need help with a care plan on MRSA

Daytonite, BSN, RN · Apr 29, 2008

impaired tissue integrity related to presence of infection as evidence by fever, chills, and pain in left shoulder.

there are problems with this diagnostic statement. this is not a correctly composed nursing diagnostic statement.

first of all,

impaired tissue integrity

defined is

damage to mucous membrane, corneal, integumentary or subcutaneous tissues

(page 227,

nanda-i nursing diagnoses: definitions & classification 2007-2008

). i would be expecting to see a description of some sort of open wound when using this nursing diagnosis. rather than use infection as the cause (etiology) of the problem since it is more of a medical decision, i would use the wording "inflammatory process" since inflammation precedes and accompanies all infection anyway. (cardinal signs and symptoms of infection are redness, heat, swelling and pain.)

secondly, fever, chills and pain are not evidence of

damage to mucous membrane, corneal, integumentary or subcutaneous tissues

. fever and chills are systemic evidence of infection. pain in the left shoulder sounds like a musculoskeletal problem.

fever and chills are defining characteristics (symptoms) of the nursing diagnosis of

hyperthermia

. pain in the left shoulder is a defining characteristic (symptom) of either

acute pain

or

impaired physical mobility

, but i can't know that since there's no other information about the patient provided.

i need help with goals and also some interventions.

can't be of much help until the correct nursing diagnosis is made. goals and interventions are based on the patient's symptoms which in this case would be the fever, chills and pain in the left shoulder.

here are interventions for the diagnosis of

hyperthermia

where the supporting evidence (symptom) is fever:

hyperthermia

- nanda's definition of hyperthermia is

body temperature elevated above normal range.

(page 108,

nanda-i nursing diagnoses: definitions & classification 2007-2008

). normal range is from 96.8 to 99.5 (oral), 97.3 to 100.2 (rectal), and 97.2 to 100 (tympanic). [page 40,

expert 10-minute physical examinations

] nursing interventions are of 4 general types. they:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
care/perform/provide/assist (performing actual patient care)
teach/educate/instruct/supervise (educating patient or caregiver)
manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

so. with those guidelines in mind, here are nursing interventions for hyperthermia:

assess and monitor:

record the patient's temperature every four hours
assess for other symptoms of fever: diaphoresis, chills and fatigue

patient care interventions:

increase fluids and provide a high nutritional diet
keep the room at a stable environmental temperature
provide linen and gown changes as necessary for patients who are diaphoretic
give antipyretics as ordered by the doctor

teach the patient:

the importance of increasing fluid intake
the proper dose of the antipyretic they are to take and any side effects to watch for

notify

the physician for a fever that is persistently over 102 and/or not responding to antipyretics (there may be doctor's orders or a facility policy for this).

goals will be based on the expected outcome of these interventions. for information and direction on how to write goal/outcome statements, see this post:

https://allnurses.com/forums/2509305-post157.html

shothannah · Jan 28, 2011

Hello, just one question..

"WHY ARE WE CHILLING IF WE HAVE A FEVER"???

As i know, chilling is our body's mechanism to increase the temperature of our body, right??

Then why are we chilling if we already have a fever where in the first place our body's temp is already high..

Its a paradox for me, i know there is an explanation but i can't find one..

Thanks in advance..

More powers!!!