Need help with creating a nursing dx with the R/T please

Daytonite, BSN, RN · Nov 21, 2008

apply the steps of the nursing process. that is how you find the nursing problems and the pathophysiology the "related to" parts that apply to them. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - this is a person who you say "feels mostly healthy for a woman her age but she is of course limited, low on energy". i am 58, had colon cancer last year, had surgery, 6 months of chemo, didn't have half her symptoms and felt like a mac truck ran over me. as i was reading the assessment and organizing the data i was amazed that this woman was up and walking around. seriously, i think she's got one foot on a banana peel. my concern is for her cardiovascular status with this greenfield filter, being on the coumadin and she now has sob. they are looking for metastasis of this cancer. is she on any other medications for her heart?

medical diseases/conditions:
- ovarian cancer (diagnosed in 1998, battling for 10 yrs)
- hypoxia
- nausea
- vomiting
- diarrhea
- substernal chest pain w/ sob
- gastroesophageal reflux disease
- hypertension
- osteoarthritis - how does this affect her mobility and adls. is she jumping out of bed in the mornings? is she taking something for it, perhaps some of those vitamins or supplements? osteoarthritis causes permanent damage to the joints.
- crest syndrome - did you look this up? it is related to raynaud's syndrome. what signs and symptoms does she have? how does it affect her sensations and movements of her hands and fingers? is her calcified aorta related to this?
- calcified aorta
- history of small bowel obstruction
- history of 1 or 2 deep vein thromboses
- partial hysterectomy/ total abdominal hysterectomy
- had a hip abscess that was drained a couple of times
[*]medical treatments:
- oxygen
- has a greenfield filter
- has an infuse-a-port in her right chest
- scheduled for a bronchoscopy
- scheduled for more chemotherapy (carboplatin and gezmar)
[*]medications:
- coumadin - side effects?
- nexium
- phenergan (for nausea)

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i think there may be a lot more abnormal assessment data than you have listed which you just missed. this is why looking up the signs and symptoms as well as complications of a patient's various medical conditions will often jar something you remember seeing or observing that you didn't think important at the time. this patient has multiple problems going on. the chemotherapy alone leaves all kinds of side effects in its wake.

substernal chest pain w/sob
states she doesn’t like drinking fluids
low on energy
lost hair as a result of chemo - how does she deal with this?
widowed - who does she depend on for emotional support? does she live with anyone? how does she get to appointments? how does she get to shopping, etc?

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - i think the reason instructors impose this "can’t use a nrg dx more than once" is because they want to get students to think about the evidence (signs and symptoms) the patient has and what nursing problem it is actually posing. you can actually diagnose many things two different ways if you word them carefully. my question would be--what diagnoses have you already used? "risk for" diagnoses are not actual nursing problems. this lady has several actual nursing problems which are being missed. however, i can't tell if you are missing them because you've already used that diagnosis (in which case i would need to figure out another diagnosis for them) or you just flat out missed diagnosing the problem to begin with. so, i will just diagnosis and you'll have to tell me and we'll figure itout later on. what does she do about her hair loss? does she go around without anything covering her head? does she hide the baldness with hats or a wig? the american cancer society assists women with this problem. city of hope which is a huge cancer treatment center where i live has a shop in it that is specifically for women (and men, too, i guess) that have lost their hair as a result of chemo or radiation therapy. they have the niftiest hats and scarves to cover the head in there.

ineffective breathing pattern r/t pain and fatigue aeb shortness of breath
activity intolerance r/t imbalance between oxygen supply and demand aeb shortness of breath
deficient knowledge, bronchoscopy r/t unfamiliarity with information resources aeb [will need a verbalized statement or some evidence to indicate that the patient needs information about this procedure and what it involves]
disturbed body image r/t chemotherapy aeb intentional hiding of head when around others due to complete loss of hair - the covering of the head with a hat or wig may seem subtle, but it is intentional and it is to promote a specific body image.
risk for imbalanced fluid volume r/t upcoming chemotherapy
risk for injury r/t altered clotting factors [this is specifically referring to a risk for hemorrhage because of being on blood thinners--the coumadin]
risk for infection r/t invasive medical equipment [this is specifically referring to a risk for sepsis because of the presence of the infusa-a-port, especially if it is being accessed.]

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem - now you can write your goals and interventions.

risk for infection r/t compromised/ suppressed immune system - what compromised immune system? her white count is normal.

risk for infection r/t chemotherapy - it is not the chemotherapy that causes infection

risk for situational low self esteem - i don't agree

risk for disturbed body image - i think this already exists--see above

i am not one to jump into using psychosocial diagnoses unless there is good evidence for them. psychosocial diagnoses are difficult to determine interventions for if you don't know anything about them. stick with what you do know and can treat.

