HeLp!!! RA & sepsis -->stumping me on my care plan

Esme12, ASN, BSN, RN · Oct 5, 2012

Welcome to AN! The largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. 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.

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.

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. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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 (ex:confusion) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN · Oct 5, 2012

I'm having the hardest time figuring out my nursing diagnosis for my patient this week. She was a 49 year old female with rheumatoid arthritis that recently underwent an experimental stem cell transplant and since has been hospitalized 3 times due to sepsis. She currently has gangrene on 5 metatarsals, slight edema, and is currently non weight bearing (mainly due to her toes-she just started PT). Her H & H, Albumin, & total protein are low, and WBCs, Lymphs, & Monos are high. Great spirits, she just can't get up, still has pain r/t RA, & keeps developing sepsis.
I leaning towards:
Activity Intolerance
Ineffective Peripheral Tissue Perfusion
Impaired Physical Mobility
The ongoing/reoccurring sepsis is what's stumping me...I keep thinking this needs to be incorporated with my nursing diagnosis but can't figure out how. Does it sound like I'm on the right page with my diagnosis? Any advice is welcomed. Thanks ahead of time!

So how do you start....What is RA? What is sepsis? What is a stem cell transplant. Why does this patient keep getting sepsis? Is this patient immune-supressed? Are they on immune-supression drugs? What is gangrene? How does this affect the patient? Why is her albumin and protien low? Is she nutritionally deficient? can she perform her ADL's? This is a young patient how is her self image/confidence/body image? How is the family coping? What does the PATIENT say? What does you assessment show you? What does the PATIENT need? How does she rate her pain? Is the sepsis related to the gangrene? What is the treatment for the gangrene? Where/what is her sepsis?

nurseprnRN, BSN, RN · Oct 5, 2012

What nursing diagnoses in the NANDA-I 2012-2014 have defining characteristics that match your assessment of her condition and situation? Nursing diagnoses do not come from medical diagnoses. You can't say "My patient has RA and SCT and sepsis, what are her nsg dx?"

What, you don't have that book? Amazon.com, free two-day delivery to students. You're entirely welcome.

TBRN2013 · Feb 11, 2013

Thank you to everyone for your feedback, except GrnTea. I did not say ""My patient has RA and SCT and sepsis, what are her nsg dx?". All I asked was for feedback on being on the right page. Yes, I do have the book. Have you heard of lateral violence? Sarcasm will get you no where but unliked. And Esme12 - thank you for taking your time and writing such a detailed response, I was aware of most of your points and I do hope this thread helps someone else.

I went with: "Ineffective peripheral tissue perfusion related to altered motor function/limited mobility due to chronic RA & joint pain, edema, diminished pulses, extremity pain, decreased albumin & total protein, delayed peripheral wound healing resulting in gangrene of metatarsals, sepsis/infection resulting in poor blood flow."

I wish I could attach the rest of the document, but I did it in chart form and it doesn't paste well. Needless to say my clinical instructor was quite pleased she excused me from paperwork for remainder of clinical rotation.

allnurses Guide · Feb 11, 2013

Thank you to everyone for your feedback, except GrnTea. I did not say ""My patient has RA and SCT and sepsis, what are her nsg dx?". All I asked was for feedback on being on the right page. Yes, I do have the book. Have you heard of lateral violence? Sarcasm will get you no where but unliked.

She is not the one that is out-of-line.

Esme12, ASN, BSN, RN · Feb 11, 2013

Thank you to everyone for your feedback, except GrnTea. I did not say ""My patient has RA and SCT and sepsis, what are her nsg dx?". All I asked was for feedback on being on the right page. Yes, I do have the book. Have you heard of lateral violence? Sarcasm will get you no where but unliked. And Esme12 - thank you for taking your time and writing such a detailed response, I was aware of most of your points and I do hope this thread helps someone else.

I went with: "Ineffective peripheral tissue perfusion related to altered motor function/limited mobility due to chronic RA & joint pain, edema, diminished pulses, extremity pain, decreased albumin & total protein, delayed peripheral wound healing resulting in gangrene of metatarsals, sepsis/infection resulting in poor blood flow."

I wish I could attach the rest of the document, but I did it in chart form and it doesn't paste well. Needless to say my clinical instructor was quite pleased she excused me from paperwork for remainder of clinical rotation.

I'm glad your teacher was pleased. I don't think GrnTea was participating in any "lateral violence" at all. We get students here form all over the US and Europe. Not all schools are forth coming with all the material you need and not all students by the tool necessary to be competitive in school .....because a certain book was only "recommended" they feel it isn't necessary to purchase. Some students are not fortunate enough to live in a country such as ours and the opportunities it provides to it's occupants.

