need help with diagnosis careplan

KBICU · Oct 30, 2012

Infection and shock are medical diagnosis. Look at your assessment data to help you decide. Is he really at a RISK for infection if he has all those bugs? What about impaired skin integrity? With his body contracted and his multiple wounds how do you think he feels about his self concept? Sounds like he could also be at a risk for fluid and electrolyte imbalance because with multiple wounds comes multiple areas of fluid loss and ineffective healing. Just some ideas...look at your assessment data and you will do great :)

Esme12, ASN, BSN, RN · Oct 30, 2012

My patient is a 57 year old male who is not alert to person or time. He has a flex monitor BP and pulse ox are good on room air. His lungs are diminished all lobes, hypoactive bowel all quads, incontinent stool, supra pubic cath big lateral leg ulcers and decubi on his coccyx, ishium packed with wet to dry dressing. His admitting diagnosis is urosepsis and gram + pseudomonas auruginosa and mrsa. He is contracted with MS. Should my primary diagnosis be impaired skin, infection, or shock? I need a primary secondary and a psychosocial? Please help I'm terrible with this part.

First.......

His ishium is packed???? Are you sure???? The ishium is a bone in the hip.....The ischium forms the lower and back part of the hip bone

....bone #3.

File:Skeletpelvis-pubis.jpg - Wikipedia, the free encyclopedia

What is a flex monitor B/P?

You are falling in that trick bag of looking at the medical diagnosis for your nursing diagnosis. Many students do......

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? This givens me no information about what your patient needs, what brought them to the hospital...what is their complaint? What is their history?

Sonow looking at your case scenario....

My patient is a 57 year old male who is not alert to person or time. He has a flex monitor BP and pulse ox are good on room air. His lungs are diminished all lobes, hypoactive bowel all quads, incontinent stool, supra pubic cath big lateral leg ulcers and decubi on his coccyx, ishium packed with wet to dry dressing. His admitting diagnosis is urosepsis and gram + pseudomonas auruginosa and mrsa. He is contracted with MS. Should my primary diagnosis be impaired skin, infection, or shock? I need a primary secondary and a psychosocial? Please help I'm terrible with this part.

What does your patient NEED? Are they verbal? What is their main concern/complaint? TELL me about your PATIENT! What do THEY NEED?

nurseprnRN, BSN, RN · Oct 30, 2012

I am SO feeling like a broken record this evening :) So this is a little different. If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever tempted to foolishly ignore my friend Esme's recommendation and want to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Kaysmom8 · Oct 30, 2012

Esme12, after the day I've had I feel like I'm such an idiot. Maybe I'm not cut out for this field for some reason I can't get the hang of careplans not to mention the med error I received last week. Let me try this again he is verbal but mumbles when he communicates, he is able to follow simple commands. He knows his first name but doesn't know where he's at or where he lives. He is unable to perform any ADLS. His vitals were bp 118/64, pulse 87, respirations 18, temp 97.7, O2 sat 98% on room air. My assessment finding were breath sounds diminished in all lobes, hypoactive bowel sounds, fecal incontinence, supra pubic cath with maceration and leakage, decubitis ulcer present on his coccyx also on his left and right heels and a ischial ulcer that were present on admit. He has foot droop and a contracture of his right arm with weak grip strength. He was admitted to the ER from a nursing home when he was found unresponsive, initially he was thought to have had a stroke but his admitting diagnosis is UTI- Urosepsis and currently treated with Zosyn IV 4.5 gm Q8 hr along with D5 1/2 KCL 20 meq q10 hours. He has a medical history of MS, Dm II, neurogenic bladder, bi lateral hemiplegic with right sided neglect. His labs were wbc 9.4, rbc 4.39, Hgb 9.8, Hct 29.6, Monos 15, BUN 6, Creat 0.56, Na 135, K 3.8, Alt 111, Ast 77. Sorry I can't seem to get the whole picture I appreciate any help.

Thanks

hodgieRN · Oct 31, 2012

There is a GI nursing diagnosis for pts with incontinent stool. See if you can find it :)

If he has decub ulcers, then something lead him to get those ulcers. What nursing diagnosis can you think of that would describe what caused him to get those ulcers. As Esme said, don't think of the medical reason why he got. He did or didn't do something that caused it.

