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I have an 82 year old pt with sepsis and hypothermia. The sepsis is likely due to a UTI. She also has alot of ulcers. She is non-responsive, non-verbal and was in hospice before being admitted to the hospital for hypothermia (84 F).

My instructor said i should use impaired skin integrity and something related to the infection for my diagnoses. The only diagnosis in my NANDA book is risk for infection. Should i use ineffective coping? I'm feeling a bit confused as I'm new to this. Any input would be appreciated.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

diagnosing (determining a problem) is based upon finding the evidence of the problem. police detectives do this all the time, only they already know the problem (a crime) and have to track back and find the evidence (assess) so they can figure out who did it. we look for evidence (assess) to establish a crime (nursing diagnosis). the who did it (organ of the body) involves knowing the pathophysiology. skip any of the steps in this process and you have a situation of garbage in = garbage out.

the tool we use to help us is the nursing process. it is logical and helps to keep us on the right path if used correctly. here is the nursing process adapted for care planning (which, by the way, is one big hunt (investigation) for all the patient's nursing problems):

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you need to look up the signs and symptoms of a uti and sepsis (http://www.merck.com/mmpe/sec06/ch068/ch068a.html) as well as the pathophysiology of how a uti becomes septic (https://allnurses.com/forums/f205/pathophysiology-uti-septicemia-268443.html). why is she hypothermic rather than having a fever? (https://allnurses.com/forums/f50/need-help-nursing-care-plan-304181.html - see post #8). what kind of ulcers does she have, what do they look like, how did they happen and what is being done about them? your instructor must have thought their treatment was important since she suggested the use of impaired skin integrity which tells me that they are, at most, stage ii ulcers. what treatments and medications has the doctor ordered for this patient for the sepsis?

  • 82 year old female
  • sepsis
  • probably has a uti
  • hypothermia
  • has a lot of ulcers

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - this is the only data beside the medical diagnoses that you supplied about this patient and i know there is more you just haven't posted. what is here isn't enough to make any kind of educated decision about any specific problems this patient has

  • non-responsive - what do you mean by non-responsive?
  • non-verbal
    • impaired verbal communication r/t ??? aeb inability to speak

something related to the infection

infection is a medical decision and diagnosis, so you will never see an actual nursing problem with the word "infection" in it. it is in the "risk for infection" diagnosis only because we are trying to prevent its occurrence. what is "related to" an infection is what is causing it or what the symptoms of it are. in nursing diagnosing it is perfectly ok to break down a medical diagnosis into its component signs and symptoms and then use those signs and symptoms, if the patient has any of them, to match them with well-defined groupings of symptoms that describe nursing diagnoses. every nursing diagnosis has a listing of signs and symptoms called defining characteristics. you need a nursing diagnosis reference to see them. i listed where you can find this kind of information above under
#2
determination of the patient's problem(s)/nursing diagnosis
in the outline.

what you need to do is list the patient's symptoms of her uti and sepsis. did she have any signs and symptoms of dysuria? (see
https://allnurses.com/forums/2756543-post13.html
for a definition and care plan information on dysuria). i gave you a link to information on sepsis above. any diagnosis you might decide upon would be based on any symptoms this patient might have in relation to the uti or sepsis. this is what all the care plan books mean when they say we focus on and treat the patient's
response
to their disease and not the disease itself. when you develop your interventions and goals it will be for those responses to their disease (signs and symptoms) not the disease itself. curing the disease is left to higher powers.

hope this has helped. you still have a lot of work to do on this.

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It helps me to remember that a medical diagnosis is not a nursing diagnosis. This is why the only ND about infection is "risk for."

A nurse independently intervenes when there is risk for infection, to prevent it, but collaborates with other health care providers when there is an ACTUAL infection (such as the physician who writes an order for an antibiotic).

It's the same as kidney failure or a broken bone or other condition... not a nursing diagnosis. Instead, those patients are "risk for fluid volume excess r/t decreased kidney function as evidenced by..." and "immobility r/t pain from broken femur aeb..." The effects of the infection (or whatever) become part of the etiology of the diagnosis.

Hope that helps!

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ineffective body temp. regulation, acute pain, and yeah, the impaired skin integrity.Ineffective coping would be used if the pt was not dealing with her dx, was in denial, grieving, etc. I really don't see ineffective coping for your pt's dx. Does she have problems breathing? Can she keep her O2 sats stable? Start with ABCs, those are always first diagnoses..Then go off your assessment...Did the pt. have pain, cyanosis, edema, confusion, etc...Do careplans like that, and they will get much easier..I promise!

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