Need help with Maxi Map (care plan)

Daytonite, BSN, RN · Jun 13, 2006

Here are the possible nursing diagnoses based on the signs and symptoms (AEB) you listed in your post. I've listed each of the diagnoses below and listed out some of the related factors that go with those particular diagnoses below the list. There is a related factor of fatigue that you have listed with Activity Tolerance which I disagree with you on. My conflict with you is based on the source I am using to define the related factors which is the NANDA Nursing Diagnoses Definitions & Classifications 2005-2006. The "related to" factor has to be the cause of the patient's response, or resulting nursing diagnosis. So, fatigue is not really a cause of activity intolerance and the NANDA guideline clearly lists it as a defining characteristic or symptom of it. Also, there is so much physical assessment data that you don't have that could be very useful if you had it, such as lung sounds, heart rates, blood pressure readings, descriptions of the patient's skin in the lower extremities, any sputum. And what about self care deficits? How much of his daily bathing, dressing, grooming, feeding, and toileting was this man able to actually do for himself and what did he need nursing help with? Was his breathing problem or all the ICU equipment causing a lack of sleep problem for him? These are other things that nursing diagnoses could address. At the end I also list Risk for Infection related to chronic disease (diabetes). I was also thinking that the CPK might fit with Risk for Injury related to chronic disease state (cardiomyopathy or the diabetes), but didn't have time to look that up.

exertional Dyspnea/Dyspnea on exertion

Activity intolerance
Ineffective Airway Clearance
Decreased Cardiac Output
Impaired Verbal Communication
Excess Fluid Volume
Impaired Gas Exchange
Impaired Physical Mobility
Ineffective Tissue Perfusion (Cardiopulmonary)

descreased peripheral pulses - Decreased Cardiac Output

hypotension - Decreased Cardiac Output

edema

Decreased Cardiac Output
Excess Fluid Volume
Ineffective Tissue Perfusion (Peripheral)

orthopnea

Ineffective Airway Clearance
Ineffective Breathing Pattern
Decreased Cardiac Output
Excess Fluid Volume

restlessness

Ineffective Airway Clearance
Anxiety
Decreased Cardiac Output
Excess Fluid Volume
Impaired Gas Exchange

ejection fraction40% - Decreased Cardiac Output

pulmonary vascular congestion on x-ray - Excess Fluid Volume

Hbg 11.7 - Excess Fluid Volume

Hct 34.0 - Excess Fluid Volume

Anxiety - Anxiety

JVD

Decreased Cardiac Output
Excess Fluid Volume

Increased heart rate on exertion

Activity intolerance
Impaired Gas Exchange

verbal report of fatigue

Activity intolerance
Decreased Cardiac Output
Fatigue
Anxiety

Activity Intolerance – related factors are things such as bed rest, immobility, generalized weakness, being sedentary, and an imbalance between the supply and demand for oxygen – fatigue is not a related factor, but a symptom

Ineffective Airway Clearance – related factors are things such as an obstructed airway due to blockage by secretions or foreign bodies, pulmonary infection, COPD, asthma – if you have any assessment data about breath sounds, cough or sputum in addition to the dyspnea, orthopnea and restlessness you should include it with your AEB part of the diagnostic statement.

Anxiety – related factors are things such as conflict, unmet needs, situational crisis, threat of death, stress, threat to or change in health status

Ineffective Breathing Pattern - related factors include anxiety, fatigue, respiratory muscle fatigue

Decreased Cardiac Output – related factors include altered heart rate and rhythm, altered preload, afterload and/or contractility – I disagree with using the CPK of 164 as defining characteristics of this diagnosis and I'm not sure where it fits in – rather than decreased activity intolerance NANDA lists specific symptoms like dyspnea, cough, fatigue, palpitations, etc. as defining characteristics (AEB)

Impaired Verbal Communication related to physiological conditions as evidenced by dyspnea

Fatigue related to diseased state as evidenced by anxiety

Excess Fluid Volume – related factors include compromised regulatory mechanisms, excess fluid intake, excess sodium intake (BUN does not increase with fluid volume excess. It increases with dehydration.)

