Prioritzing my NANDAS!! HELP!!!!

  1. Hey guys.. i need help prioritizing these NANDAS.. my pt has a hx of COPD, along with a bunch of other stuff. she was admitted for a UTI and now I have to come up with a careplan and prioritize my top 5 NANDAS...

    So far I have:

    Impaired gas exchange r/t ventilation-perfusion impairment AEB abnormal breathing pattern of 28RPM, dyspnea, and oxygen dependence 2-3L

    Ineffective peripheral tissue perfusion r/t interupted venous flow secondary to +2 pedal edema bilaterally

    Imparied skin intergrity r/t inflammatory response secondary to skin tear on forearm 2cm X 3cm

    Impaired physical mobility r/t limited strength AEB activity intolerance, dyspnea, and pedal edema

    anxiety r/t SOB, and change in health status AEB 28RPM, dyspnea, and exacerbated symptoms of COPD

    acute confusion r/t decreased oxygen saturation AEB periods of confusion, and disorietnation assoicated with low oxygen levels

    readiness for enhanced nutriton r/t willingness to follow new diet regimen AEB pt. verbalizing understanding of specific diet needs and restrictions, and showing full compliance.

    impaired urinary elimination r/t urinary tract infection AEB periods of inconintinence and an increased urgency and frequency.

    I know that gas exchange and tissue perfusion are definitely priority #1 and 2... but after that i'm stuck... I am not even sure if these NANDAS are completely appropriate... this is why i hate case studies instead of working on actual patients from our clinical rotations... if anyone could help me out I'd appreciate it!!!
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    About ConniePN

