Help! Nursing Dx -

zenurse · Jan 29, 2008

Impaired tissue integrity?

LovinNursing · Jan 29, 2008

What would be my related to?? I know the associated with but this semester we have to do the related to at a cellular level

zenurse · Jan 29, 2008

I'm not really sure that this is the most important ND, I was just trying to suggest one that might apply to the evidence you mentioned. Have you considered Maslow's hierarchy in order to prioritize the patient's most significant problem? It may not be related to this wound at all, you know?

Daytonite, BSN, RN · Jan 29, 2008

whoa! before i answer you i have to say that this kind of hit a personal note. that patient could have been me. my chemo was delayed for two months because i got a septic infection (which they had trouble tracking down). i wanted an infusaport or portacath in the worst way, but they insisted on a picc line because they said the ports had a lot of problems and complications connected with them. as i've been going to my chemo now for the last 6 months i have seen one patient after another who has had to have their implanted port removed for one complication or another. guess i'm glad i got the picc line which has now been in since july and has not been the cause of one single problem. [sorry. had to get that out of my system.]

now, the first thing i'm going to nail home with you is that a care plan is based upon the symptoms, not the medical conditions, your patient has and you really haven't posted any symptoms that i can work with. a symptom is an objective observation or a subjective perception of the patient. i get that you can't use risk for infection (by the way, there is no nanda nursing diagnosis of infection). in this case, the infection is really a medical diagnosis so you couldn't use it anyway or nanda police would be at your door hauling you off to nanda jail. you only get bread and unsalted soup there. ha! ha!.

actually, with infections you have to understand the underlying pathophysiology to get to any nursing diagnoses. infection is actually a bacterial invasion and it causes damage to tissues. the real culprit that does most of the damage is the inflammation response that occurs at the time of the bacterial invasion and along with it. remember that old thing from pathophysiology (if you took that class), the cardinal signs (and symptoms) of inflammation: redness, heat, swelling and pain, in that order of occurrence? now, for a boo-boo on the skin you can see this response quite easily. but, when it is occurring internally, like in a lung or over a pocketed area where an infusaport was placed under the skin, it's a little harder to see these signs and symptoms so you have to be a detective and ferret them out. but, i guarantee you, they are there if there is still an active infection going on. so, you want to try to figure out what is going on with this inflammatory response and question and observe the patient closely for symptoms of the infection (remember: symptoms are what you are going to base your care plan on).

tenderness and pain in the area of the infection [possible dx: acute pain]
edema - swelling will cause all kinds of problems with the tissues surrounding it [possible dx: risk for impaired skin integrity; excess fluid volume, acute pain]
increased pulse rate
fever and/or look for a pattern of spikes in the afternoon or evening with a return to normal by morning [possible dx: hyperthermia]
elevated wbc count [possible dx: ineffective protection]
patient complaint of chills [possible dx: hyperthermia]
questions to ask yourself?
- does she have diarrhea or loose stools secondary to the antibiotics she is being given? [possible dx: diarrhea, deficient fluid volume]
- is she complaining of fatigue? [possible dx: fatigue]
- any confusion? [possible dx: impaired memory, disturbed thought processes]
- any headache? [possible dx: acute pain]
- what kind of movement does she have in the arm associated closest to where this implanted port was--is she able to move it as well as the other arm, or is it painful to move it? [possible dx: impaired physical mobility, any of the self-care deficits]

all of the above can be clues to possible symptoms that the patient might be having that you might have missed--good clues that will lead you to problems that you will be able to care plan for.

the minithoracotomy, decortication and removal of a blood clot followed by the chest tube was a pretty serious invasion of this patient's body. decortications aren't normally done for pneumothoraxes. i'm wondering what else is going on here. a decortication is removal of lung tissue--either the pleura or some of the lung surface. what are her abgs looking like? is she on supplemental oxygen yet? is she producing any sputum? is she coughing at all? just what is going on with her respiratory state? and what is this chest tube site looking like? that's a healing wound. it's impaired tissue integrity since it goes deeper than the subcutaneous tissue.

