Just want to run my data and nsg dx's by you. Please critique!

ChipNurse · Apr 13, 2014

Pain

Fluid and Electrolyte Imbalance

Dehydration

Risk for skin breakdown

Failure to Thrive

lwandel · Apr 13, 2014

Thank you ChipNurse! Those are great ones too!

Esme12 and GrnTea...do you wonderful ladies have any critiques for me too?

lwandel · Apr 13, 2014

ChipNurse, do you think I need to tweak my nursing diagnosis at all before I turn them in for my care plan?

Thanks,

Leslie

ChipNurse · Apr 13, 2014

Well I think you need to put the as evidenced by part to complete them, but it looks good. I would probably substitute activity intolerance for something more important such as Dehydration/Fluid volume deficit, but I don't know what you assignment is mandating. If it is 3 top priorities, then I would go with the top 3 that if not corrected will harm the patient the most. Good Luck!

Esme12, ASN, BSN, RN · Apr 13, 2014

What surgery did she have recently. What was your assessment of her abdomen? Were there bowel sounds? Was she tender? When was the surgery?

I wold say pain control seems to be a big one for her as well.

imbalanced Nutrition: less than body requirements: Intake of nutrients insufficient to meet metabolic needs

Defining Characteristics

Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication

Related Factors (r/t)

Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors

1. Imbalanced nutrition: less than body requirements r/t protein and vitamin requirements for surgical wound healing and decreased desire to eat.

Does your statement answer these question according to the NANDA definition? As GrnTes says.....

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

1.NANDA-diagnoses

2.“related to” or abbreviated “r/t”

3.The processes causing the symptoms

4.“As evidenced by” or abbreviated “aeb”

5.The observed physiology or behavior

So...your patient has Imbalanced nutrition: less than body requirements r/t (Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors) ______ AEB (Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication).

So how would you re-word this statement?

Esme12, ASN, BSN, RN · Apr 13, 2014

2. Constipation r/t effects of immobility on peristalsis. or is there a way to relate it to the removal of a large portion of her colon, daily use of laxatives, and immobility?

So we look at NANDA again. Constipation: Decrease in normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics

Feeling of rectal fullness; feeling of rectal pressure; straining with defecation; unable to pass stool; abdominal pain; abdominal tenderness; anorexia; atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); borborygmi; change in bowel pattern; decreased frequency; decreased volume of stool; distended abdomen; generalized fatigue; hard, formed stool; headache; hyperactive bowel sounds; hypoactive bowel sounds; increased abdominal pressure; indigestion; nausea; oozing liquid stool; palpable abdominal or rectal mass; percussed abdominal dullness; pain with defecation; severe flatus; vomiting

Related Factors (r/t)

Functional

Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregular defecation habits; insufficient physical activity; recent environmental changes

Psychological

Depression, emotional stress, mental confusion

Pharmacological

Aluminum-containing antacids; anticholinergics, anticonvulsants; antidiarrheal agents, antidepressants, antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers, diuretics, iron salts, laxative overdose, nonsteroidal antiinflammatory drugs (NSAIDs), opioids, phenothiazines, sedatives, and sympathomimetics

Mechanical

Neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprung’s disease, obesity, postsurgical obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal fissures, rectal anal stricture, rectal prolapse, rectal ulcer, rectocele, tumors

Physiological

Change in eating patterns, change in usual foods, decreased motility of gastrointestinal tract, defecation disorder, dehydration, inadequate dentition, inadequate oral hygiene, insufficient fiber intake, insufficient fluid intake, poor eating habits

By your assessment how would you tweak your statement?

Esme12, ASN, BSN, RN · Apr 13, 2014

3. Activity Intolerance r/t compromised oxygen transport system secondary to anemia.

Personally I would address her pain. What meds is she on?

Pink Magnolia, BSN, RN · Apr 13, 2014

I would also remember that your patient has gastritis. Major surgery and traumatic injuries can certainly exacerbate gastritis and if you haven't ever had it before...it's very uncomfortable. It makes you not want to eat because inflammation causes pain. I don't know what meds she is on, but NSAIDS can irritate the stomach even further and potentially cause bleeding. So, imbalanced nutrition r/t decreased oral intake associated with... pain, fatigue, decreased absorption assoc. w/ inflammation/scaring of the bowel may sound like something to look in to! Nutrition is a physiological need. Just make sure you have evidence for the etiology part. You have some labs above you can use to back it up.