Impaired Gas Exchange – related factors include alveolar-capillary membrane changes and ventilation perfusion imbalances

Impaired Physical Mobility related to limited cardiovascular endurance as evidenced by dyspnea on exertion

Ineffective Tissue Perfusion (Cardiopulmonary) related to hypervolemia as evidenced by dyspnea

Ineffective Tissue Perfusion (Peripheral) related to hypervolemia as evidenced by edema

Risk for infection related to chronic disease (diabetes)

luv2shopp85 · Jun 13, 2006

Well my patient had clear lung sounds, heart rate was between 80 and 90. Blood pressure readings were low, whic i talked to my instructor about, and she determined it was normal for the patient, and she was on 2 antihypertensive drugs. Had pitting edema in lower extremeties and was wearing ace bandages around them. No sputum.

She was able to do pretty much all of her adl's without any discomfort or fatigue. She was able to do everything herself. The only thing that did cause her to get short of breath was walking up and down steps, she'd have to stop after every few steps.

She said she always sleeps good and didn't have any problems. I talked to her about sleep apnea and what it causes you to feel like and she said she didn't have any of htose symptoms which i found odd?

And I"m a little confused here... what is the difference between restlessness and anxiety? Also what is the difference between activity intolerance, and impaired physical mobiltiy? I think my brain is just dead again at the end of the day.. so sorry if these questions are stupid.

And how could i relate ineffective breathing pattern, or ineffective airway tolerance to chf? By using as manifested by orthopnea? I really dont understand the difference between the 2 of those either.

And about ineffective tissue perfusion... how do i know if my patient had hypervolemia?

luv2shopp85 · Jun 13, 2006

I didn't include all of the assessment data and lab values becaues I didn't want to make my post realllly long and then no one would read it.

But here are the various abnormal labs:

RBC 4.14

HGB 11.6

HCT 34.0

MONOS 11

GLUCOSE 152

BUN 33

CPK 164

assessment data and s/s

Decreased peripheral pulses, dyspnea on exertion, murmur, pitting edema in lower extremeties, low blood pressure, heart rate between 80 and 90 but with activity it incnreased over 100.

meds:

Mucinex, Nasarel, Advair, Avandia, Prinivil, Denadryl with Avelox to decrease itchiness, Baby aspirin, Coreg, Lasix, Glucophage, NPH insulin, Flagyl

Daytonite, BSN, RN · Jun 14, 2006

This is in answer to both your recent posts.

OK, I was just wondering if the patient had more symptoms. From what you already had she seems like a sick cookie and I was thinking perhaps there might be more symptoms than what you had listed. I was trying to visualize what this patient might look like in my mind. What I did was make a list of the symptoms from your initial post and put them onto a word document and then look at the defining characteristics of certain obvious nursing diagnoses that they seemed to belong with. I gave you choices of nursing diagnoses that might fit with the symptoms. It's up to you to chose the ones you want to go with. Decreased Cardiac Output is going to cover a lot of bases for you, so you definitely need to use that one. The symptoms you've mentioned: decreased peripheral pulses (Decreased Cardiac Output), dyspnea on exertion (Activity intolerance, Ineffective Airway Clearance, Decreased Cardiac Output, Impaired Verbal Communication, Excess Fluid Volume, Impaired Gas Exchange, Impaired Physical Mobility, Ineffective Tissue Perfusion (Cardiopulmonary)), low blood pressure (or hypotension is Decreased Cardiac Output) and increased heart rate with exertion (Activity intolerance, Impaired Gas Exchange) are already covered in the lists of nursing diagnoses I found for you.

Murmurs are a defining characteristic of Decreased Cardiac Output

Pitting edema is the same as edema. So, all the nursing diagnoses listed for edema will also apply to pitting edema (Decreased Cardiac Output, Excess Fluid Volume, Ineffective Tissue Perfusion (Peripheral))

You are asking about the difference between restlessness and anxiety. Restlessness is more of a physical situation where the patient is almost constantly moving, particularly their arms and legs when they are in bed. You can observe restlessness in a patient with your own eyes, so it is an objective observation. Anxiety is more of a subjective thing. It is a feeling of dread and worry where the person often doesn't know why they are feeling that way.