i also like to suggest to students that they look at the list of the patient's medical diagnoses and look up information about them in textbook resources. if you have difficulty finding information there is always the internet. find out what the signs and symptoms are of these diseases and think about what you observed in your patient and what the doctors said about her in their documentation in her medical record. if you missed something, add it to her list of symptoms because it is likely you'll be able to use it in developing your care plan.

did you assess her ability to perform adls. this is a nursing biggie and a lot of students forget about this. if her arm or upper torso is bothering her as a result of pain from the chest tube or the implanted infusaport, you've got a mobility problem. the adls you should be assessing are: bathing, dressing, transferring from bed or chair, walking, eating, toileting, and grooming.

and something i know about because it happened to me and that is her state of mind about beginning chemotherapy. my chemotherapy is being given to cure me, but i was told i had a two-month window for it to start. that two-month window was getting eaten up by my septic infection and then another complication (i had to have a pacemaker inserted and they couldn't do it while i was "hot" with sepsis). i could only imagine that the aggressive cancer i had might be metastasizing as i was being treated for these things. so, one can't help but wonder what is going on in the mind of this patient about her cancer and chemotherapy, hmmm? it is a very emotional time for people. this is a ripe issue for a psychosocial nursing problem. however, you have to have statements (subjective data) from the patient to support using a psychosocial nursing diagnosis. i posted a list of the psychosocial diagnoses recently on post #145 of this thread: https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html.

now, after all that you should have come up with a list of symptoms that your patient has. guess what? this is only step #1 (assessment) of the nursing process. you haven't even gotten to the part where you look for a nursing diagnosis! all this preliminary work is vital to determining your patient's problem(s) and getting to a nursing diagnosis. and, your entire care plan is going to focus on that list of symptoms that you have come up with.

the nursing diagnosis is academic, but it's what you asked about, so here goes. . .it is a statement of your patient's problems. you pick them to satisfy step #2 of the nursing process and your instructors and that's the last you're going to see of them with regard to the care plan. the remainder of your care plan (steps #3, #4, and #5) focus mainly on that list of symptoms). in actuality, what you call the nursing diagnosis is actually a shorthand label of the definition of the diagnosis. the actual definition of the nursing diagnosis more clearly expresses the patient's problem. step #2 of the nursing process is to identify the patient's problems. the nursing diagnosis is just attaching a label to the problem as a descriptor. as you are learning to work with nursing diagnoses you really should read these definitions so you know what the heck you are diagnosing a patient with. the shorthand labels (ex: deficient fluid volume, decreased cardiac output) do not clearly define the problem and it is very possible to accidentally diagnose incorrectly by just going by the label. some people confuse impaired skin integrity and impaired tissue integrity all the time. if they read the definition of each instead of relying on the shortened label, they wouldn't have that dilemma. (definition of impaired skin integrity: altered epidermis and/or dermis. definition of impaired tissue integrity: damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.) another point is to check the defining characteristics (symptoms) that each nursing diagnosis has. nanda has gone to great pains to create a listing of them for each diagnosis. a doctor always assesses a patient and considers their symptoms before pronouncing a diagnosis. we nurses must follow that same process. we just have different types of symptoms in some cases in doing this. our nursing idea of symptoms includes a patient's response to their disease condition (that's an important point to remember). we also have the nanda taxonomy to help us out here. we have but to learn to use it. most current care plan books contain the nanda taxonomy a little chopped up and spread out within these books, but it is there.

so, to summarize, to get to any nursing diagnoses for this patient you need to revisit a list of symptoms for this patient. then, with that list of symptoms you look for nursing diagnoses that have those symptoms. you'll find some and they won't be risk for infection, i guarantee! if you still need help with this, post a list of your patient's symptoms (objective observations or subjective perceptions made by the patient) and i will help you determine the nursing diagnoses.

when you move on to step #3 the goals and nursing interventions, you base them entirely on those symptoms you worked so hard to ferret out. without those symptoms, you would have no care plan.

hope this was helpful for you. nursing diagnosis is just a way of refiguring your thinking.

LovinNursing · Jan 29, 2008

Well first of all THANK YOU THANK YOU THANK YOU. This is my first time posting here so I wasn't really sure what all I should put down.

