Published Oct 28, 2008
Natasha1978
15 Posts
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.
Daytonite, BSN, RN
1 Article; 14,604 Posts
risk for systemic infection related to dialysis fistula infection
resolve fistula infection
monitor dm
monitor esrd
what should i write in "evaluation" then?
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.
4. ?
please spell "pus" correctly. you are spelling it "puss" which is a shortened diminutive of the word for pussycat.
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)
[*]plan:
[*]implementation (this gives specific direction on how to carry out each plan--kind of like a procedure manual):
[*]evaluation:
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.
i tried to develop the plan for "risk for developing sepsis" diagnosis. here it is. is it good?
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.
This is only second care plan I am writing and the instructor usually gives very brief comments. Thank you very much!