Some come here to have their work done for them...which we will not do. That will not make them the best nurse they can be....if we do the work for someone we are not supporting our field to greater horizons and assisting new nurses to become the best they can be.....there by providing the best care possible for the patient.

When we answer questions we have limited information about the student, what they have done so far, what they are confused about, what program are they in...what semester you are...ESPECIALLY when it is your first post. As difficult as it is to believe I see an alarming number of students asking for care plan help when they have no care plan book or even a book with NANDA I diagnosis with the definitions/characteristics.

Making a suggestion about where to purchase a valuable tool to your success at school....IMHO

....does not qualify as "Lateral Violence". Nurses with experience sharing their infinite knowledge is an act of generosity. We always suggest these things and ask students show what they have done so we know best how to assist them.

I am happy your CI has excused you from further paperwork for this rotation. If you need assistance we are here to help.

I wish you the best on your nursing journey.

morte, LPN, LVN · Feb 11, 2013

I can understand the OP's response to Green.....I think Green can be uproaringly funny, when you get to know he/she. But in this case Green did come on a little heavy handed, in my opinion. I think his/her unwillingness to take what he/she discerns to be rudeness/bullying, will serve the OP well.

allnurses Guide · Feb 11, 2013

I think his/her unwillingness to take what he/she discerns to be rudeness/bullying will serve the OP well.[/quote']
Unfortunately, snapping a response is very seldom in a nurse's best interest. I venture to guess you aren't a nurse yet?

nurseprnRN, BSN, RN · Feb 11, 2013

I went with: "Ineffective peripheral tissue perfusion related to altered motor function/limited mobility due to chronic RA & joint pain, edema, diminished pulses, extremity pain, decreased albumin & total protein, delayed peripheral wound healing resulting in gangrene of metatarsals, sepsis/infection resulting in poor blood flow."

So sorry to be late to this party-- the blizzard had the electricity off here for a few days. :)

I'm looking in my NANDA-I 2012-2014 and I find "Ineffective tissue perfusion," defined as "decrease in blood circulation to the periphery that may compromise health" in the section for Activity/Rest, CV/Pulmonary responses.

Defining characteristics (the evidence used to formulate the diagnosis) include altered motor function (caused by the decreased perfusion, not the other way around), absent pulses, altered skin characteristics (hair, temp, etc), ankle/brachial index 3sec, claudication, color does not return to leg upon lowering it, delayed wound healing, diminished pulses, edema, extremity pain, femoral bruit, shorter total and pain free distances achieved on the six-minute walking test, paresthesia, and skin color pale in elevation.

{Note that it is possible to have delayed wound healing caused by, for example, the low serum proteins (and vitamins and testosterone, even in females), but these are not related to ineffective perfusion; these would properly be included in another diagnosis related to delayed wound healing, such as Impaired tissue integrity, defined as damaged or destroyed tissue, related factors including (among others) altered circulation (did she have DIC with her sepsis?), and nutritional factors. This is why I'm not seeing it as evidence of decreased blood flow per se.}

Related factors for ineffective tissue perfusion = deficient knowledge of aggravating factors, e.g. smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility; deficient knowledge of disease process, e.g., diabetes, hyperlipidemia; DM; hypertension; sedentary lifestyle (this is not bedrest, but lifestyle); smoking. I don't see any of these documented in your assessment or diagnostic statement. You have to have at least one to use this diagnosis-- this is the "related to" that your defining characteristics are caused by. For example, you could say, "Ineffective peripheral perfusion related to DM, as evidenced by poor capillary refill >3sec, a/b index .56, claudication in 2 minutes walking." That's your diagnosis, cause, and supporting evidence. This is a vascular diagnosis.

I don't see anything about serum proteins or sepsis/infection resulting in poor blood flow unless you mean DIC; I actually don't see anything in your assessment that speaks to poor blood flow (BP, capillary fill, claudication, 6-minute walking test (for obvious reasons), color pale on elevation and does not regain color when lowered, etc.) as a cause of her problem. You can get gangrene from sepsis (DIC is the usual cause, though direct destructive effects of some bacteria will do), and she would be at higher risk for sepsis due to the immunosuppressive action of most RA meds. Gangrene from poor perfusion, e.g., diabetic, is dry, not wet. Not specified here; is she diabetic?

In summary, you pulled a lot of things into this, but it lacks, in my view, a coherent cause/effect/diagnosis statement because there are too many factors in this pot. You have two or even three nursing diagnoses here, when you look at the required defining characteristics and related factors you mention.