First case study and nursing dx

hakuna_matata · May 26, 2013

Great! Your on track! First and foremost consider possible DVT as you mentioned. She displays positive Homans sign. Call MD asap regarding that, pain, and her HX AFIB. Question whether she was on anticoagulants for the AFIB and propholactically know. The MD should order dopplers to r/o DVT and put her on anticoags. That is priority! I've heard conflicting evidence regarding getting pt. oob to amb with questionable DVT. PT should know, but to cover your "bottom line" run that by the MD when you call about the leg pain and homans...get an order for activity first. Maybe just oob to chair until doppler result is in. But even then I'd get it in an activity order.

Secondly, she needs to drink PO fluid. Four hours isn't very long to not pee and hasn't has many hours of IV fluid. Encourage PO fluids and get her OOB at least to chair if MD okays it. This should help her void. If in 6-8 hrs still no void then I'd perform bladder scan and notify MD. of results of scan, time since last void, and IVF type and rate.

GOOD JOB and GOOD LUCK! Be a good nurse with good morals ;0) and you will do great!

Esme12, ASN, BSN, RN · May 28, 2013

You are falling in that trick bag of looking at the medical diagnosis for your nursing diagnosis. Many students do......Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying? What was the "acute blood loss? Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? This givens me no information about what your patient needs, what brought them to the hospital...what is their complaint?

Actual complaints precede risk of complaints.

LJ85, ADN, BSN, CNA, LPN · May 29, 2013

Thanks for the input. What I listed about my patient is the only data I received from my instructor to formulate my care plan and nursing dx. Step one is just to complete the assessment as nanda dx r/t the assessment. I did review my nursing dx and care plan book by doenges. I will update when I complete the next step!

Esme12, ASN, BSN, RN · May 30, 2013

Thanks for the input. What I listed about my patient is the only data I received from my instructor to formulate my care plan and nursing dx. Step one is just to complete the assessment as nanda dx r/t the assessment. I did review my nursing dx and care plan book by doenges. I will update when I complete the next step!

This is why students have such a hard time....care plans are all about the assessment of THE PATIENT and what the PATIENT NEEDS......

Ok looking at this assessment

a 64 year old obese woman who maintains an active lifestyle. She has a history of rheumatoid arthritis and atrial fibrillation and ASHD (arterio-sclerotic heart disease) She was on high doses of steroids for many years pre-operatively and had a Left TKR (total knee replacement) surgery yesterday. She complains of pain not just in the knee, but in the calf of the leg that was operated on. She states the pain is worse when she flexes her foot. Physical therapy says they will get her out of bed for the first time this morning. She also has an IV infusing of D5 ½ NS at125 ml/hour. She has not eaten yet, but has taken sips of fluid. Her catheter was removed 4 hours ago, and she has not voided yet.

Your beginning is good.

I have highlighted the issues that are important right now.......

She is a fresh surgical with calf pain and surgical pain should PT get her OOB without checking about calf pain?, her foley is out and getting fluids at 125ml/hr for 4 hours(500ml)

So is you highest a risk for infection post operatively over acute pain?

HouTx, BSN, MSN, EdD · May 30, 2013

I am a (very) experienced nurse - just wanted to say how much I continue to learn from Esme. We're lucky to have her here on AN!

Esme12, ASN, BSN, RN · May 30, 2013

Thanks.... :lol2:

BrooklynRN11201 · May 30, 2013

4 hours of no voiding after having a foley in isn't a huge concern, but you would keep an eye on it and assess for retention for sure (also, how much was she putting out per hour before the removal? but that's just something to keep in mind). Pain and infection are always going to be concerns post surgery, and hand hygiene and aseptic technique is a given for all patients... as stated above, DVT should be your priority concern because that is what the patient is reporting to you - I would always list priority nursing dx first, and it will really help you to get in the habit of including the rationales behind the interventions, even if they're not required by your Prof, you will retain the WHYs and nursing thinking processes for clinicals and exams. nursing dx related to DVT will be things like "ineffective peripheral tissue perfusion..." check this out to get your thought process going: http://wps.prenhall.com/wps/media/objects/737/755395/deep_vein_thrombosis.pdf