He is not alert and he is confused. What nursing diagnosis can you think of for someone who is confused.

Psychosocial.....if you were in his position, would you have a certain psychological outlook on the overall situation. If you were in his condition and you looked in a mirror, would that have any impact on what you see or feel. That is a ND for that. See if you can find it...

Kaysmom8 · Oct 31, 2012

I think I'm over analyzing things, he has decub ulcers from impaired physical mobility r/t MS. He already has an infection of MRSA and P. Aeruginosa does that rule out the risk for infection because he already has one? Does his current infections pose a further risk for sepsis? I'm so frustrated because I have been working on this for 5+ hours now and have not one care plan done, I have 4 careplan books, tabers and my med surg book in front of me and yet I can't make it all fit even with the goal because he isn't capable of any of these on his own. I don't know what is wrong with me that I can't get this. Thanks for your help though I appreciate it :)

Esme12, ASN, BSN, RN · Oct 31, 2012

Esme12, after the day I've had I feel like I'm such an idiot. Maybe I'm not cut out for this field for some reason I can't get the hang of careplans not to mention the med error I received last week. Let me try this again he is verbal but mumbles when he communicates, he is able to follow simple commands. He knows his first name but doesn't know where he's at or where he lives. He is unable to perform any ADLS. His vitals were bp 118/64, pulse 87, respirations 18, temp 97.7, O2 sat 98% on room air. My assessment finding were breath sounds diminished in all lobes, hypoactive bowel sounds, fecal incontinence, supra pubic cath with maceration and leakage, decubitis ulcer present on his coccyx also on his left and right heels and a ischial ulcer that were present on admit. He has foot droop and a contracture of his right arm with weak grip strength. He was admitted to the ER from a nursing home when he was found unresponsive, initially he was thought to have had a stroke but his admitting diagnosis is UTI- Urosepsis and currently treated with Zosyn IV 4.5 gm Q8 hr along with D5 1/2 KCL 20 meq q10 hours. He has a medical history of MS, Dm II, neurogenic bladder, bi lateral hemiplegic with right sided neglect. His labs were wbc 9.4, rbc 4.39, Hgb 9.8, Hct 29.6, Monos 15, BUN 6, Creat 0.56, Na 135, K 3.8, Alt 111, Ast 77. Sorry I can't seem to get the whole picture I appreciate any help.
Thanks

YOU are not an idiot...you are learning how to be a nurse......there is nothing more humbling.

I must be misunderstanding....for where I know the ischial bone is you can't get an ulcer there. But that isn't a major point...he has decubiti.

First what is MS? what does it do? What are the symptoms of progressed MS? How does his co-morbidities (diabeties, hemiplegia) affect his care?

Look at your NANDA diagnosis....what can fit this patient....what does he NEED. He has Bowel incontinence....what is the defining characteristics of bowel incontence....per NANDA?

He has Impaired verbal Communication....related to his MS AEB........

His confusion is not ne so he has........Chronic Confusion.....R/T....AEB....

His DM II leaves him at Risk for unstable blood Glucose level...right?

His SP tube leaves him permanently at Risk for Infection........His MS causes Impaired physical Mobility that also causes Bathing Self-Care deficit....His immobility causes Impaired Skin integrity AEB the decubiti........

Do you see where this is going???? Use your books....use the NANDA definition.

PalmHarborMom · Oct 31, 2012

Esme12- An ischial pressure sore is a ulcer that forms on a patients buttocks.... You know when a young kid with a bony butt sits on your lap? That bony part of their butt that is poking you in the leg is their Ischial Tuberosity. Patients tend to get them there from sitting up too long in bed or being in a wheelchair or regular chair for too long.

Esme12, ASN, BSN, RN · Oct 31, 2012

Yup..... I know the spot she was referring to.......I was hoping the student would look up and answer my question.