My patient had a low temp (97.1)- the room temp was 78 and the pt. was warm, normal pulse - 87, Systolic was a little high (157/73 at noon up from 123/57 at 7AM over ), pulse ox, 98% and respirations 16. The patient does have a nasal cannula turned to 3L of O2 sitting beside her bed (the nurse said it was for her on an as needed basis) . THe pt. didn't use it at all. The nurse said the pt. is noncompliant and that is why the pt. is in sich bad shape.

The pt. also suffers from Type II Diabetes Mellitus, Hypertension, Anemia (these are the other medical diagnosis )> THe pt. is 60 with a weight of 273

On Assessment, tthe pt. was A & O x's 4. The Pt. suffers from glaucoma, but has no corrective devices. No edema, except at the wound site on the pts. right side. Peripheral pulses present though the right side was diminshed. Neck veins were extended with a bounding pulse and cap. refill

Now Labs:

RBC 3.39L

Hg 9.2L

Hct 27.7L

WBC 13.1H

MCHC 33.1L

K+ 2.7L

Ca++ 8.5L (pharmacy had it flagged but is norm in all books)

Albumin 1.9L

CO2 34H

Glucose 162H

ALT 25L

Platelets 698H

My nursing Dx:

Impaired gas exchange r/t Increased levels of CO2 a/w pneumothorax

Ineffective tissue perfusion r/t decreased arterial blood flow a/w pneumothorax

Acute pain r/t inflammation of tissues and prostaglandin release a/w right minithoracatomy and decortication of lung

Impaired tissue perfusion r/t decreased Hg concentrationin blood a/w anemia

Impaired skin integrity r/t impaired metabolic state and physical immobilization a/w diabetes mellitus

noncompliance r/t patients value system a/w hypertension

meds the pt is taking:

Avandia, Diphenhydramine HCL, Effexor, Enalapril, Ferrous sulfate, Heparin SQ, Ibuprofren, Indapamide, Klor Con, Lidocaine, Linezolid, Lovostatin, Metoprolol, Novolin R, Protonix, Zofran, Docusate sodium, Morphine sulfate. Percocet, Nitroglycerin

The wound is infected with MRSA and staph, it is red, tender, swollen and very warm. Serous drainage, yellow/green.

Daytonite, BSN, RN · Jan 29, 2008

from the data you list i come up with a symptom list of:

edema in the wound site on the pts. right side
peripheral pulses diminished on the right side (which pulses, by the way? radial or pedal?)
neck veins were distended with a bounding pulse
right lung sounds diminished
productive cough of clear light yellow sputum
uses a walker for long distances
skin is dry on all extremities
stage two breakdown on coccyx
sob during bathing
unable to sit up for long periods of time
thoracotomy wound with yellow/green drainage (right chest?)
the longest you saw the pt. out of bed was thirty minutes
with a lot of prodding the patient was compliant
needs help with most adl's
rbc 3.39l
hg 9.2l
hct 27.7l
wbc 13.1h
mchc 33.1l
k+ 2.7l
ca++ 8.5l (pharmacy had it flagged but is norm in all books)
albumin 1.9l
co2 34h
glucose 162h
alt 25l (also known as the sgpt)
platelets 698h

when you are choosing nursing diagnoses you need to use a nursing diagnosis reference. right off the bat i knew you didn't. let's look at your first diagnosis.

impaired gas exchange r/t increased levels of co2 a/w pneumothorax

first of all, "increased levels of co2" is not a related factor that nanda lists for this diagnosis. secondly, "increased levels of co2" is a symptom. symptoms do not belong in the place of related factors. next, the a/w part of your diagnostic statement (i have never seen the terminology "a/w", only aeb [as evidenced by]) is always your patient's symptoms--

always

. pneumothorax is not a symptom. it is a medical diagnosis and has no place in a nursing diagnostic statement

[important rule: no medical diagnoses are allowed in nursing diagnostic statements unless they are worded in a very specific way after the r/t part of the statement and before the aeb part.]

if you look at the related causes for

impaired gas exchange

that nanda lists, there are only two:

alveolar-capillary membrane changes
ventilation perfusion imbalance

ventilation perfusion imbalances are due to debris and exudate that clog up the bronchioles and alveoli as in pneumonia, and when there is a lot of mucus or pus. however, in the case of alveolar-capillary membrane changes, they are referring to permanent damage to the structural membranes as occurs with diseases like copd. it's hard to know what the underlying problem is in your patient's case but with all the sputum production i'd tend to go with the ventilation perfusion imbalance if there was no documentation in the chart to indicate that there was disease in the lung. however, in looking over your list of symptoms, i can't see that you can really use this diagnosis because the patient doesn't have any symptoms of this problem! see the defining characteristics (symptoms) for this diagnosis on these websites:

