Correct me if im wrong

LMRN10 · Aug 22, 2008

just wondering, were you taught 2 part and 3 part?

the way i was taught was:

2 part (only used for risk):

risk for deficient fluid volume r/t vomiting, gastric suctioning

3 part (aeb - as evidenced by):

imbalanced nutrition: less than body requirments related to inadequate dietary intake, impaired pancreatic secretions, increased nutritional needs secondary to acute illness and increased body temperature aeb weight loss and decreased energy

i know these aren't spectacular, but i'm just throwing out basic things (plus i don't have my book in front of me!)...you have to give the evidence to support the diagnosis.

Daytonite, BSN, RN · Aug 23, 2008

problem: severe pain

dx: acute pain and discomfort related to edema, distention of the pancreas and periotoneal irritation

-------------and------------

problem: discomfort

dx: discomfort related to nasogastric tube

the official nanda diagnosis is

acute pain

. discomfort is a synonym for pain. the "related to" part of the nursing diagnostic statement refers to the cause, or etiology, of the problem which in this instance is pain. the nanda taxonomy gives you many of the related factors for each of the diagnoses. for

acute pain

the etiology needs to be a biological, chemical, physical or psychological injury. edema, distention of the pancreas and peritoneal irritation are due to inflammation that is occurring because of the pancreatitis, so those are correct etiologies of

acute pain

.

the presence of a nasogastric tube is a foreign body that elicits the inflammatory response as well. the inflammatory response includes these cardinal signs: redness, warmth, swelling, and pain. so, with an n/g tube a patient will have pain (a sore throat), swelling in the throat and often a lot of mucous production.

i would correct this to read

acute pain related to

edema, distention of the pancreas, peritoneal irritation and the presence of a nasogastric tube as evidenced by [the symptoms that prove the patient has pain]

[color=#3366ff]acute pain

problem: decreased oral intake

dx: imbalanced nutrition: less than body requirements related to inadequate dietary intake, impaired pancreatic secretions, increased nutritional needs secondary to acute illness and increased body temperature

problem: difficulty breathing

dx: ineffective breathing pattern related to splinting from severe pain, pulmonary infiltrates, pleural effusion and atelectasis

pulmonary infiltrates, pleural effusion and atelectasis are medical diagnoses and you cannot use medical diagnoses as the basis for nursing diagnoses.

i would correct this to read

ineffective breathing pattern related to splinting from severe pain.

problem: vomiting

dx: risk for deficient fluid volume related to excessive losses: vomiting, gastric suctioning

rewrite this:

risk for deficient fluid volume related to excessive losses from vomiting and gastric suctioning

problem: limited activity intolerance

dx: activity intolerance related to pain

the definition of activity intolerance is

insufficient physiological or psychological energy to endure or complete required or desired daily activities

(

nanda-i nursing diagnoses: definitions & classification 2007-2008

)

.

the related factors that nanda lists include bed rest or immobility, generalized weakness, sedentary lifestyle, imbalance between oxygen supply and demand. pain has nothing to do with why the patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities. this diagnosis is used when the patient is out of physical condition.

activity intolerance

problem: risk for altered tissue perfusion

dx: risk for altered tissue perfusion related to enforced bed rest , poor nutritional status

this is not an appropriate diagnosis. what is it you anticipate might happen? that is always the primary focus of these "risk for" diagnoses. you always need to have something in mind that you anticipate might happen. above, you were anticipating dehydration as a result of vomiting and loss of gastric fluid. altered tissue perfusion is almost always a chronic problem or the result of an acute event such as a stroke or heart attack. think about what it takes for blood not to perfuse through the tissues and give them adequate oxygen and how long it takes that to happen. nutrition is a long term problem and requires a nutrition diagnosis. where you thinking of the potential for bedsores and skin breakdown because of immobility because of bed rest (

risk for impaired skin integrity

)?

deanikins211 · Aug 23, 2008

thank you . Activity intolerance related to pain. What if i'll change it to limited body movement related to pain? and another question, does all nursing diagnosis requires "secondary to" evidenced by? thank you. Lets say secondary to acute pancreatitis is it the same with secondary to disease process?

Wsmith16, ADN, BSN · Aug 23, 2008

thank you . Activity intolerance related to pain. What if i'll change it to limited body movement related to pain? and another question, does all nursing diagnosis requires "secondary to" evidenced by? thank you. Lets say secondary to acute pancreatitis is it the same with secondary to disease process?