Your patient may be constipated because of diminished defecation reflex, decreased ability to respond to urge bc weakened abdominal muscles/impaired physical mobility, decreased GI motility assoc. w/ morphine sulfate (if on it), OR decreased intake of fluids and foods high in fiber. Hypoactive bowel sounds and constipation is also an expected finding in the older adult, but that certainly doesn't mean you should ignore it. It should be corrected by dietary and/or pharmacological ways because proper elimination is a physiological need (Maslow's).

I agree with Esme and would also get a pain scale. I use OLDCARTS:

Onset

Location

Duration

Characteristics

Aggravating Factors

Relieving Factors

Treatment

She just had surgery, which may = pain...gastritis may = pain...constipation may = pain for your patient. If you are in pain, how can you function normally?

I'm a student like you, but this is what I thought or asked myself when I saw your data. Good luck and let us know how it goes. :)

nurseprnRN, BSN, RN · Apr 13, 2014

1. Imbalanced nutrition: less than body requirements r/t protein and vitamin requirements for surgical wound healing and decreased desire to eat. (Should I put a "secondary to" here? If so, would it just be anorexia? Or should I go so far as to say "secondary to pain and fatigue" even though she was unable to relate her lack of appetite to anything specific when asked?)

2. Constipation r/t effects of immobility on peristalsis. or is there a way to relate it to the removal of a large portion of her colon, daily use of laxatives, and immobility?

3. Activity Intolerance r/t compromised oxygen transport system secondary to anemia.
or I could go with a more psychosocial dx, but these are the ones that seemed pretty relevant.

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. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised! Wonder where you learned that??? :) Amazon.com: Nursing Diagnoses: Definitions and Classification 2012-14 (9780470654828): NANDA International: Books

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for: to learn how to plan nursing care.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings and at least one of the related / caustive factors are present. If so... there's a match. Congratulations! You have made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. Make sure it's congruent with your patient's wishes-- never forget that any patient can refuse any care or intervention, any time.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence; you want the most current edition, 2011.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can't get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.

Now, as to your specific work above:

1) There are six related factors for you to use to make this nursing diagnosis (defined as "Intake of nutrients insufficient to meet metabolic needs") in the NANDA-I 2012-2014 (page 174), and not one of them is "protein and vitamin requirements for surgical wound healing" or "decreased desire to eat."

"Related to," "caused by," and "secondary to" all mean exactly the same thing. I am not sure what you mean by "put (in) a secondary."

There are many defining characteristics for this diagnosis; you have not given any in your diagnostic statement, though you list several in your data collection list.

2) Constipation ("decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool")(page 203) has a list of related/causative/due to/secondary to (all the same thing) factors as long as your arm (several in each of the following categories, and you only need to pick one from one of them, though this lady sounds like she has several: functional (6), psychological (3), pharmacological (16), mechanical (15),and physiological (9) ) , but not one is "effects of immobility on peristalsis." You will find exactly what you want to know in the list, so you can make an appropriately-based diagnosis.

3) Activity intolerance ("Insufficient physiological or psychological energy to endure or complete required or desired daily activities")(page 231) does not have "compromised oxygen transport system secondary to anemia" as a related factor. It does, however, note "imbalance between oxygen supply and demand," and anemia would cover a decreased supply to tissues. It has specific defining characteristics (8 of them), none of which is in evidence in your diagnostic statement.

So let's see you restate these diagnoses using approved language, rationales, and defining characteristics. Remember, to make a nursing diagnosis you need to assess the patient for presence of a related factor and identify defining characteristics in your assessment. You can't just make them up or pick a diagnosis off a list and make up your own rationales for having made that diagnosis, i.e., "because it sounds plausible" doesn't make it.

lwandel · Apr 13, 2014

What surgery did she have recently. What was your assessment of her abdomen? Were there bowel sounds? Was she tender? When was the surgery?
I wold say pain control seems to be a big one for her as well.
imbalanced Nutrition: less than body requirements: Intake of nutrients insufficient to meet metabolic needs
Defining Characteristics
Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication
Related Factors (r/t)
Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors
Does your statement answer these question according to the NANDA definition? As GrnTes says.....
1.NANDA-diagnoses
2.“related to” or abbreviated “r/t”
3.The processes causing the symptoms
4.“As evidenced by” or abbreviated “aeb”
5.The observed physiology or behavior
So...your patient has Imbalanced nutrition: less than body requirements r/t (Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors) ______ AEB (Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication).
So how would you re-word this statement?