[color=#3366ff]impaired gas exchange

and

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=23

however, your patient does have plenty of symptoms of this problem:

inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

and, that is

ineffective airway clearance r/t infected pneumothorax wound and production of excessive mucus a/w diminished breath sounds in right lung, and productive cough of clear light yellow sputum.

the fact that she's getting incentive spirometry to keep her coughing and deep breathing attests to this problem.

i want to address this issue of the patient getting sob when doing any kind of activity. this is a critical problem and is related to her respiratory and heart status. this is a nursing problem: insufficient physiological or psychological energy to endure or complete required or desired daily activities. the label of this problem is activity intolerance and although you don't have the ekg and vital signs to support it you do have some other patient responses that do. activity intolerance r/t generalized weakness a/w sob during bathing and unable to sit up for long periods of time. an alternative to using this would be impaired physical mobility. i did also note that this lady is morbidly obese and i'm sure that is contributing to her mobility problems.

there are two tissue perfusion nursing diagnoses. between them they address all the body systems. decreased cardiac output was split away from ineffective tissue perfusion (specify) because it is so complicated. all other body systems go to ineffective tissue perfusion (specify). but when you are talking only about the tissue perfusion of the heart you must use decreased cardiac output. so, i'm a little confused as to what you are getting to with

ineffective tissue perfusion r/t decreased arterial blood flow a/w pneumothorax and impaired tissue perfusion r/t decreased hg concentration blood a/w anemia.

first of all, you have to identify the body system you are addressing in the very first part of the nursing diagnosis label--you didn't, so anyone reading this has no idea if you are talking about the kidneys, lungs, brain, guts or peripheral circulation. if you are referring to the heart, you've diagnosed wrong. secondly, as before, your related factors are symptoms and your a/w's are medical diagnoses. here are websites that have the nanda information for this nursing diagnosis so you can see what i'm talking about:

[color=#3366ff]ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral

and

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

from your symptom list i get this:

ineffective tissue perfusion, peripheral r/t hypovolemia

[i'm basing this on the fact that the patient has anemia, but it's quite possible that she may have an interruption in blood flow since she is diabetic and vascular disease is a complication of diabetes, but you did not mention that this was one of her problems]

a/w diminished right (upper?, lower?) extremity peripheral pulses and dry skin.

then,

decreased cardiac output r/t altered preload a/w distended neck veins and fatigue in performing activities.

next up, impaired skin integrity r/t impaired metabolic state and physical immobilization a/w diabetes mellitus.

ok, i'll buy the related factors that you listed. however, diabetes mellitus is a medical diagnosis and you needed to list the symptoms after the "a/w". you needed to give some description of that wound; mention that it is a stage ii decubitus and that it is on the coccyx. so your nursing diagnosis should read:

impaired skin integrity r/t impaired metabolic state and physical immobilization a/w a stage ii decubitus ulcer on the coccyx that measures xxx. and thoracotomy wound on right chest (?) with swelling and yellow green drainage

acute pain r/t inflammation of tissues and prostaglandin release a/w right minithoracotomy and decortication of lung

are you getting the idea by now that you can't use "right minithoracotomy and decortication of lung" as a symptom? what is a symptom of pain?

pain!

describe the patients complaints of pain. "8 on a scale of 10", "it hurts like hell and i need something stronger than vicodin." those are symptoms! your r/t part is ok. so, your diagnostic statement should look more like:

acute pain r/t inflammation of tissues and prostaglandin release a/w patient statement of pain of 8 on a scale of 10.

now, noncompliance r/t patients value system a/w hypertension

i need to clear up this definition of "noncompliant". nanda's definition of noncompliant and the medical profession's definition, or use, of the word are two different things. i just talked about this on another post for someone's care plan the other day. remember i said something above about

reading

the definitions of these nursing diagnoses. well, this is what the nanda definition of

noncompliance

is:

behavior of a person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan [doctor's orders]

agreed on by the person

(and/or family and/or community)

and health care professional

. in the presence of an agree-on, health-promoting or therapeutic plan, person's or caregiver's behavior is fully or partially nonadherent and may lead to clinically ineffective or partially ineffective outcomes.