I wouldn't change it stick with what Daytonight wrote--you can't go wrong.

deanikins211 · Aug 23, 2008

okay thanks. Im now starting making my ncps

Daytonite, BSN, RN · Aug 23, 2008

the appropriate and more correct diagnosis for problems with moving is impaired physical mobility and that can be related to pain as well as decreased endurance and deconditioning (something you were alluding to with activity intolerance). its definition, however, differs from activity intolerance in that in means a limitation in independent, purposeful physical movement of the body or of one or more extremities. [color=#3366ff]impaired physical mobility

nanda does not permit the use of medical diagnoses in the nursing taxonomy and spent a lot of time rewording and changing medical language into what they now call nursing language. for learning purposes though it sometimes helps to stick these "secondary to" statements into diagnostic statements. they can be added to help clarify or define the etiology of the nursing problem if your instructors allow it. using a "secondary to" is a sly way to work the medical diagnosis into the nursing diagnostic statement. it is done to help you see the rational progression in reaching these problem determination decisions as learners. when you graduate and move into the working world you are only expected to know the nursing diagnosis and interventions for it. no one will grill you about why you chose that diagnosis unless you come up with some really bizarre stuff that no one can figure out!

remember back in your other thread, https://allnurses.com/forums/f50/nursing-diagnosis-need-help-326004.html - nursing diagnosis need help, i gave specific information about what a thorough patient assessment included. this applies to all patients and all case scenarios. part of the preparation in getting to the writing of nursing diagnoses for a patient is knowing all about his underlying disease processes--in this case, acute pancreatitis. there is acute and chronic pancreatitis.

first off, the word acute (look it up in a medical dictionary to verify this) differs from chronic.

acute - having rapid onset, severe symptoms, and a short course; the opposite of chronic - the implication here is that it is reversible, so a cure is a likely outcome
chronic - of long duration; showing little change or of slow progression; the opposite of acute - the implication here is that it is never going away so stabilization or deteriorization are your outcomes

for example, i would write acute pain related to obstruction of pancreatic and biliary ducts, chemical contamination of the peritoneum with pancreatic exudate and byproducts of autodigestion and inflammation of the retroperitoneal nerve plexus secondary to pancreatitis as evidenced by the patient's statement of pain of 10 on a scale of 0 to 10. and everyone reading this is wondering what hat i pulled that out of. i looked at a couple of references although i have taken care of many of these patients. per sue e. heuther on page 1363 of pathophysiology: the biologic basis for disease in adults and children, third edition, by kathryn l. mccance and sue e. heuther "the pain [of acute pancreatitis] is caused by edema, which distends the pancreatic ducts and capsule; chemical irritation and inflammation of the peritoneum; and irritation or obstruction of the biliary tract." also, and this goes back to your problem of nausea, "nausea and vomiting are caused by hypermotility or paralytic ileus secondary to the pancreatitis or peritonitis." there is more on the pathophysiology. . ."abdominal distension accompanies bowel hypermotility and the accumulation of fluids in the peritoneal cavity. hypotension and shock occur frequently because plasma volume is lost as enzymes and kinins released into the circulation increase vascular permeability and dilate vessels. hypovolemia, hypotension, and myocardial insufficiency result. a small percentage of individuals develop tachypnea and hypoxemia secondary to pulmonary edema, atelectasis or pleural effusions caused by circulating pancreatic enzymes. in severe cases hypovolemia decreases renal flow sufficiently to impair renal function. tetany may develop as a result of deposition of calcium in areas of fat necrosis or as a decreased response to parathormone. transient hyperglycemia also can occur if glucagon is released from damaged alpha cells in the pancreatic islets."

these are the diagnoses i would use based on the information you've posted and what i know about acute pancreatitis. they are sequenced in order of priority:

decreased cardiac output related to decreased preload and afterload and hypovolemia [this is why the patient gets hypotensive and what you were trying to get into with the diagnosis of risk for altered tissue perfusion. when you are specifically dealing with perfusion of the heart you use decreased cardiac output, when you deal with shock you use ineffective tissue perfusion: cardiopulmonary and peripheral]
impaired gas exchange related to ventilation perfusion imbalance secondary to pulmonary edema, atelectasis or pleural effusion as evidenced by hypoxemia
ineffective breathing pattern related to abdominal distension as evidenced by tachypnea
deficient fluid volume related to loss of fluids entrapped in the bowel and vomiting secondary to paralytic ileus
imbalanced nutrition: less than body requirements related to vomiting, npo status, and pancreatic outflow obstruction as evidenced by inadequate food, fluid and electrolyte intake
hyperthermia related to disease process
impaired physical mobility related to abdominal pain, decreased endurance and deconditioning
acute pain related to obstruction of pancreatic and biliary ducts, chemical contamination of the peritoneum with pancreatic exudate and byproducts of autodigestion and inflammation of the retroperitoneal nerve plexus secondary to pancreatitis as evidenced by the patient's statement of pain of 10 on a scale of 0 to 10.
disturbed body image related to skin discoloration secondary to obstructed common bile duct [due to jaundice]
deficient knowledge (discharge needs) related to unacquainted with information resources (diet, allowed physical activity, special medications they need to take, any treatments and tests they need to be doing after discharge, referrals to any outside agencies or support groups, follow up appointments with doctors, teaching materials and/or contact with outpatient professionals for continued care, and that the patient knows what symptoms need to be reported to the doctor if they occur)
risk for infection related to immunosuppression [i'm talking about the infection going septic]
risk for impaired skin integrity related to bedrest and immobility