what is code status?

Daytonite, BSN, RN · Nov 4, 2009

what is code status?

this refers to whether or not a patient is to be resuscitated if they stop breathing or their heart stops beating. if the patient is a "full code" a code blue would be called and everything possible would be done to keep the patient alive. all patients will have a code blue called for them unless the doctor directs otherwise. if the patient were a dnr (do not resuscitate) the patient would be allowed to expire. most hospitals have protocols involving code status that define exactly what is to be done if a patient stops breathing or their heart stops beating. code blue and dnr are not the only code designations, but they are the two most commonly used.

Daytonite, BSN, RN · Nov 4, 2009

fall r/t dizziness and loss of short-term memory as evidenced by history of falling 6 times in the last 8 months.

fall

is not an official nanda approved nursing diagnosis. the r/t part of the diagnosis should tell anyone reading the statement why the patient falls (this is why your instructor was asking you why he falls). the appropriate way to have written this diagnosis was

risk for falling r/t

history of falling 6 times in the last 8 months and dizziness.

"risk for" diagnoses are anticipated problems and do not have "as evidenced by" items in the diagnostic statements.

the nursing interventions for anticipated problems like this need to be:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional

so, all of your interventions would be appropriate.

what do you hope will happen as a result of doing these interventions (your goals)? evaluation is based on whether or not you have achieved those goals.

if you do not have a care plan book, a nursing diagnosis reference manual or a current edition of taber's cyclopedic medical dictionary which has the nanda taxonomy in the appendix, you can see information about this diagnosis on this website:

risk for falls

impaired urinary elimination r/t inflammation of urinary system secondary to pyelonephritis as evidenced by voiding 4-6 times a day.

the diagnosis is fine until you get to the "as experienced by" part of the statement. that should be the symptoms of the

impaired urinary elimination. voiding 4-6 times a day

is a normal occurrence. don't you void 4-6 times a day? to get the symptoms correct you need to read about utis and pyelonephritis and compare what a textbook tells you the signs and symptoms are with what the patient was experiencing. see:

http://www.merck.com/mmpe/sec17/ch231/ch231b.html

. there are very specific symptoms associated with utis such as urgency and frequency which is what you were trying to convey in your diagnostic statement. these are acceptable terms to use in connection with a nursing diagnosis. so, if a patient is voiding frequently your diagnostic statement can be written as

impaired urinary elimination r/t inflammation of urinary system secondary to pyelonephritis as evidenced by urinary frequency.

you can see information about this diagnosis on this website:

impaired urinary elimination

what would be your short-term goal, nursing interventions and evaluate that interventions?

nursing interventions are aimed at the symptoms, which would be the frequency the patient is having because we are not doctors and other than assisting the doctor in treating the pyelonephritis we cannot independently treat this disorder. what we can do is help make the patient more comfortable as they experience this condition. monitor vital signs. encourage fluids. make sure they have easy access to the bathroom. palpate the bladder and make sure there is no urinary retention. monitor their intake and output. give medications as ordered. goals are your predicted results of doing these interventions. evaluations are based upon whether or not your goals were achieved.

what is verbalization of learning needs? (please give me an example)

a learning need is some item you decide that the patient needs to be taught. verbalization means "to express in words". i am not sure in what context you took this phrase from but it sounds as if it refers to a patient asking for information about some subject.

identified learning need(s)

a subject that you have decided that the patient needs to be taught.

learning objective(s)

the specific information that the learner will get from any teaching you will give them.

impediments to learning

such things as a person's formal educational background, their level of interest, attention spans, prior knowledge and learning experiences, special needs or accommodations, learning preferences, length of time you have to accomplish the teaching, language barriers, visual problems.

123_y_321 · Nov 4, 2009

what is code status?
this refers to whether or not a patient is to be resuscitated if they stop breathing or their heart stops beating. if the patient is a "full code" a code blue would be called and everything possible would be done to keep the patient alive. all patients will have a code blue called for them unless the doctor directs otherwise. if the patient were a dnr (do not resuscitate) the patient would be allowed to expire. most hospitals have protocols involving code status that define exactly what is to be done if a patient stops breathing or their heart stops beating. code blue and dnr are not the only code designations, but they are the two most commonly used.

thanks for taking time and replying my thread.

i have read over your posts several times. i have got a most part of it. but there is place that i still have concern about.

do you ask pt/pt's family about how they want their code status while you are doing health history? or we just assume everyone wants full code?

is there anyway you can put fall into a actuall ndx? (i think not but just asking)

SolaireSolstice, BSN, RN · Nov 5, 2009

Do you have a NANDA book? If not, you should get one.

Risk for injury could work. Risk for injury related to frequent falls secondary to dizziness.

A patient is a full code unless they have opted to be DNR. A patient who has opted to be DNR will have a purple wristband (usually) and (definitely) a DNR order on the chart.

Daytonite, BSN, RN · Nov 5, 2009

do you ask pt/pt's family about how they want their code status while you are doing health history? or we just assume everyone wants full code?

yes. federal law requires that patients are asked by the admission clerks as well as the nurse doing their admission assessment if they have some sort of durable power of attorney now. it is the doctor's responsibility to write dnr orders if that is what the patient desires. nurses can discus this with patients, but all hospital personnel must code a patient who becomes apneic or pulseless if there is no order from their physician to do otherwise. this is something that is made clear with all hospital employees during their orientation period when they are hired and first begin working. nurses can discuss and give information to patients on obtaining a healthcare durable powers of attorney or advanced directive, however, each state has laws regarding them and how they are honored. in most states a doctor still must write a dnr order if the patient does not want to be resuscitated. the california medical association has an advanced directive health care kit that you can preview here:

http://www.cmanet.org/bookstore/product.cfm?catid=12&productid=154

.

i went to a lawyer and had an advanced directive drawn up several years ago. it says that i do not want to be kept alive under certain specific circumstances and it has them in writing. i have given a copy of this document to each of my doctors and the hospital where i have been a patient several times has this document on file. i have discussed this, as well, with my physicians so they know exactly what i want done in case i become unable to tell them. my sister and brother who are appointed my power of attorney in this document also have copies of it because they will make decisions for me if i cannot and they know what i want them to do and i talk with them about it from time to time. i did this because i worked in a critical care area for many years and i saw many patients in hopeless situations who did not have something like this and were kept alive because the healthcare personnel had no choice but to keep them alive and i do not want something like that to happen to me.

is there anyway you can put fall into a actual ndx? (i think not but just asking)

no. the appropriate diagnosis that nanda wants nurses to use is

risk for falls.

if you are looking for an actual problem, about all you can do is diagnose for any actual injury the patient might have sustained from a previous fall such as

impaired skin integrity

for bruising.

DolceVita, ADN, BSN, RN · Nov 5, 2009

Em....while you are at it...

At my clinical they have people who are "No CODE" and others who are "DNR". What is the difference?

Daytonite, BSN, RN · Nov 5, 2009

Em....while you are at it...
At my clinical they have people who are "No CODE" and others who are "DNR". What is the difference?

No difference.

123_y_321 · Nov 5, 2009

I got it. Thanks alotttttttttttttttttttt Daytonite. You help me be a better nurse.