help please :)

Esme12, ASN, BSN, RN · Feb 3, 2014

Hi, we have our second care plan due this Thursday. My lady is an 87 year old woman with end stage alzheimers disease who cannot communicate and is completely immobile due to contractures of her arms and legs. She is incontinent of bowel and bladder. She has a PICC line for TPN. She is NPO. she has had several fevers and the nurse gave her Tylenol rectally. she had a CBC done and came back with slightly elevated WBC and neutrophils. I looked all through her chart and could not find any mention of infection. She also has mild CHF and slight wheezing upon inhalation. Her HR is 112 and her respirations are 32. We have to have two physiological and one psychosocial nursing diagnosis.
I came up with
Powerlessness related to irreversible progressive degenerative neurological dysfunction secondary to end stage alzheimers disease aeb inability to communicate, complete immobility due to contractures of arms and legs.
risk for infection related to picc line
risk for impaired skin integrity related to complete immobility
Hyperthermia related to infection of unknown origin manifested by temperature of 102.4 F.
I'm not sure of my nursing goals for the powerlessness because she won't make any improvements. Is there a better psychosocial nursing diagnosis I should be using? and which risk for is more important? Im so confused! Any help would be GREATLY appreciated! thank you :)

Care plans are all about your assessment. What care plan book do you have? How do you look up your care NANDA I statement. What is you actual assessment of this patient ? Is this a real patient? What semester are you?

Each NANDA I statement has certain criteria/taxotomy/defining characteristics that it must follow. Your patient needs to "fit " into these definitions.

Powerlessness is defined by NANDA I: The lived experience of lack of control over a situation, including a perception that one’s actions do not significantly affect an outcome

Defining Characteristics: Dependence on others; depression over physical deterioration; nonparticipation in care; reports alienation; reports doubt regarding role performance; reports frustration over inability to perform previous activities; reports lack of control; reports shame

Related Factors (r/t): Illness-related regimen; institutional environment; unsatisfying interpersonal interactions

Can your patient report anything? I would think that this patient has a better diagnosis of Risk for compromised Human Dignity.

Out of your assessment above there are plenty more symptoms that I would place at a priority.

My lady is an 87 year old woman with end stage alzheimers disease who cannot communicate and is completely immobile due to contractures of her arms and legs. She is incontinent of bowel and bladder. She has a PICC line for TPN. She is NPO. she has had several fevers temperature of 102.4 F.and the nurse gave her Tylenol rectally. she had a CBC done and came back with slightly elevated WBC and neutrophils. I looked all through her chart and could not find any mention of infection. She also has mild CHF and slight wheezing upon inhalation. Her HR is 112 and her respirations are 32.

Your statement

risk for infection related to picc line

how do you know its the PICC line? she is incontinent.... Has her urine been tested? How do you know it's not pneumonia? Has she had a CXR? you are making assumptions that on information you don't have.

I' be concerned with her rapid breathing, fever, wheezing and fluid status.

What are you patients vital signs? What was your assessment? Is her skin intact? Care plans are all about the patient and the patients problems. 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?. 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.

Now...tell me about your patient.

MendedHeart · Feb 3, 2014

We have some assessment data, and could use more if you have it. I would also be interested in CXR or Urinalysis results as well. She definitely has qualifying symptoms on sespsis screen. Are you all allowed to use P.C.'s, or strictly just Nursing Diagnosis?

Have you thought about Airway clearance?(wheezes)

Is she needing any supplemental oxygen?

Hows the BP?

classicdame, MSN, EdD · Feb 3, 2014

OP: you mentioned that you do not expect much improvement. A goal could involve a sign/symtom not getting WORSE, especially if your assessment shows she is at risk for something that has not yet occured, like pressure ulcers.

nurseprnRN, BSN, RN · Feb 3, 2014

Powerlessness related to irreversible progressive degenerative neurological dysfunction secondary to end stage alzheimers disease aeb inability to communicate, complete immobility due to contractures of arms and legs.

Unfortunately, this is another example of trying to cram a patient into an extant nursing diagnosis that probably sounds good in a list but for which (required) defining characteristics are lacking.

This diagnosis is placed in the taxonomy in Domain 9, coping/stress tolerance; class 2: coping responses. The nursing diagnosis "Powerlessness" is defined in NANDA-I 2012-2014 as "The lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome."

I am frankly skeptical that a noncommunicative person in the throes of end-stage Alzheimer's could give you enough information to allow you to assess her lived experience and perceptions about her personal efficacy and coping. Evidence for the diagnosis, the defining characteristics, specifically do not mention inability to communicate or complete immobility. Also, the related to/causative factors for the diagnosis do not include "irreversible progressive degenerative neurological dysfunction," or, for that matter, any medical diagnosis.

Defining characteristics of Powerlessness are:

Dependence on others

Depression over physical deterioration

Nonparticipation in care

Reports alienation

Reports doubt regarding role performance

Reports frustration over inability to perform previous activities

Reports lack of control

Reports shame

Related factors:

Illness – related regimen

Institutional environment

Unsatisfying interpersonal interactions

While someone who is completely disabled by end-stage Alzheimer's disease, as your patient is, understandably looks powerless to you, you cannot make the diagnosis of powerlessness caused by end-stage Alzheimer's and evidenced by inability to communicate and complete immobility, because it does not meet criteria. The nursing diagnosis specifically is pegged to "the lived experience of lack of control… perception that one's actions do not ... affect an outcome." You have no evidence as to this woman's lived experience, and no assessment of her perception or coping is possible. Therefore, I don't think it possible for you to use this as a psychosocial nursing diagnosis for this patient.