    Joined: Jun '09; Posts: 4
    from US

    5 Comments

  3. by   Daytonite
    i based the priority on maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs)
    1. impaired gas exchange r/t ventilation-perfusion impairment aeb abnormal breathing pattern of 28rpm, dyspnea, and oxygen dependence 2-3l
      • if this patient has copd, then the etiology (r/t) is because there have been physiological changes to the alveoli that have resulted in such things as destruction of alveolar septa, enlargement of the alveoli along with narrowing of the airways so that the inspired air gets trapped in these enlarged alveoli and cannot get out. because of the alveolar enlargement the surface area where gas exchange occurs is diminished. so, the more correct cause of the impaired gas exchange is a physical change in the alveolar-capillary membrane.
      • an oxygen dependence 2-3l is a sly way of stating a physician's order. a physician's order for 2-3 liters of o2 is not assessment data of hypoxia. the aeb information should come from physical assessment data and at the end of the day 2-3l of o2 is still a medical treatment and what the doctor is going to do for the dyspnea and impaired gas exchange.
      • confusion due to low oxygen levels is a defining characteristic (symptom) of this diagnosis and not the acute confusion you are trying to put it with elsewhere in this care plan.
      • i would write this as impaired gas exchange r/t alveolar-capillary membrane changes aeb tachypnea of 28, dyspnea and confusion.
    2. ineffective peripheral tissue perfusion r/t interupted venous flow secondary to +2 pedal edema bilaterally
      • this is a new nanda diagnosis as of the 2009-2011 guide. interupted venous flow is not one of the related factors that is listed for this diagnosis. this is what nanda international nursing diagnoses: definitions and classifications 2009-2011 lists as the related factors for this diagnosis:
        • deficient knowledge of aggravating factors (e.g. smoking, sedentary lifestyle, trauma, obesity, salt intake immobility)
        • deficient knowledge of disease process (e.g., diabetes, hyperlipidemia) [and i have written in "venous insufficiency, leg vein valve failure"]
        • diabetes mellitus
        • hypertension
        • sedentary lifestyle
        • smoking
        • [i have written in: venous insufficiency, leg vein valve failure]
      • a "secondary to" only allows for the introduction of a medical diagnosis. +2 pedal edema is not a medical diagnosis but assessment data. it belongs with the aeb part of this diagnostic statement which is missing.
      • i can't state your r/t factor because i don't know what your case study information was, but this diagnostic statement needs to be re-written: ineffective peripheral tissue perfusion r/t ___ aeb 2+ (bilateral ?) pedal edema
    3. impaired urinary elimination r/t urinary tract infection aeb periods of inconintinence and an increased urgency and frequency.
      • i will tell you the same thing i posted in an earlier thread. you have to be more scientific in your measurement of these symptoms because they come back to bite you when you write your goals and do later evaluations. if the patient has "periods of incontinence" now how are you going to distinguish them from the "periods of incontinence" they might have tomorrow or next week? also, if this patient is incontinent then you have diagnosed this incorrectly because there is a nursing diagnosis (several, in fact) for incontinence.
    4. impaired physical mobility r/t limited strength aeb activity intolerance, dyspnea, and pedal edema
      • activity intolerance is another diagnosis and if you have symptoms of this you need to use that nursing diagnosis.
      • dyspnea and pedal edema are not symptoms of impaired physical mobility.
      • you have no symptoms of impaired physical mobility. this patient probably does not have this problem. look at the defining characteristics of activity intolerance. dyspnea on exertion, fatigue, changes in heart rate and blood pressure with activity and usually the need to stop activity and sit down are symptoms of that diagnosis.
    5. imparied skin integrity r/t inflammatory response secondary to skin tear on forearm 2cm x 3cm
      • the inflammatory response does not cause impaired skin. the inflammatory response occurs whenever the skin is broken as when the skin tears. it is a normal body mechanism.
      • again, using "secondary to" only allows for the introduction of a medical diagnosis and skin tear on forearm 2cm x 3cm is not a medical diagnosis but assessment information.
      • this should say: impaired skin integrity r/t trauma aeb 2cm x 3cm skin tear on (left/right) forearm
    6. anxiety r/t sob, and change in health status aeb 28rpm, dyspnea, and exacerbated symptoms of copd
      • related causes of anxiety are threats of danger or changes to the person's level of safety. sob is a respiratory system symptom.
      • 28rpm, dyspnea, and exacerbated symptoms of copd are not symptoms of the nursing diagnosis of anxiety.
      • unless there are symptoms of anxiety in the case study (i haven't seen any others in the information you have posted) this patient does not have this nursing problem.
    7. acute confusion r/t decreased oxygen saturation aeb periods of confusion, and disorietnation assoicated with low oxygen levels
      • decreased oxygen saturation is not an appropriate related factor for acute confusion and sounds exactly like impaired gas exchange.
      • periods of confusion and disorietnation is a restatement of the diagnosis and tells us nothing about the evidence that supports the reason this patient is acutely confused.
      • assoicated with low oxygen levels - this again, only confirms why this is impaired gas exchange.
    8. readiness for enhanced nutriton r/t willingness to follow new diet regimen aeb pt. verbalizing understanding of specific diet needs and restrictions, and showing full compliance.
      • the related factor (r/t) for all "readiness for" diagnoses is that the patient desires to improve that particular area, in this case nutrition or diet.
      • pt. verbalizing understanding of specific diet needs and restrictions, and showing full compliance is not enough aeb (evidence) that the patient wants to improve his diet. you also need to have evidence that the patient is willing and wants to do better.
  4. by   ConniePN
    thanks so much!! I think you're more critical then my professors..but either way I'm glad!! ) thank you so much for your help! I may have been taught incorrectly on how to do this... I changed some things I wanted tos how you...

    for the inneffective peripheral tissue perfusion... I changed in completely to Excess fluid volume r/t compromised regulatory mechanism AEB dyspnea and +2 pedal edema

    not sure if thats correct...

    also... Functional urinary incontinence ?? is that better than impaired urinary elim?? I'm having so much trouble with r/t and AEB with this careplan... my case study is very detailed.. too detailed to write.. but I can write some...

    84 yo female resides at a nursing home for the last 2 years. She was independently at home until she was no longer able to manage in her home after a hospitalization for COPD exacerbation. SHe has ben 02 dependant for the past 2 years. Presently she is being treated for a UTI. as tolerated, she attends PT daily.
    HX: emphysema, HTN, type 2 DM, OA, gout, CAD, Hypothyroidism, CHF, pneumonia
  5. by   Daytonite
    i may be critical, but i am not mean. i read every word you post and spend time and impart what little knowledge of care planning i have. i spend a great deal of time with care plan posts. you will get out of them what you put into them. i can only work with the information that people give me, so part of my problem is that many times students aren't even aware of what it is that they are doing incorrectly.

