basic Nursing DX help...

[windmill182]

"Henry is diagnosed with PCP. Vital signs are BP 127/65, pulse 70, respiratory rate 25, temperature 101.7oF & O2 sat= 90%. Henry's admitting orders include IV sulfamethoxalone to treat the PCP, acetaminophen for fever, oxygen at 2 liters via nasal cannula. "

Question, when you are doing nursing diagnoses can you do them even if admitting orders have already been addressed to treat the problem? For instance, the above patient has a fever, but was already prescribed acetaminophen. Can you still do a Nursing Dx for hyperthermia?

Im sorry if this is a silly question. I am very very very new at this...And my instructors can be challenging to get help from (thats a whole other post, lol)

I was wanting to do Hyperthermia related to (illness?) (invading infection?) as evidenced by temperature of 101.7oF. Does that sound right? I just didnt know if that's okay considering they already prescribed acetaminophen... Obviously, you want to treat the patient with nursing interventions too, right?

I would also do one for the respiration/oxygen problem if its okay to do a dx on something that is already being "treated"

I really appreciate the help.

[grantz]

"Henry is diagnosed with PCP. Vital signs are BP 127/65, pulse 70, respiratory rate 25, temperature 101.7oF & O2 sat= 90%. Henry's admitting orders include IV sulfamethoxalone to treat the PCP, acetaminophen for fever, oxygen at 2 liters via nasal cannula. "

Question, when you are doing nursing diagnoses can you do them even if admitting orders have already been addressed to treat the problem? For instance, the above patient has a fever, but was already prescribed acetaminophen. Can you still do a Nursing Dx for hyperthermia?

Im sorry if this is a silly question. I am very very very new at this...And my instructors can be challenging to get help from (thats a whole other post, lol)

I was wanting to do Hyperthermia related to (illness?) (invading infection?) as evidenced by temperature of 101.7oF. Does that sound right? I just didnt know if that's okay considering they already prescribed acetaminophen... Obviously, you want to treat the patient with nursing interventions too, right?

I would also do one for the respiration/oxygen problem if its okay to do a dx on something that is already being "treated"

I really appreciate the help.

I suggest you do the one with oxygen problem. Because in the interventions you provided there's no intervention addressing to the O2 problem. So when don't make a problem in O2 right? Like Ineffective Airway Clearance r/t retained lung secretions as e/b O2 sat of 90 %

[xtxrn, ASN, RN]

"Henry is diagnosed with PCP. Vital signs are BP 127/65, pulse 70, respiratory rate 25, temperature 101.7oF & O2 sat= 90%. Henry's admitting orders include IV sulfamethoxalone to treat the PCP, acetaminophen for fever, oxygen at 2 liters via nasal cannula. "

Question, when you are doing nursing diagnoses can you do them even if admitting orders have already been addressed to treat the problem? For instance, the above patient has a fever, but was already prescribed acetaminophen. Can you still do a Nursing Dx for hyperthermia?

Im sorry if this is a silly question. I am very very very new at this...And my instructors can be challenging to get help from (thats a whole other post, lol)

I was wanting to do Hyperthermia related to (illness?) (invading infection?) as evidenced by temperature of 101.7oF. Does that sound right? I just didnt know if that's okay considering they already prescribed acetaminophen... Obviously, you want to treat the patient with nursing interventions too, right?

I would also do one for the respiration/oxygen problem if its okay to do a dx on something that is already being "treated"

I really appreciate the help.

Yes, it's ok to use alteration in body temperature (or whatever the phrasing is these days- LOL). You can also do other things for fevers to increase comfort (another possible nursing diagnosis)- which is what the APAP is for - not just decreasing the fever. Check your fundamentals text for more nursing interventions for fevers. (extra blankets or not if chilling, cool washcloths, or not, etc).

Yep- even if the doc has ordered something, there are going to be nursing care interventions that you can address (and should :)). Not a silly question ! It's hard to learn care plans. And, nursing has to monitor what the doc orders, so having it on the care plan addresses that Include Universal Precautions (or any other specific isolation concerns) under the infections problem :)

Good luck :)