Medical Dx UTI, can't seem to find Nsg Dx

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So I'm looking for a little help today, I'm always lost as far as nursing dx after taking care of someone for a few hours and then they are discharged. I always ask myself to find my priority "what needs to happen for this patient to leave the hospital." This usually guides me but I'm stumped today...any help is appreciated.

Pt admit with fever, chills, polyuria, nausea, and general weakness. Found UTI gram - sepsis treated with antibiotics. Was in hospital total 3 days. When I worked with her she was independent, no pain, no weakness, and ambulating x3 during my shift prior to being discharged.

Now, I know I should write the care plan based on the UTI, so priority Asepsis followed by pain. I'm not sure how to choose nsg dx, I don't see Infection as an option and she already has an infection so it's not Risk for. Or maybe do I do a teaching dx ie: ineffective health maintenece on ways to prevent UTIS? Any help is appreciated!

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Try going down the Impair elimination route. I could say more but you need to learn.

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Specializes in HH, Med/surg- liver & kidney transplant, ortho, ++.

I was given a little cheat sheet by my instructor that has been sooooo helpful. It is a list of all the 250 nursing dx and the FHP that it goes with. I always refer to that and then look up the dx to see if it fits my patient.

You said your pt had nausea? You could always use a dx of nausea if you

have the information to back it up.

We have to have 3 dx for our clinical worksheets. We pick 1 of the 3 and then have to write out 5 interventions with a rationale to go with it.

If you want I could scan my little cheat sheet and email it to you. PM me so we can exchange addresses.

I agree with Alex, try something under the FHP of elimination.

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I actually think I'm going to go with safety. This patient was admitted not b/c of the UTI but b/c they wanted to further observe. It was stated that the condition of the patient on admission they were unlikely to return to home. The patient recovered pretty well for their age so they were able to be d/c to home. Thanks for the reply

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i want you to think about these questions i am now going to ask you

  • how does a doctor diagnose a medical condition in someone?
  • how does a nurse diagnose a nursing problem in someone?
  • is there a difference in how these two diagnoses are arrived at?

a doctor diagnosed that uti in your patient by taking a history of the patient's urinary system (asking questions about their voiding) and listening to what the patient had to report. the doctor also did some type of examination, did vital signs and ordered a ua and possibly a c&s of the urine. some other labwork might have been done as well. this was assessment. after considering the findings, some abnormal data surfaced and some signs and symptoms became evident that suggested to the doctor that the patient's symptoms fit the profile of a uti (urinary tract infection). it was a logical decision making action that followed a step-by-step process--the medical decision making process.

the nurse receives the patient and also does an interview and history of the patient. the nurse focuses their assessment not only on the physical symptoms they have but also on their response to the illness and how it has affected their ability to perform their adls (activities of daily living). the nurse looks at what the doctor documents and orders. part of the nurse's responsibility is to carry out the doctor's orders. another part of the nurse's responsibility is to help the patient get through their day and live with the symptoms of their medical disease/condition. after considering the findings, some abnormal data surfaces and some signs and symptoms (nanda calls them defining characteristics) become evident that suggests to the nurse that the patient's symptoms fit the profile of a several different nursing diagnoses. every nursing diagnosis, like every medical diagnosis, has a set of signs and symptoms. it was a logical decision making action that followed a step-by-step process--the nursing process.

is there a difference in how these two diagnoses are arrived at? no. what is different is the set of diagnoses used by each. we nurses do not use medical diagnoses to define nursing diagnoses. we have the nanda taxonomy that does that for us. you need a nursing diagnosis reference to help you when you are new at diagnosing. there are currently 188 nursing diagnoses that have definitions, defining characteristics and related factors already worked out for you. where can you find this information? nanda doesn't just give it away:

prioritizing doesn't enter into a written care plan until you have looked at all the evidence you have assembled. and then, you consider maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs)

the fist thing you need to do in sitting down to work on this care plan is to look up and read about utis and sepsis. do not assume that a uti is simple. if it were, this patient would not have spent 3 days in the hospital for sepsis! sepsis is a serious matter and 3 days didn't fix the problem. she is hardly out of woods. she got 3 days of the "big guns" (ivs) but i'm sure she's going home on 7-14 days of some big time atbs, right? this is a medical treatment! so, what were the signs and symptoms of the sepsis? what did the chart have to say on this? i think this is still a problem that needs to be addressed and monitored for. she also needs to be watched for the side effects of the atbs she is on. at the end of your post you said something about her having some pain? what was that about? uti is likely to be a reoccurring problem. discharge planning includes diet, allowed physical activity, medications they will need to take, treatments and tests they need to be doing after discharge, follow up appointments with doctors have been made and patient knows about them, referrals to any outside agencies or support groups have been made, and teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient. this thread has weblinks to all kinds of websites where you can find information about medical diseases and conditions:

happy care planning!

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I love love love the Mosby's book on nursing diagnosis. It has a huge index by medical diagnosis and then lists possible diagnoses under each one. It's so helpful!!!

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