Esme's suggestion about looking at Risk for Compromised Human Dignity is a possibility, although it too looks at self-perception and self-concept, aspects of her life which may be sadly lost to this woman forever.

Moving along, remember that your patient/client/healthcare consumer isn't just the person in the bed. By definition of the American Nurses Association Scope and Standard of Nursing Practice, it's also the family and/or community. This is not sophistry, it's expanding your scope of thought in considering this question. How are her family members dealing with her progressive disability and imminent death?

Have you looked through the NANDA-I 2012-2014 for psychosocial nursing diagnoses that could be made on those assessment findings? Check the sections on role, coping, and life principles for some suggestions. $29 and free 2-day delivery from Amazon, and $24 and instant delivery for your kindle or other e-reader (I have a copy in my iPad). Do it now.

samanthaAnn2014 · Feb 4, 2014

Thank you all for so much feedback. I'm in my second semester of an lvn program and I do not currently own a nanda book just the one at the back of our fundamentals book. Her cxr and urine culture both came back normal. The only thing was the CBC with raised WBC and neutrophils. She has a history of septicemia. Her bp was 164/98. She is on oxygen 2 l via nasal cannula. I do understand that powerlessness is not a fit for this patient ( who is a real patient lol) due to her inability to communicate. Her family does not come to visit so i cannot use them for info. I didn't think that her hr and respirations were priority because that is her normal according to previous record in her chart.

I did think that her temperature was important because it could be a sign of infection so i did have hyperthermia related to infection of unknown origin Aeb temperature of 102.4..

I don't know if it was the picc line that caused an infection i was just thinking that she may be at risk for developing an infection just from having a picc line.

MendedHeart · Feb 4, 2014

Your number one priority here is Gas exchange if this patient needs supplemental oxygen. Remember ABCs.

Emergent, RN · Feb 4, 2014

I am no expert on Nursing diagnosis, but shouldn't code status be a priority of a pt in this condition? How about knowledge deficit, as related to her family? A frank conversation with the decision making family member sounds like it should be at the top of the list in this scenario.

samanthaAnn2014 · Feb 4, 2014

I'm not sure what you mean by code status? DNr? And I can't have a conversation because as I mentioned her family does not come and visit and as a student i can't just call them to ask questions.

samanthaAnn2014 · Feb 4, 2014

impaired gas exchange related to use of oxygen aeb wheezing upon inhalation?

Esme12, ASN, BSN, RN · Feb 4, 2014

Thank you all for so much feedback. I'm in my second semester of an lvn program and I do not currently own a nanda book just the one at the back of our fundamentals book. Her cxr and urine culture both came back normal. The only thing was the CBC with raised WBC and neutrophils. She has a history of septicemia. Her bp was 164/98. She is on oxygen 2 l via nasal cannula. I do understand that powerlessness is not a fit for this patient ( who is a real patient lol) due to her inability to communicate. Her family does not come to visit so i cannot use them for info. I didn't think that her hr and respirations were priority because that is her normal according to previous record in her chart.
I did think that her temperature was important because it could be a sign of infection so i did have hyperthermia related to infection of unknown origin Aeb temperature of 102.4..
I don't know if it was the picc line that caused an infection i was just thinking that she may be at risk for developing an infection just from having a picc line.

Does your textbook have the definitions/defining characteristics of the diagnosis that you choose or does it just list them. Your patient must have the defining characteristics....or the "symptoms so to speak....that are listed. Read GrnTeas post....does your patient REPORT

Reports alienation
Reports doubt regarding role performance
Reports frustration over inability to perform previous activities
Reports lack of control
Reports shame

If so HOW does she report these things if she in non verbal. She does however have a Risk for compromised Human Dignity.

At risk for perceived loss of respect and honor
Honoring an individual’s dignity is imperative and consists of the following elements:
Physical comfort (bathing, positioning, pain and symptom relief, touch, and a peaceful environment). Encompasses aspects of privacy, respect, and autonomy. Also includes staff expertise, effectiveness, and safety of care
Psychosocial comfort (listening, sharing fears, giving permission, presence, not dying alone, family support and presence). Includes elements of client participation and choice. Clients feel at ease, safe, and protected; neither intimidated nor threatened
Spiritual comfort (sharing love and caring words, being remembered, validating their lives, praying with and for, reading scripture and Bible, clergy and referral to other providers [i.e., hospice])
Risk Factors
Cultural incongruity; disclosure of confidential information; exposure of the body; inadequate participation in decision-making; loss of control of body functions; perceived dehumanizing treatment; perceived humiliation; perceived intrusion by clinicians; perceived invasion of privacy; stigmatizing label; use of undefined medical terms

Looking at this patient scenario...I think there are things that are a greater priority that need to be considered. What is this patients 02 sat? I realize that this patient is in a nursing home so this data may not be available...however....just because it is documented that her respiration's are 32 breaths per min...DOES NOT LESSEN the priority of this finding. Can you imagine breathing 32 times a min?

impaired gas exchange related to use of oxygen aeb wheezing upon inhalation, rapid respiration's how does that impair gas exchange

iF the CXR and UA negative...(I am curious does this patient have a foley cath?) then it probably is the PICC line however you can't say that for you have no proof. Were blood cultures done? But you can still point out hyperthermia as a nursing diagnosis but risk of infection? She clearly HAS an infection AEB fever and elevated WBC's.

nurseprnRN, BSN, RN · Feb 4, 2014

impaired gas exchange related to use of oxygen aeb wheezing upon inhalation?

Impaired gas exchange is not caused by use of oxygen, which is what you say here.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)