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Discussion

Need help in Identifying the nusing diagnosis

i need to make my first care plan, but not sure how to proceed. please help.

this is the scenario:

j.p. is an 87 y/o female residing in an e.c.f for 3.5 years, after progressive decline in function. she has been using a wheelchair x2 years, is aao x3. past medical history: hypertension, osteoarthritis. three weeks ago she asked the cna to provide her with diapers since she would be staying in bed from now on, stating she wants to enjoy her favorite t.v shows. today the cna noted persistent erythema in sacral area. the nurse just medicated j.p. for joint pain (8). the patient tells her she does not want interruptions. she wants to rest.

current meds: norvasc 5mg po twice daily, naproxen 200mg po every 12 hrs prn

i am considering "impaired physical mobility" as my diagnosis. related factor is pain and is evidenced by asking for diapers . but the reason for asking diaper is enjoying the tv too. so i am not very confident with this diagnosis.

from my understanding, persistent erythema is "risk for impaired skin integrity" and so i can not have that diagnosis, b'cos i need to have a real one.

i am considering "activity intolerence" too.

give me some help. thank you.......

Featured Replies

  • Expert

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans sticky for information on constructing a care plan.

follow the steps of the nursing process. tear the scenario apart and pull out all the data and organize it. you can't do anything until you assess what is going on.

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 - before beginning you need to look up information about this patient's two medical problems (hypertension and osteoporosis) and find out what their pathophysiology is, their signs and symptoms and what their complications are. you will need that information for the development of any nursing diagnostic statements later and you need to know if any of the behavior she is exhibiting is a potential complication. you also need to look up each drug she is getting and find out why patients get this drug (maybe they forgot to tell you about a medical condition) and what the side effects of them are. again, you need to know if any of the behavior she is exhibiting is a potential side effect of the medication she is taking.

  • medical diseases
    • hypertension
    • osteoarthritis

    [*]medeical treatments

    • norvasc - antihypertensive/calcium channel blocker
    • naproxen - nsaid

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i made a list of data from the scenario. some of it is very clear and some of it suggests some behavioral changes on the part of the patient. certain things are very clear: her age, that she uses a wheelchair, that she has joint pain (because the nurse medicates her for it), that she has erythema (redness) on her sacrum and that she has taken to staying in bed. at 87 years old with osteoarthritis she may be too tired and in pain to want to move. what did you find out when you read about osteoarthritis?

  • has joint pain
  • uses a wheelchair (unable to walk without assistance)
  • told cna 3 weeks ago that she would be staying in bed and asked to be supplied with diapers
  • wants to stay in bed, watch tv and not be interrupted
  • wants to stay in bed and rest
  • persistent area of erythema in sacral area

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 - this is the point where you can start to identify the nursing diagnoses, not before doing all the above. the list of symptoms just above will become the defining characteristics of the nursing diagnoses you decide to use. your reading back in step #1 helps you identify the etiologies for the diagnoses:

  • impaired physical mobility r/t joint pain aeb inability to walk without assistive device and wants to stay in bed and rest (controlling behavior)
  • acute pain r/t inflammation of joints aeb joint pain
  • impaired skin integrity r/t pressure and physical immobilization aeb persistent area of erythema in sacral area

  • ineffective coping r/t inability to face problems aeb wants to stay in bed and rest and asked to be supplied with diapers and wanting to stay in bed, watch tv and not be interrupted, or you could use ineffective health maintenance r/t ineffective coping aeb wants to stay in bed and rest and asked to be supplied with diapers and wanting to stay in bed, watch tv and not be interrupted

step #3 planning (write measurable goals/outcomes and nursing interventions) - your goals and interventions are aimed mostly at the aeb items. sometimes you can target the etiology (related to) item, but not always.

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

"impaired physical mobility" related factor is pain and is evidenced by asking for diapers and enjoying the tv too.

yes, you can do
impaired physical mobility r/t pain
. however, it isn't fully describing the underlying etiology, or cause of the pain. this patient has osteoarthritis which means her joints are inflamed. inflammation produces these 4 symptoms: redness, heat, swelling and
pain
. you should burn those 4 symptoms into your memory. any medical condition with "-itis" on the end of it will have those symptoms. it is the inflammation caused by her disease process that is the reason for the pain, so you didn't get close enough to the etiology.