in other words, it's like there had to have been a contract between the doctor and the patient and the patient broke it. if the patient from the get-go has said they

weren't

going to do what the doctor has been ordering, then it's not noncompliance by nanda's definition and you can't use that nursing diagnosis. but if she's looking him in the eye and not saying one way or the other that she's going to use the oxygen, then it is more appropriate to use the nursing diagnosis of

ineffective health maintenance r/t ineffective coping

(or grieving) aeb refusal to follow doctors orders of keeping oxygen on. it's more likely she's rebelling or in a state of anger over her present situation with her cancer and grieving or having difficulty coping with the entire situation and thinking, "what the hell, what's the difference if i use the oxygen or not?" i know. i've been there. many cancer patients have. there's a lot of anger and "why me?" connected with a diagnosis of cancer.

you could also use some of the self-care deficit diagnoses with this patient if you look them over. i didn't go through all your patient's medications or integrate the labwork into the nursing diagnoses. i'll let you work on that. the main points i wanted to make were that you get your symptom list made and that you get the information in your 3-part nursing diagnostic statements corrected.

Daytonite, BSN, RN · Jan 30, 2008

it dawned on me as i was driving around this afternoon that i really didn't explain to you how a 3-part nursing diagnosis is supposed to be constructed and you might not have the full picture of what i was saying in my last post.

the three part nursing diagnosis consists of:

p-e-s

where

p is the problem; e is the etiology, or cause; and s is/are the patient's symptoms.

or, stated in nanda language

p is the nursing diagnosis; e is the related factor(s); and, s is/are the defining characteristic(s)

the nursing diagnosis statement cannot contain a medical diagnosis. the exception is when it is written something like this: impaired gas exchanged r/t alveolar-capillary membrane changes due to emphysema aeb crackles in lung fields, pursed-lip breathing, inspiratory wheezing and clubbed fingers. note the way it is written into the statement "due to emphysema". it can also be written as "secondary to emphysema".

in that example, the etiology (underlying cause and reason for the presenting symptoms of increased crackles in lung fields, pursed-lip breathing, inspiratory wheezing and clubbed fingers) of the impaired gas exchange is alveolar-capillary membrane changes (permanent damage that has occurred to the structural membranes). this is very different from the etiology you will be using for your patient who only has gunk blocking her alveoli. this is why you need to know the underlying pathophysiology of your patient's disease process. it's why i'm always telling students they need to look up information about the patient's medical diseases. you have to know about these diseases. it's part of your nursing education. if you look at some of the related factors with some of the various nursing diagnoses, you will see that they have to do with different pathophysiologies that are going on in a person's body. each pathophysiological screw up produces a symptom. it's your job to be able to match the pathophysiological screw ups with the symptoms that go with them. so, as in the case of impaired gas exchange, you need to know what is going on physiologically so you can get the correct etiology and, therefore, the correct related factor, for your diagnostic statement in order for it to make sense. this is critical thinking.

irishnoreenRN · Jul 31, 2008

What a fabulous forum and an excellent explanation. KUDOS

digoxin229 · Jul 31, 2008

:tku: :up:

Live&Love:) · Apr 7, 2010

@daytonite

i envy your wisdom! :) i smiled while reading your responses because they shined a light in all of my dark places that i earned while making progress in my 1st block of nursing classes! i hope that as i continue to move forward in my progress, during my clinical experience, i learn and learn and learn so that i may possess the critical thinking and analytical skills that you have. i love it! :)

i pray that you never become discouraged in your profession or in your willingness to share your knowledge. it is so necessary. i wouldn't want a nurse who doesn't know how to think and put together a plan to help me regain my health! individuals like you who are well-rounded in their career are the ones who will be able to fertilize a new generation of intelligent nurses.

i will (if i am able and god allows) forever follow your posts. i am a student entering my 2nd block of nursing classes, and i am determined to suceed! thank you, and keep up the good work! :up: :yeah: