Care Plan Priority HELP PLEASE!

nurseprnRN, BSN, RN · Apr 10, 2015

Hey!

Ok so I am trying to work through my care plan and am afraid that I may be picking the wrong diagnosis for priority reasons.

PT: 72 y/o M hx of COPD, HTN, MI admitted for septic bursitis of elbow.
On the date of care there were multiple skin issues: the elbow ^, skin tear on leg, stage 2 on coccyx, 2+ edema.
so I went with Impaired Tissue Integrity R/T altered circulation secondary to COPD AEB.....
My concern is that my instructor may find a higher priority bc of his COPD. He was on O2, didn't move well out of bed (2 assist). His vitals were fine throughout my shift.
Thank you for any help!

Wait, what? Nurses can't make a nursing diagnosis based solely on a medical diagnosis. And you don't "pick" or "choose" one either. Read on.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors. They are the origins of nursing diagnoses, however.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk forâ€ diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. This poster is asking specifically for a ranking in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Now, as to your specific question:Let's look at this nursing diagnosis and its defining characteristics and related (causative) factors).

Diagnosis: impaired skin integrity (page 399)

Definition: altered epidermis and/or dermis

Defining characteristics:

* alteration in skin integrity

* foreign matter piercing skin

Related factors:

* external: chemical injury agent, extremes of age, humidity, hyperthermia, hypothermia, mechanical factors, moisture, pharmaceutical agent, radiation therapy

* internal: alteration in fluid volume, alteration in metabolism, alteration pigmentation, alteration and sensation, alteration in skin turgor, hormonal change, immunodeficiency, impaired circulation, inadequate nutrition, pressure over bony prominence

Okay, then. The first hit you have that you may not have made the correct nursing diagnosis is the fact that you have no evidence. Evidence comes first. What evidence do you have that this gentleman has impaired skin integrity? Oh, so you have evidence: he has several skin tears and areas of damaged skin. So, why does he have these? Those are your related factors. Looking at this list of related factors, I don't see anything that says "impaired circulation due to COPD." If you think he got skin tears from impaired circulation, make your case. However, I don't think that's where you're going with this.

I think it's very clear, however, that he does have related factors for impaired skin integrity. He has pressure over a bony prominence with breakdown, doesn't he? He has an alteration skin turgor (edema). If he has long-standing COPD, research suggests that he has inadequate nutrition, and if he is taking steroids for his COPD, he has relative immunodeficiency, because prednisone and related medications are immunosuppressive.

Therefore, it is perfectly reasonable for you to say that you have made the diagnosis of impaired skin integrity (pressure ulcer)related to pressure over bony prominence and edema, and skin tears. Having made this diagnosis, now it should be clear to you what nursing interventions you will apply to make him better, or at least decrease his risk of being worse.

What else did you observe about your patient? It sounds to me that you might want to look at activity intolerance (page 225), because you describe his needing help for an activity of daily living, getting out of bed. He does have an infection already, but he is at risk for other kinds of infection, isn't he? He may be afraid, he may have death anxiety, he may be stuck in ineffective denial. He may feel powerlessness. You have given me no other hints as to what your assessment of this man's condition is, so there is no more data from which to derive these or other nursing diagnoses. However, if you look in your NANDA â€“ I 2015 â€“ 2017, I'm very confident that you will see your way clear to making other nursing diagnoses based on your observations.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Natasha A., CNA, LVN · Apr 10, 2015

Thank you Grntea