Ambitiouz · Nov 21, 2008

Thank you for your response.

This client was very social when I was with her. She never spoke of her hair loss bothering her but I didn't specifically ask her directly because I didnt want to be rude but she was very nice. She walked alot and was very limber. She did not cover her head at all. Her son did later come visit and brought her a hat. She said that she lives alone with her mininature dauchshund and doesn't have any dependents. I used 'risk for' because I didn't really see evidence that she had self-concept issues about her hair loss. I forgot to add that she does have a history of chronic neuropathy. I am not allowed to use fluid deficit since we haven't covered that in lecture. I have already used ineffective breathing as a dx. I had not thought of the other dx's you mentioned. I think I will use the risk for infection r/t invasive medical equipment since she has a port and had a bronchoscopy. She mentioned that she doesn't believe she needs to be on home O2, so she was hoping that her bronchoscopy results would reveal that it was unneeded. She said that she believed she was immunosuppressed and took several vitamins daily. I was also thinking that since she doesn't drink fluids often, she could be at risk for a bladder infection as well. I agree that there is not enough evidence for the psychosocial dx, I am having trouble getting enough assessment data to support it. I asked her directly about any breathing problems, she stated she has had pneumonia a couple times, but that she wasn't particularly SOB. By looking through her chart, I was able to find out about the chest pain. She is taking plaquenil, nexium, phenergan, atrovent and lisinopril in addition to the coumadin.

Daytonite, BSN, RN · Nov 21, 2008

she never spoke of her hair loss bothering her but i didn't specifically ask her directly because i didnt want to be rude but she was very nice. she did not cover her head at all. her son did later come visit and brought her a hat. i didn't really see evidence that she had self-concept issues about her hair loss.

one thing that you will need to learn as a nurse is that we ask questions to learn information and being rude has nothing to do with it. we have to learn to get over our own uncomfortable feeling at discussing subjects that we think might be rude to the patient or uncomfortable to us. our object in doing this is ultimately to help the patient and that is our focus. covering up the head

is

a symptom of

disturbed body image

. i posted a link to a webpage on it so you could read the defining characteristics of this problem. it might not seem like a big, overwhelming, hit you in your face, kind of symptom, but it is, nonetheless, a defining characteristic of this diagnosis.

she does have a history of chronic neuropathy.

i was wondering if there was any of this related to the crest syndrome or as a result of side effect of prior chemotherapy. this is

disturbed sensory perception

(probably tactile)

r/t altered sensory reception

(

disturbed sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory

). there needs to be more specific symptoms to define exactly what the patient experiences.

i have already used ineffective breathing as a dx.

then use

activity intolerance

.

she mentioned that she doesn't believe she needs to be on home o2, so she was hoping that her bronchoscopy results would reveal that it was unneeded. she said that she believed she was immunosuppressed and took several vitamins daily. i was also thinking that since she doesn't drink fluids often, she could be at risk for a bladder infection as well.

these are obvious misconceptions on her part that require correcting and education. this is abnormal and is a patient problem. the diagnosis to use to do that is

ineffective health maintenance r/t ineffective coping aeb belief that she doesn't need to be on home oxygen although o2 sats are below 80% and the belief that she is immunosuppressed although labwork reveals that wbcs are within normal limits

. this diagnosis allows you to teach her why she needs to use oxygen and what immunosuppression is.

she is taking plaquenil, nexium, phenergan, atrovent and lisinopril in addition to the coumadin.

plaquenil is an interesting medication to be taking. it is usually given for malaria or problems with arthritis. it also has a big side effect of anemia and thrombocytopenia. i'm wondering if this might be where some of her fear of immunosuppression comes from? why the heck was she put on this? is it related to the crest syndrome?

Dianacabana · Nov 24, 2008

she never spoke of her hair loss bothering her but i didn't specifically ask her directly because i didnt want to be rude but she was very nice. she did not cover her head at all. her son did later come visit and brought her a hat. i didn't really see evidence that she had self-concept issues about her hair loss.
one thing that you will need to learn as a nurse is that we ask questions to learn information and being rude has nothing to do with it. we have to learn to get over our own uncomfortable feeling at discussing subjects that we think might be rude to the patient or uncomfortable to us. our object in doing this is ultimately to help the patient and that is our focus.

its not particularly related to the topic at hand but i do have a difficult time with being "polite." this reinforces what i was just writing in my daily journal entry! although it may not have been the point of your post, daytonite, this helps clarify what i need to remember.

thanks so much (as always!) :bowingpur