Careplan - Ineffective tissue perfusion related to infection! Help please!

Daytonite, BSN, RN · Nov 8, 2008

per the merck manual:

http://www.merck.com/mmpe/sec19/ch275/ch275f.html - "biliary atresia is obstruction of the biliary tree due to progressive sclerosis of the extrahepatic bile duct. in most cases, biliary atresia develops several weeks after birth, probably after inflammation and scarring of the extrahepatic (and sometimes intrahepatic) bile ducts. . .cholestasis typically is noted in the first 2 wk of life. infants are jaundiced and often have dark urine (conjugated bilirubin), acholic stools, and hepatomegaly. if cholestasis persists, chronic pruritus is common, as are symptoms and signs of fat-soluble vitamin deficiency; progression on growth charts may show a decline."
http://www.merck.com/mmpe/sec03/ch022/ch022d.html

the 4 cardinal signs of infection are redness, heat, swelling and pain. burn those into your memory because anyone with an inflammation or infection will have them whether the site is on the skin or inside the body where you can't see it with your eyes--the symptoms are there, i'll bet my cats on it. the reason your little patient got jaundiced skin, sclera and clay colored stools (the merck manual calls them acholic, meaning without bile pigment) is because swelling caused by the inflammation of this child's presumed cholangitis (inflammation of the bile ducts) resulted in the failure of the body to be able to excrete its bilirubin. thus, the bilirubin had nowhere to go and began building up in the body. you started seeing manifestations of that on the skin and in the sclera of the eyes.

altered tissue perfusion related to infection aeb jaundice of the skin and sclera as well as discoloration of the stool

let me break this diagnostic statement down into its component parts:

problem: altered tissue perfusion -
definition:
decrease in oxygen resulting in the failure to nourish the tissues at the capillary level
(nanda) - i would specify this further and add "liver" to it since that is where the problem is actually occurring. nanda says we can do that with this diagnosis
etiology: infection - the reason for the biliary atresia and admission was presumed to be cholangitis. it was the swelling of the inflammation of the bile ducts that contributed to the atresia that we can identify as a causative factor here. infection is a medical decision and diagnosis and nanda frowns on using medical diagnoses in diagnostic statements.
symptoms: jaundice of the skin and sclera as well as discoloration of the stool - this is the evidence you collected that supports the existence of this problem.

i would re-word this diagnostic statement to say and reflect current nanda language: ineffective tissue perfusion, liver r/t inflammation of the bile ducts aeb jaundice of the skin and sclera as well as discoloration of the stool

i think you are confusing failure to thrive (nutrition) issues with perfusion issues here. you need to know what the definitions of these diagnoses are and what the aims (goals) of treatment ultimately are for each diagnosis.

the planning section (goals) that you assigned to altered tissue perfusion goes as follows:

1. patient's weight will increase - this makes no sense to me as a goal for altered perfusion to the liver. weight has to do with eating or fluid gains/losses. eating is not involved with perfusion. altered perfusion to the liver results in abdominal distension and swelling which is pathological and you want to correct that which you do mention in #3.

2. patient will not spike a fever - this is a result of collaborative interventions to treat the infection (give the antibiotics as ordered)

3. abdominal distention will decrease - the problem is that abdominal distension is not something you have assessed as evidence. i'm confused as to why you introduce it now. if it didn't exist in the patient in the first place, how can you make this a goal?

4. jaundice will decrease and stool will return to a normal color - ok!

i suggest. . .

patient's inflammation will improve aeb improved skin color and return of sclera to white and return of stools to brown color.

any interventions need to address improvement or at the least, stabilization, of the etiology, or cause, of the problem and its supporting evidence, so that would be

the inflammation of the bile ducts
jaundice of the skin and sclera and discoloration of the stool

let's look at your interventions and see what they are doing to effect changes in the inflammation or jaundice in order to improve tissue perfusion. . .

daily weights will be taken
strict intake and output
daily abdominal girth will be taken
- these top 3 interventions (i shuffled them for a reason) sound like interventions for excess fluid volume. is the patient retaining fluid? that's not the focus of this diagnosis and you don't have evidence of this. why are you doing these interventions? i see you want the patient's weight to increase, but why? it makes no sense when the problem is impaired perfusion and manifested as jaundice. ???
[*]iv antibiotics given
[*]vitals q4h
[*]liver enzymes tests
[*]how about. . .
- assess vital signs q4h
- give antipyretics as ordered for temp over ___ and reassess temp 30-60 minutes later to determine effectiveness of the medication
- give antibiotics as ordered.
- assess and document the color of skin and eyes daily.
- note frequency, amount and color of stools.
- monitor and report abnormal liver function tests, coag studies or cbcs to the physician.

evaluation:

1. pt's weight has increased - insignificant to this diagnosis

2. no fever has developed - ok

3. abdominal dissention has decreased and stabilized. - insignificant to this diagnosis because there is no evidence to support that there was ever abdominal distension in the first place

4. jaundice has decreased very little and stool still has discolouration. -factors interfering with outcome may be due to failed kasei procedure. - sounds like a medical decision. can a nurse make that determination?

an evaluation is an assessment of the goals you set for this diagnosis. go back and look at the goals (the planning section). i set a goal of "patient's inflammation will improve aeb improved skin color and return of sclera to white and return of stools to brown color." i evaluate it now as "patient's skin and sclera continue to be jaundiced." you don't have to give a reason. initial assessment has a more

negative

connotation. evaluation has a more

positive

one. goals and outcomes can end up to be

improvement of the patient's condition/remedy
stabilization of the patient's condition
support for the deterioration of the patient's condition

i hate to be the bearer of bad news, but about 50% of these kids end up needing liver transplants. many never improve.

i've spent a lot of time trying to sort things out here. you need to go through and completely re-work this. keep this organized and pay attention to the problem and evidence that supports it. everything you do to treat the problem is related to the evidence. keep this in mind. . .there is never a murder without a victim and evidence. when you care plan, you are trying to erase the evidence and restore the victim to normal again. if you can accomplish that, you can say the problem is truly resolved. what is difficult for us is patients have multiple problems, and as you are finding with this patient, the problems and solutions can intertwine with each other.

happy care planning!

rosemine · Nov 9, 2008

Thank you very much!

Your rational makes much more sense. You see my professor gave most of that careplan to me (including the daily weights) which did not make sense to me. Hence why I wanted someone else to look it over first.

Everything all seemed to vague and didn't connect. Thank you again! I will take your suggestions.

And, yes, I believe the patient will need a liver transplant. If I remember correctly they were saying that his Kasei procedure wasn't a success.

Can you think of any reason why my professor was so adamant about the weight gain? Because she kept stressing it to me, and the patient was on a daily weight and abdomen check every AM.

Thank you again!

Daytonite, BSN, RN · Nov 10, 2008

Nutritional problems? Failure to thrive?