I just have never hear them called that.......Interesting. Of course I Googled it and found a TON of info. That is what I get for working in critical care for 34 years.....and I'm not a big wound girl (unless it's the ED type) You never stop learning, very cool Thanks!

sjonesrn · Oct 31, 2012

For the record..I hate Care plans..lol..but ALWAYS remember SAFETY should be one of those things at the top of the list. Is he at risk for falls? etc etc. Cant go wrong with pt safet for example. Pt at risk for falls r/t MS as evident by contractions limiting physical mobility. We all had to go through it..Good Luck!!

nurseprnRN, BSN, RN · Oct 31, 2012

I think I'm over analyzing things, he has decub ulcers from impaired physical mobility r/t MS. He already has an infection of MRSA and P. Aeruginosa does that rule out the risk for infection because he already has one? Does his current infections pose a further risk for sepsis? I'm so frustrated because I have been working on this for 5+ hours now and have not one care plan done, I have 4 careplan books, tabers and my med surg book in front of me and yet I can't make it all fit even with the goal because he isn't capable of any of these on his own. I don't know what is wrong with me that I can't get this. Thanks for your help though I appreciate it :)

It might help to look at the difference between colonization and infection. Yes, any current infection and colonization poses a risk for sepsis from that organism. Christopher Reeve died of sepsis from his pressure ulcers; this is a common cause of morbidity and mortality in another big immobility population, spinal cord injury, and will likely be in your patient.

If you have a patient who is that debilitated, he is totally dependent on others for his care...and those people are the ones responsible for his pressure ulcers. There are many preventative measures for those, and apparently nobody's bothering to do them enough.

Got your NANDA-I yet? OK, probably not. And you WILL get one, right, because everyone can tell you how cranky I am about doing homework for someone, so you have to promise me...but I will go the extra mile for someone who has obviously put some thought into it and is working at it, and just needs some better direction. So here are a few choices for you. Note: you MUST correlate them with actual findings on THIS patient:

Ineffective protection: Decrease in the ability to guard self (or in this case, for the caregivers to guard him ...) from internal or external threats such as illness or injury (like pressure ulcers, right?). Defining characteristics (some or all of which I am guessing may apply in this case): deficient immunity, disorientation, immobility, impaired healing, neurosensory alteration, pressure ulcers, weakness. Related (to) factors: Inadequate nutrition (check that serum protein level, because just looking at intake is not enough to know); pharmaceutical agents (e.g., corticosteroids, others)

Imbalanced nutrition, less than body requirements: Intake of nutrients insufficient to meet metabolic needs. Defining characteristics that might apply here: body weight 20% or more below ideal range, food intake

Impaired bed mobility: Limitation of independent movement from one bed position to another. Defining chars that might apply here: impaired ability to move from one position to another, from supine to prone, to reposition self in bed, turn side to side in bed. Related factors: cognitive impairment, deconditioning, deficient knowledge (ON THE PART OF CAREGIVERS -- that counts), environmental constraints (e.g., bed size, bed type (shouldn't he have a special bed surface? OH yes he should), treatment equipment, restraints), insufficient muscle strength, musculoskeletal impairment, neuromuscular impairment, pain

Impaired skin integrity: Altered epidermis and/or dermis. Defining chars: Disruption of skin layers, disruption of skin surface, invasion of body structures. Related factors: external: (remember, these are just ome that I think might apply here, there are others) mechanical factors (e.g., shearing forces, pressure, restraint), moisture, physical immobilization; internal: changes in fluid status, changes in turgor, imbalanced nutritional state (e.g., emaciation, obesity), impaired circulation, impaired metabolic state, impaired sensation, skeletal prominence

Impaired tissue integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues. Defining chars: damaged tissue, destroyed tissue. Related factors: same as for skin, above

Impaired comfort: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural, and social dimensions. Defining chars: anxiety, crying, disturbed sleep, moaning, restlessness... more Related (to) factors: illness-related symptoms....

So.... the way you take a nursing diagnosis, once developed, and make a plan of care out of it is generally to address the cause(s) (the "related (to)") and institute measures to address, remove, or ameliorate them. Your care plan book should be helpful with that, but I am sure you can intuit some of the things that would help with most of those.

Hope that's useful. Go get that book!

I think that should get you jumpstarted now. Roll on!