3 weeks prior to admission to the hospital, she had stimulators placed in her back (think tiny, sub-dermal TENS units). While I was working with her during my clinical, she denied pain, or said that her pain was 2-3 out of 10, except when she was repositioning her self into a laying or sitting position, then she would grimace and stop/slow down. But she would still deny pain. She denied pain medication also. Stated "it makes me sleepy and I don't like to just sleep all day. I'm not in any pain anyway".

When I ascultated her abdomen, I did hear bowel sounds. They were slow, but rhythmic. When I pressed on the 4 quadrants of her abdomen, it did feel a little tight but, again, she denied pain. She only mentioned a little tenderness in her right upper quadrant. The day that I was with her was the day they took her back for an EDG and diagnosed her with gastritis and the hiatal hernia.

The reason I'm not addressing pain in this is because she denied pain or, when she said there was pain, it was very minimal...except for the pain in her back when repositioning.

Perhaps I could go with impaired comfort instead. I'll look up that NANDA in a bit and see if her assessments are a good fit.

As for this diagnosis:

Imbalanced Nutrition: less than body requirements r/t gastritis AEB abdominal pain, aversion to eating, low BMI, and poor muscle tone.

It sounds a lot better to me, but I want to make sure. Thank you Esme12!!

Leslie

lwandel · Apr 13, 2014

2. Constipation r/t effects of immobility on peristalsis. or is there a way to relate it to the removal of a large portion of her colon, daily use of laxatives, and immobility?
So we look at NANDA again. Constipation: Decrease in normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool
Defining Characteristics
Feeling of rectal fullness; feeling of rectal pressure; straining with defecation; unable to pass stool; abdominal pain; abdominal tenderness; anorexia; atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); borborygmi; change in bowel pattern; decreased frequency; decreased volume of stool; distended abdomen; generalized fatigue; hard, formed stool; headache; hyperactive bowel sounds; hypoactive bowel sounds; increased abdominal pressure; indigestion; nausea; oozing liquid stool; palpable abdominal or rectal mass; percussed abdominal dullness; pain with defecation; severe flatus; vomiting
Related Factors (r/t)
Functional
Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregular defecation habits; insufficient physical activity; recent environmental changes
Psychological
Depression, emotional stress, mental confusion
Pharmacological
Aluminum-containing antacids; anticholinergics, anticonvulsants; antidiarrheal agents, antidepressants, antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers, diuretics, iron salts, laxative overdose, nonsteroidal antiinflammatory drugs (NSAIDs), opioids, phenothiazines, sedatives, and sympathomimetics
Mechanical
Neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprung’s disease, obesity, postsurgical obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal fissures, rectal anal stricture, rectal prolapse, rectal ulcer, rectocele, tumors
Physiological
Change in eating patterns, change in usual foods, decreased motility of gastrointestinal tract, defecation disorder, dehydration, inadequate dentition, inadequate oral hygiene, insufficient fiber intake, insufficient fluid intake, poor eating habits
By your assessment how would you tweak your statement?

How about:

Constipation r/t decreased motility of GI tract and insufficient physical activity AEB straining with defecation, inability to pass stool, abdominal tenderness, anorexia, generalized fatigue, and hard, formed stool.

Is it right to address two different causes of the same issue? I remember my instructor throwing out a dx of Impaired Skin Integrity with risk for further breakdown r/t physical immobility, inadequate nutrition, and bipap dependency (I was worried about the bipap machine causing the skin on her face to breakdown, in addition to the stage 4 sacral pressure ulcer and and the non-blanchable patches of skin on her heels). She said that I was addressing 2 different causes of the same issue and they needed to be different nsg dxs.

I really just need to print your "walkthough" and tape it on the wall by my computer so I can stop bothering you ladies. Lol

thanks,

Leslie