    with diagnosing. . .every nursing diagnosis just like every medical diagnosis has a list of patient behaviors called cues or symptoms that we can observe (they will be given to you in a case study) and are characteristic of that specific nursing problem. nanda calls these cues or symptoms defining characteristics. a related group of cues and symptoms (defining characteristics) becomes a specific nursing problem and is given a label called a nursing diagnosis. case studies specifically place key cues and symptoms into them so that students will, hopefully, be led to choose certain nursing diagnoses and nursing interventions and goals.a nursing diagnosis reference will have the definition, defining characteristics and related factors for each nursing diagnosis. this is called the taxonomy. many of the newer care plans books will contain this information. the newer editions of taber's cyclopedic medical dictionary have this information in the appendix. i have taken case studies that students have posted and shown how they are diagnosed by using the nursing process many times on allnurses. there may be a couple of them on this sticky: https://allnurses.com/general-nursin...ns-286986.html - help with care plans. when i am working with any nursing diagnosis i am always looking at a copy of the nanda taxonomy to make sure that the etiology and defining characteristics are correct in the diagnostic statement. a completed diagnostic statement should be like a photograph that captures and memorializes the nursing condition of that patient for all who read it to know

    the construction of the 3-part diagnostic statement follows this format: [font=arial unicode ms]
    p (problem) - e (etiology) - s (symptoms)
    - problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    - etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
    - symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.


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    excess fluid volume r/t compromised regulatory mechanism aeb dyspnea and +2 pedal edema
    what is the compromised regulatory mechanism you are referring to? you really should identify it. you need to know the pathophysiology that is going on. are you suggesting that it is related to the chf?
    functional urinary incontinence ?? is that better than impaired urinary elim?? i'm having so much trouble with r/t and aeb with this careplan
    the definition of functional urinary incontinence is inability of usually continent person to reach toilet in time to avoid unintentional loss of urine (page 91, nanda international nursing diagnoses: definitions and classifications 2009-2011). "function" has to do with how something is performed. this diagnosis (remember nursing diagnoses are about problems) has to do with the action of urination. this type of incontinence, or problem, is when the person can't get to the bathroom in time to be continent. the related factors that are listed for this are:
    • altered environmental factors [i would take this to mean physical restrictions posed by the physical surroundings which might be things such as stairs, poor lighting, the bathroom now being a long way away]
    • impaired cognition
    • impaired vision
    • neuromuscular limitations [this would include someone with oa and gout]
    • psychological factors
    • weakened supporting pelvic structures
    the suggested aebs for this are:
    • able to completely empty bladder
    • amount of time required to reach toilet exceeds length of time between sensing the urge to void and uncontrolled voiding
    • loss of urine before reaching toilet
    • may be incontinent only in early morning [the implication to me is that the patient moves slower in the morning, wouldn't you say? people with oa have that as a symptom]
    • senses need to void [again, the implication being that they can't get to the toilet fast enough]
    impaired urinary elimination is defined as dysfunction in urine elimination (page 98, nanda international nursing diagnoses: definitions and classifications 2009-2011). dysfunction of the action of urination means an abnormal or incomplete action or process (urination). functional urinary incontinence told exactly what the dysfunction was and started with the premise that the patient was essentially continent but others things, all of them external to the gu system, caused the incontinence. this diagnosis is used when the causes of the dysfunction are located in the gu system and it includes a whole bunch of things. the related factors that are listed for this are:
    • anatomical obstruction
    • multiple causality
    • sensory motor impairment
    • uti
    the suggested aebs for this are:
    • dysuria
    • frequency
    • hesitancy
    • incontinence
    • nocturia
    • retention
    • urgency
    ... my case study is very detailed.. too detailed to write.. but i can write some...84 yo female resides at a nursing home for the last 2 years. she was independently at home until she was no longer able to manage in her home after a hospitalization for copd exacerbation. she has ben 02 dependant for the past 2 years. presently she is being treated for a uti. as tolerated, she attends pt daily. hx: emphysema, htn, type 2 dm, oa, gout, cad, hypothyroidism, chf, pneumonia.
    this is all historical and none of it reveals any assessment data that pertains to nursing problems. the medical disease information should be explored because it provides pathophysiology for the etiology of some of the nursing diagnoses you will end up using.
  6. by   ConniePN
    i really do thank you so much for your advice... I hope my reply didn't sound critical or as though I was looking for answers. I am putting a great deal of work into this careplan and your helpful advice and tools is making it so much better!!!! ) so thank you again!
  7. by   Daytonite
    You are welcome. Good luck with your care plan. If you have more questions, just ask.

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