Need help with care plan.Nursing Diagnosis. Dialysis Fistula Infection.

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Specializes in home health, acute rehab.

Hello. I have to write a nursing careplan on the patient who was admitted with puss from Dialysis Fistula today. She also has history of Dibetes and ESRD.

They are trying to prevent systemic infection and to stop Dialysis Fistula infection. What do you think if I write Nursing Diagnosis as following:

"Risk for Systemic Infection related to Dialysis Fistula Infection"

and then in "Plan" I would write:

1.Prevent Systemic Infection

2. Resolve Fistula Infection

3. Monitor DM

4. Monitor ESRD

And then in "Implementation" I would list administration of antibiotics and other medicine related to each goal of the plan.

What should I write in "Evaluation" then? Thank you.

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

risk for systemic infection related to dialysis fistula infection

you want to prevent the patient from developing sepsis. the risk for the patient developing sepsis is more likely because of the fact that the part of their body that is infected has a direct link into the circulatory system already so it would be very easy for the bacteria to take a ride in the blood to another site to find residency. the blood system of esrd patients may be compromised because of the chronic nature of their condition. see the risk factors for infection listed on this webpage for the nursing diagnosis of
[color=#3366ff]risk for infection
.

see
http://www.merck.com/mmpe/sec17/ch234/ch234b.html

with these anticipated problems (sepsis, in this case), your goal is clearly to not any of signs and symptoms of sepsis occur. interventions need to be:

  • strategies to
    prevent
    the problem from happening in the first place

  • monitoring for the specific signs and symptoms of this problem

  • reporting any symptoms that do occur to the doctor or other concerned professional

  • if
    symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis

resolve fistula infection

is this a goal? it sounds like a goal. only a doctor can write a goal like this because "fistula infection" is a medical diagnosis.

what kind of symptoms is the fistula infection causing for the patient? fever? then use a diagnosis of
hyperthermia
. is the skin around the fistula inflamed and in need of wound care? you mentioned the patient had pus coming from the fistula. that is
impaired tissue integrity
. with poorly controlled diabetes and/or the patient being given a lot of antibiotics to clear this infection you might want to consider using
ineffective protection
instead of the
risk for systemic infection
.

monitor dm

is this another goal? it is too broad and needs to be broken down and stated in more specific parameters. however, i don't see how you are making a connection between diabetes and the patient developing sepsis since you stated the risk factor for the sepsis was a "dialysis fistula infection". how is a "dialysis fistula infection" related to diabetes?

monitor esrd

how is esrd related to the patient getting an infection? monitoring the patient's esrd isn't going to prevent sepsis from occurring.

what should i write in "evaluation" then?

the way a problem is discovered to begin with is when normal assessment findings are discovered to be abnormal. when you work with an
anticipated
problem of sepsis you are saying you think the patient might get sepsis. so, you are planning strategies to prevent that from happening. what do you evaluate? you evaluate for the appearance of the signs and symptoms of sepsis. so, one of the first things you need to do is find out what the signs and symptoms of a septic infection are because one of your interventions is going to be to monitor for them. one of your goals is going to be that the patient's vital signs remain within certain parameters. your evaluation will be whether or not the goal(s) that you wrote were achieved or not. goals are what you expect to happen when your interventions are carried out. if your interventions to prevent sepsis are carried out, the no sepsis should occur. but that needs to be stated in measurable terms. (how to write a goal statement:
https://allnurses.com/forums/2509305-post158.html
)

criteria for sirs (systemic inflammatory response syndrome) is based upon the presence of two or more of the following signs/symptoms:

  • pulse > 90 beats per minute

  • temperature > 38° c or
  • respirations > 20 breaths per minute or, blood gas of paco2
  • white blood cell count 12,000 cells/mm³ or the presence of greater than 10% immature neutrophils

sirs becomes sepsis when the bacteria causing the inflammatory response has been identified.

(see
http://www.merck.com/mmpe/sec06/ch068/ch068a.html
)

Specializes in home health, acute rehab.

daytonite, thank you very much for your reply! i tried to follow your instructions and to write the careplan. althoug, i still am not sure what to write in implementation and evaluation. could you, please look at what i wrote?

i. patient's assessment:

first level behaviors:

frank puss from dialysis fistula.

pulse ox 99% on r/a.

b/p - 124/69

p - 74

r - 18

t - 97.7 f

focal:

states that there is bleeding at the location of fistula.

states:" it's bleeding on my arm."

residual:

past history of

esrd and

diabetes mellitus

contextual:

g- 58 y.o. female, single, lives with her daughter.

generativity vs. stagnation

i - shunt infection.

h - admitted 10.27.08

m-

vancomycin, amikasin,lantus,

renagel,

nephrocaps.

ii nursing diagnosis

risk for developing sepsis related to dialysis fistula infection.

impaired tissue integrity related to dialysis fistula infection.

goal:

prevent sepsis,

resolve dialysis fistula infection.

iii plan

1. monitor for the specific signs and symptoms of sepsis.