Here are the definitions of Activity Intolerance and Impaired Physical Mobility:

Activity Intolerance (definition) – Insufficient physiological or psychological energy to endure or complete required or desired daily activities. Abnormal heart rates and blood pressures are the patient's response to activity with this diagnosis. Activity will bring on cardiac arrhythmias or tissue ischemia along with dyspnea.

Impaired Physical Mobility (definition) – Limitation in independent, purposeful physical movement of the body or of one or more extremities. Use of this diagnosis is for persons who have difficulty maintaining a stable body position while performing their activities of daily living, have limited range of motion, jerky movements, tremor with movement. It also includes movement induced SOB along with those things.

Based on what you have told me about your patient, Activity Intolerance would be the more appropriate nursing diagnosis to use for her. While shortness of breath and dyspnea are elements of both Activity Intolerance and Impaired Physical Mobility, the diagnosis of Impaired Physical Mobility includes having physical conditions of the muscles/bones/joints/sensorium that are also causing the restriction of their activities. That doesn't seem like it applies to your patient, so I would eliminate that diagnosis.

Here are the definitions of Ineffective Breathing Patterns and Ineffective Airway Tolerance(?) which I take to mean Ineffective Airway Clearance:

Ineffective Breathing Pattern (definition) – Inspiration and/or expiration that does not provide adequate ventilation. Here are the related factors (causes) of this diagnosis per NANDA: hyper- or hypoventilation, bony deformity, pain, chest wall deformity, anxiety, decreased energy, fatigue, neuromuscular dysfunction, musculoskeletal impairment, perceptual or cognitive impairment, obesity, spinal cord injury body positioning, neurological immaturity, and respiratory muscle fatigue. So, what the diagnosis is saying is that the patient is basically capable of breathing normally, but is restricted in some way by a physical problem or restraint placed upon him.

Ineffective Airway Clearance (definition) – Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. In addition to the dyspnea, orthopnea and restlessness the patient has mucus and retained secretions in the respiratory tract. Diminished breath sounds as well as any rales, rhonchi and wheezes and any kind of productive cough will qualify the patient to have this diagnosis. By the way, is this patient on Flagyl for a respiratory infection? Because if she is then this nursing diagnosis will support that.

Moving on. . .Ineffective Tissue Perfusion (definition) – decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. Hypervolemia and hypovolemia are both related factors of this diagnosis. As far as hypervolemia is concerned, what are the signs and symptoms of hypervolemia which is an increase in the volume of circulating blood? Does your patient have any of those symptoms? If not, then you won't use this diagnosis.

I don't know where to fit all your labwork in to the diagnoses, particularly the blood counts and the BUN. The low blood counts may be a manifestation of her chronic condition. The BUN, I just don't know. A BUN of 33 is not something that the docs get worried about even though it's slightly elevated.

I think I would add a diagnosis to handle the diabetes which is under control, is it not? That diagnosis would be Effective Therapeutic Regimen Management related to diabetes mellitus as evidenced by blood sugar of 153 which is within a range of expectation. This will cover the Insulin and Glucophage.

A point for you to remember about nursing diagnoses. . .a nursing diagnosis DESCRIBES the patient's RESPONSE to whatever the related factor(s) is(are). So, when you are using CHF as a related factor, think of all the responses the patient exhibits because of the CHF. That is how you chose the nursing diagnoses to use. If the patient's response is to keep their disease condition (such as diabetes) under control, then Effective Therapeutic Regimen Management is an appropriate nursing diagnosis to use. What I gave you was potential diagnoses that you could use with each symptom. It's then up to you to figure out which of those diagnoses will be the most appropriate. In some cases it will be cut and dry as in the case of choosing between Ineffective Breathing Pattern and Ineffective Airway Clearance. In other cases, two different diagnoses may be perfectly appropriate and it is just a matter of deciding which will be the better choice—it's a totally creative decision on your part. The purpose of the diagnostic statement is to help you rationalize that you have chosen well.

Do you have a care plan book or handbook that gives you definitions of each of the 172 NANDA nursing diagnoses? This might be a big help for you. I have been using Carpenito's books up to now, but I just ordered Ludwig's care plan handbook the other day and am waiting for it to arrive. I want to see for myself if it is as good as all the reviews about it are.