"
asking for diapers and enjoying the tv too
" are not proof that her ability to move is limited. that is the result of her inability to move. proof of limited physical movement is actually seeing the patient having difficulty moving, slow gaits, the patient telling you "i have a hard time walking", "i can barely lift my arm up to get clothes out of the closet."

you can see the related factors and defining characteristics for this diagnosis listed on these webpages:

"risk for impaired skin integrity" because of the persistent erythema, but i can not have that diagnosis, because i need to have a real one.

a nursing diagnosis is a label. (
definition
: a descriptive word or phrase attached to an object to indicate its nature and contents.) you might label a drawer "pens" but you still look inside it to see if what you want is there because the label is only suggestive of what is in the drawer. the same is true of nursing diagnoses. they are only labels. to get the true intention of what a diagnosis is you need to read its definition which is a much longer statement and is found in the taxonomy. the definition for
risk for impaired skin integrity
is
"at risk for skin being adversely altered
" (page 200,
nanda-i nursing diagnoses: definitions & classification 2007-2008
) and the definition for
impaired skin integrity
is
"altered epidermis and/or dermis"
(page 199,
nanda-i nursing diagnoses: definitions & classification 2007-2008
).
impaired skin integrity
includes stage i and ii skin ulcers. a persistent area of erythema on the skin of the sacrum is a classic beginning stage i decubitus ulcer. so,
risk for impaired skin integrity
would be inappropriate to use.

for information about wounds and ulcers (because you will see this come up a lot in nursing) see

you can see the related factors and defining characteristics for this diagnosis listed on these webpages:

i am considering "activity intolerance" too.

going back to the definition of these diagnoses, the definition of
activity intolerance
is
insufficient physiological or psychological energy to endure or complete required or desired daily activities
(page 3,
nanda-i nursing diagnoses: definitions & classification 2007-2008
). now, that does kind of sound like what is going on with this patient, but there is a problem of evidence. this particular diagnosis is actually classified by nanda as being in the cardiovascular and pulmonary class. the evidence that a patient needs to qualify for this diagnosis, according to nanda, are ekg and heart changes as well as shortness of breath with movement. this patient doesn't have any of that kind of evidence to support
activity intolerance
. she doesn't even want to move! my feeling is that her not wanting to move at all was her own misconception of how to deal with the pain of her joint disease: if she doesn't move, then she won't have pain. that is how she figures she is going to deal with it. little old people come up with some cockamamie ideas sometimes. that falls into the category of
ineffective coping
because it is psychosocial. another diagnosis that could be used would be
ineffective health maintenance r/t ineffective coping aeb
wants to stay in bed and rest and asked to be supplied with diapers and wanting to stay in bed, watch tv and not be interrupted
[these show a lack of adaptive behaviors to a health problem]. [
ineffective health maintenance
:
inability to identify, manage, and/or seek out help to maintain health
]

Are you looking at this as a pressure ulcer? Id research stage 1 pressure ulcers....somethings that i would relate to a pressure ulcer is

1. Risk for impaired skin integrity

2. risk for impaired mobility

3.risk of secondary infection

just somethings i thought may go but like i said id research it...there are many great examples of care plans online!

  • Expert
are you looking at this as a pressure ulcer? id research stage 1 pressure ulcers....somethings that i would relate to a pressure ulcer is

1. risk for impaired skin integrity

2. risk for impaired mobility

3.risk of secondary infection

just somethings i thought may go but like i said id research it...there are many great examples of care plans online!

let me explain why these diagnoses you are relating to a pressure ulcer for this patient are wrong. . ."persistent erythema in sacral area" is classic for a stage i pressure ulcer. go on the websites i listed in my previous post and read the information that explains the staging of pressure ulcers. combine that with the information provided in the scenario that the patient has started to remain in bed x 3 weeks ago. this is definitely impaired skin integrity. the time for risk for impaired skin integrity is long gone. risk for impaired mobility has nothing to do with the decubitus. this patient has no infection. she has a chronic inflammatory condition--osteoarthritis. diagnosing risk for secondary infection is inappropriate since no primary infection exists.

fyi. . .there are not many great examples of care plans online. i know because i've looked. if you find any complete, free care plans with diagnoses, goals/outcomes and nursing interventions on the internet please post the urls here.

  • Author

I really appreciate your reasoning ability and good heart. I really felt like sitting in front of an instructor.

Thank you very much for enlightening my brain with so much knowledge. Now I can see the scenarios in a more organised way to identify the etiology and evidences.

I never thought of ineffective coping or health maintenence, but was looking for something like that rather than physical mobility or skin integrity. In this scenario ineffective coping or health maintenence is more appropriate as there are lot of evidences.

Since I do not see any ABC's, I am going for the Safety concern and I see all the above diagnoses except ineffective coping are categorized as safety. For me ineffective coping takes priority over health maitenence, but, since is coping is not safety, I have to chose health maintenance.

Once again thank you for your time and knowledge. If you have any more thoughts please post it.

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