2. report any symptoms that do occur to the doctor or other concerned professional

3. if symptoms occur, re-evaluate the care plan and change the nursing diagnosis

4. resolve dialysis fistula infection.

iv implementation

1. monitored the symptoms of fever, shaking chills, hypotension and confusion every hour.

2. i don't know what to write.

3. ?

4. a) administer vancomycin + sodium chloride

0.9$ + 250 ml

at the rate of 250 ml/hour ivpb for 60 minutes q 72 hours.

b) administer

amikacin + sodium chloride 0.9% 50 ml 900 mg ivpb at the rate of 100 ml/hour

infuse over 30 minutes q 72 hours

v evaluation

1.symptoms of fever, shaking chills, hypotension and confusion did not appear.

2.i don't know.

3. ?

4. ?

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

please spell "pus" correctly. you are spelling it "puss" which is a shortened diminutive of the word for pussycat.

frank
pus
from dialysis fistula

i don't understand why you are putting all your goals, plans and implementations together. each nursing diagnosis has it's own goals, it's own plan (nursing interventions), how it is implemented and how it is evaluated. it is all based on the evidence that supports each diagnosis.

your first actual diagnosis and problem which exists should be listed as: impaired tissue integrity related to dialysis fistula infection and should be written as impaired tissue integrity r/t chemical irritants of inflammatory response. you cannot use a medical diagnosis in a nursing diagnosis. what is the evidence that supports the impaired tissue integrity? what does this wound look like? what do you (or the doctor) want to be done to help it heal? your goal is "resolve dialysis fistula infection" and i told you in my previous post that "only a doctor can write a goal like this because "fistula infection" is a medical diagnosis." as nurses we can only help the wound to heal. the patient's body must do the healing. goals reflect the result you expect to see when the nursing interventions (plan) is implemented. you are going to "administer vancomycin + sodium chloride" which would be "give antibiotics as ordered". is there any wound care being done?

now, look at how i take that diagnosis and work a plan of care for it and how everything is related to it. i cannot get very specific because you don't give specific assessment information or specific information about what kind of care was being done other than the antibiotic that was ordered which is a medical intervention.

--------------------------------

impaired tissue integrity r/t chemical irritants of inflammatory response. ("chemical irritants of inflammatory response" is the cause of the wound having pus, redness and swelling. the chemical irritants are the chemical by-products that are produced by the inflammatory response of the body fighting off this infection at the site of the fistula)

  • goal:
    • to promote an environment conducive to the healing of the wound. (this is what you hope all your efforts are going to do)
    • or, in one week the wound will be free of pus. (this goal would be a little more specific--within a week after giving the antibiotics and maintaining sterility when doing dressing changes as well as keeping the dresssings clean as much as possible and removing soiled ones, you want to see some progress toward healing. no pus means the inflammatory response has cut back because there is less bacteria to be fought off.)

    [*]plan:

    • monitor the size and amount of drainage coming from the wound daily (you need measurements to prove the wound is getting smaller and healing)
    • change the fistula dressing daily and prn (cleanliness supports healing)

    [*]implementation (this gives specific direction on how to carry out each plan--kind of like a procedure manual):

    • each day, the wound is to be measured and described and this information documented in the patient's chart.
    • each day, the nurse will use sterile technique to change the dressing on the fistula. the old dressing will be observed for amount, type, color and any odor of any drainage that is present and the information documented in the patient's chart.

    [*]evaluation:

    • decrease in size will indicate healing is taking place (this is how you are going to tell if the intervention is working or not)
    • decrease in the amount of drainage and number of dressing changes because of dressings saturated with drainage will indicate a decrease in inflammation activity. (this is how you are going to tell if the intervention is working or not)

now, you do the same with risk for developing sepsis related to dialysis fistula infection. the risk factor, however, i think, needs to be something else. a local infection goes septic because of a compromised immune system, the antibiotics aren't working giving the infection a chance to run wild or sometimes malnutrition is enough to put the patient at risk. just having the infected fistula isn't a good enough risk factor. you should be able to come up with a goal and 2 items each for a plan, implementation and evaluation to merge with what i just posted above to complete this care plan.

Specializes in home health, acute rehab.

i tried to develop the plan for "risk for developing sepsis" diagnosis. here it is. is it good?

risk for developing sepsis related to dialysis fistula infection.

  • goal:
    • appropriate treatment will be initiated.

    • patient will be free of infection in one week.

  • plan:
    • administer antibiotic drugs as ordered.

    • monitor vital signs regularly.

  • implementation

    • the nurse will administer prescribed antibiotics in a timely manner, monitor for toxicity from antibiotic therapy and document the information in the patient's chart.

    • the nurse will monitor vital signs every hour and document any abnormal changes in the patient's chart.

  • evaluation:

    • the patient's vital sings will be consistent and won't indicate the presence of infection. the patient will remain free of fever, swelling and drainage from fistula site.

    • drug therapy will be effective.

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

if that is your best effort and you are satisfied with it, then that is all that matters, isn't it? what counts is what your instructor has to say about it. you already know my opinion about the diagnosis risk for developing sepsis related to dialysis fistula infection. good luck to you.

Specializes in home health, acute rehab.

This is only second care plan I am writing and the instructor usually gives very brief comments. Thank you very much!

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