Help!!

Daytonite, BSN, RN · Dec 5, 2008

nursing diagnosis are based upon the signs and symptoms the patient has, so those should have come from your nursing assessment. if you did a systems assessment that would tell you what body system these belong under. if you look up the defining characteristics (signs and symptoms) of activity intolerance (you will find them on this webpage: activity intolerance) you will see that they closely fit the respiratory system. the risk factors for risk for infection are listed on this webpage: risk for infection which i would say is the immune system.

you can find information about crohn's disease, bowel obstructions and atelectasis in the online merck manual (http://www.merck.com/mrkshared/mmanual/sections.jsp). it will help you discover what you might have overlooked when you assessed this patient. i would be thinking about impaired gas exchange and ineffective airway clearance with an atelectasis and deficient fluid volume with a sbo since fluids get trapped in the bowel with sbos (you can read about how that happens in the merck manual).

BACKYARDIGANMOM · Dec 5, 2008

I am using impaired gas exchange or ineffective breathing pattern-kind of confused again because he has no signs or symptoms-the mild pleural effusions and basilar atelectasis were seen on a CT looking at the SBO which is now resolved. I am doing an imbal nutrition and I wanted to do a R/F-picc line/corticosteroid, my problem is this..infection-I think immune system too, but on our care plans there is no immune category so I am assuming you put it where integumentary/MS??? Thanks for the website!

Daytonite, BSN, RN · Dec 5, 2008

i recommend that you re-assess the patient. he didn't get a pleural effusions and atelectasis out of the blue. read references on the pathophysiology of atelectasis and how it develops. the symptoms are there, just subtle.

http://www.merck.com/mmpe/sec05/ch060/ch060d.html#sec05-ch060-ch060d-1244 - pleural effusion

imbalanced nutrition: more or less than body requirements? you still need to have symptoms of excessive or insufficient intake of nutrients to use one of these diagnoses.

a risk for infection of a picc line means you are going to prevent the development of sepsis. sepsis is the only possible infection that can occur with a picc line because this line dwells directly in the circulatory system. receiving corticosteroids contributes to the immunosuppression. infection in the blood stream can only be sepsis. interventions and outcomes are to prevent the sepsis from occurring. see https://allnurses.com/forums/2751313-post8.html for information on how to write interventions for these types of diagnoses.

if the immune system is not a category on your care plan sheet, think about the organs in the immune system and what systems they might be included in on the systems that are listed on your sheet.

i've been writing care plans for a l-o-n-g time. the process of diagnosing in nursing is done just the same as it is done in medicine by doctors. we use the nursing process to help us. first, assess to find the abnormal data. secondly, match abnormal data with criteria of established nursing diagnoses (the nursing problem). you need nursing diagnosis references to do this. every nursing diagnosis, except for the "risk for" diagnoses, have lists of defining characteristics (signs and symptoms) just as every medical diagnosis does. third, write goals and interventions for each nursing diagnosis. interventions target and treat the abnormal data and sometimes the cause of the nursing diagnosis. the reason you are confused is because you are not following this activity sequence which will keep you organized and your thinking rational.

BACKYARDIGANMOM · Dec 6, 2008

Sorry, I do know where the pleural effusion and atelectasis came from-he has crohn's and a sbo-he was not breathing deeply due to the abdominal pain and had alveolar collapse as a result. I have a number of NANDAS to use my problem lies in trying to fit them into the body system categories, as I said above, there is no immune (or endocrine for that matter) category so it is very hard to figure out what Nanda to put where unless it is straight forward, decreased CO etc. Anyway, the problem lies with the care plan tool we are made to use, not a lack of pathophys or care plan writing knowledge, so I thought I would throw it out there to see what others think-but, we probably all use different tools. Thanks for the info!