Published Feb 5, 2008
wackyj2000
1 Article; 74 Posts
:w00t:Hey everyone, sorry im in a little trouble. Im at the library right now and i forgot my nursing diagnosis books from class, and im trying to find out some good websites to help me out. I have a 93 yr old female that came in yesturday with a mental status change due to the uti, and fever. She is alert but not oriented and at times she is veryy confused. Her past PMH is dementia, macular degneration with legal blindness, joiunt disease and depression. Not too much, they are just going by her records since she does not have any family in the area. Any ideas about what kind of diagnosis i could come up with... 1. being the first priority, OR any helpful websites for nursing diagnosis? Thank you all!!
CT Pixie, BSN, RN
3,723 Posts
http://www.rncentral.com/nursing-library/careplans
http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
here are the 2003/2004 nanda's (can't find my more current list..sorry) but with all these to choose from, i'm sure you can come up with as many as you need.
activity intolerance
activity intolerance, risk for
adaptive capacity: intracranial, decreased
adjustment, impaired
airway clearance, ineffective
anxiety
anxiety, death
aspiration, risk for
attachment, parent/infant/child, risk for impaired
body image, disturbed
body temperature: imbalanced, risk for
bowel incontinence
breastfeeding, effective
breastfeeding, ineffective
breastfeeding, interrupted
breathing pattern, ineffective
cardiac output, decreased
caregiver role strain
caregiver role strain, risk for
communication, readiness for enhanced
communication: verbal, impaired
confusion, acute
confusion, chronic
constipation
constipation, perceived
constipation, risk for
coping: community, ineffective
coping: community, readiness for enhanced
coping, defensive
coping: family, compromised
coping: family, disabled
coping: family, readiness for enhanced
coping (individual), readiness for enhanced
coping, ineffective
decisional conflict (specify)
denial, ineffective
dentition, impaired
development: delayed, risk for
diarrhea
disuse syndrome, risk for
diversional activity, deficient
dysreflexia, autonomic
dysreflexia, autonomic, risk for
energy field, disturbed
environmental interpretation syndrome, impaired
failure to thrive, adult
falls, risk for
family processes, dysfunctional: alcoholism
family processes, interrupted
family processes, readiness for enhanced
fatigue
fear
fluid balance, readiness for enhanced
fluid volume, deficient
fluid volume, deficient, risk for
fluid volume, excess
fluid volume, imbalanced, risk for
gas exchange, impaired
grieving, anticipatory
grieving, dysfunctional
growth, disproportionate, risk for
growth and development, delayed
health maintenance, ineffective
health-seeking behaviors (specify)
home maintenance, impaired
hopelessness
hyperthermia
hypothermia
identity: personal, disturbed
infant behavior, disorganized
infant behavior: disorganized, risk for
infant behavior: organized, readiness for
enhanced
infant feeding pattern, ineffective
infection, risk for
injury, risk for
knowledge, deficient (specify)
knowledge (specify), readiness for enhanced
latex allergy response
latex allergy response, risk for
loneliness, risk for
memory, impaired
mobility: bed, impaired
mobility: physical, impaired
mobility: wheelchair, impaired
nausea
neurovascular dysfunction: peripheral, risk for
noncompliance (specify)
nutrition, imbalanced: less than body
requirements
nutrition, imbalanced: more than body
requirements, risk for
nutrition, readiness for enhanced
oral mucous membrane, impaired
pain, acute
pain, chronic
parenting, impaired
parenting, readiness for enhanced
parenting, risk for impaired
perioperative positioning injury, risk for
poisoning, risk for
posttrauma syndrome
posttrauma syndrome, risk for
powerlessness
powerlessness, risk for
protection, ineffective
rape-trauma syndrome
rape-trauma syndrome: compound reaction
rape-trauma syndrome: silent reaction
relocation stress syndrome
relocation stress syndrome, risk for
role conflict, parental
role performance, ineffective
self-care deficit: bathing/hygiene
self-care deficit: dressing/grooming
self-care deficit: feeding
self-care deficit: toileting
self-concept, readiness for enhanced
self-esteem, chronic low
self-esteem, situational low
self-esteem, risk for situational low
self-mutilation
self-mutilation, risk for
sensory perception, disturbed (specify: visual,
auditory, kinesthetic, gustatory, tactile,
olfactory)
sexual dysfunction
sexuality patterns, ineffective
skin integrity, impaired
skin integrity, risk for impaired
sleep deprivation
sleep pattern disturbed
sleep, readiness for enhanced
social interaction, impaired
social isolation
sorrow, chronic
spiritual distress
spiritual distress, risk for
spiritual well-being, readiness for enhanced
spontaneous ventilation, impaired
sudden infant death syndrome, risk for
suffocation, risk for
suicide, risk for
surgical recovery, delayed
swallowing, impaired
therapeutic regimen management: community,
ineffective
therapeutic regimen management, effective
therapeutic regimen management: family,
therapeutic regimen management, ineffective
therapeutic regimen management, readiness for
thermoregulation, ineffective
thought processes, disturbed
tissue integrity, impaired
tissue perfusion, ineffective (specify: renal,
cerebral, cardiopulmonary, gastrointestinal,
peripheral)
transfer ability, impaired
trauma, risk for
unilateral neglect
urinary elimination, impaired
urinary elimination, readiness for enhanced
urinary incontinence, functional
urinary incontinence, reflex
urinary incontinence, stress
urinary incontinence, total
urinary incontinence, urge
urinary incontinence, risk for urge
urinary retention
ventilatory weaning response, dysfunctional
violence: other-directed, risk for
violence: self-directed, risk for
walking, impaired
wandering
[color=#231f20]
source. nanda nursing diagnoses: definitions
and classification, 2003-2004. [color=#231f20]philadelphia:
north american nursing diagnosis association.
used with permission.
Kina21
71 Posts
It really sucks that you don't have your diagnosis ref manual because all you have to do is look up the UTI and it has a list of nursing diagnoses for it. I don't know of any websites but I can suggest a few ideas...
-Acute pain
-Impaired Urinary elimination
-Urge urinary incontinence
I'd say the pain/fever is the priority...
Good luck :)
Daytonite, BSN, RN
1 Article; 14,604 Posts
All diagnoses are based upon the symptoms that a patient has. The only ones you have listed are:
From that you can probably use the following nursing diagnoses (in priority order, by Maslow):
Until you come up with the symptoms of the patient's urosepsis, any diagnosis would be just a guess--you MUST have the symptoms (NANDA language: defining characteristics) to support any diagnosis.