck!

[shelbias]

Agree with ckh23. Can't use a RF infection NANDA if he already has an infection. The impaired gas exchange is a good dx. Can also use RF falls due to physical weakness.

No need for the AEB part for RF diagnoses because the problem is not there yet, so nothing would manifest just yet. :)