Need help for a Nursing care plan

lwhatley · Nov 16, 2013

Alright, I'm not sure if there is some sort of language barrier going on here or if you're genuinely confusing terminology, but let me clarify a few things so that you can correctly refer to these things in the future...

I have a pt who diagnosis with fever of unkown origin.

should probably be: I have a patient with a diagnosis OF fever of unknown origin. (even though the symptoms you list with the chief complaint, specifically the diarrhea, can arguably be considered evidence of an infection process) but we don't have to fight the medical diagnosis, at least not now, lets focus on the other elements related to a nursing diagnosis/care plan.

for my nursing intervention i have are
1, infection r/t disease process as evidence by temp 101.9 and pt received with antibiotics.
2, risk for electrolyte imbalance r/t diarrhea

The items that you have listed are referred to as nursing diagnoses, which even then aren't constructed 100% correct, but they are not nursing interventions. A nursing intervention is what you, as a nurse, DO to treat the patient. Nursing interventions are the implementation of actions that are outlined in a nursing care plan, which is generated after a nursing diagnosis is made. Nursing diagnoses are developed after conducting a nursing assessment. I'll go more into why your listed diagnoses are incorrect later on in this post.

With all that being said, I can try and help you brain storm other possible nursing diagnoses to consider, but the summary you've given about this patient is really limited (this means you need a more comprehensive patient assessment in order be able to apply multiple diagnoses to this patient)

I'll try to outline my thinking process for you to maybe apply in your future of development of nursing dx's and care plans...but again, this is a really constricted scenario given the lack of information about the patient.

1. What I know:

Patient is moderately feverish (101.9) suffering from diarrhea (for an unknown amount of time, unless you have that information handy), being treated with a course of antibiotics.

Normally during this first step, I've usually got a lot of information from a thorough patient assessment to draw from. A thorough patient assessment will allow for you to draw information about not just the physical symptoms the patient is presenting, but also about non-physical conditions that would be beneficial to address in a nursing care plan, things like: ability to cope with stress/illness, support system, learning/language barriers, medical/physical history that could relate to the current condition, etc. Before sitting down to write a care plan, make sure you've done as thorough of an assessment as you could. Sometimes this isn't possible due to time constraints and patient presenting unresponsive, in these isolated incidence, just get as much of an assessment done as you can, develop some nursing diagnoses and a plan of care, and re-assess and revise it when an opportunity to better assess the patient arises.

2. Relate what was listed above to the systems that will be effected, the actual problems present that can be associated with the current condition, and potential problems that can arise from the information given that should be prepared for or prevented.

Fever/hyperthermia: an increase in body temperature. Usually in response to infection or disease, but sometimes related to medications, teething, autoimmune disorders, some cancers, or endocrinological malfunction.

do I have any information from my assessment to support any of the listed causes of fever that I have just made?

No, not really, only the exact temperature to support me calling this fever a fever. Not really important though because we aren't aiming to make a MEDICAL diagnosis, we just want information that could be used to support any nursing diagnoses we may eventually come up with relating to the objective finding. Getting this kind of information in most cases would require a medical history, lab results, and other information only available through directly asking the patient. Moving on.

What do I know about the systemic effect of a fever?

Given the massive amount of information I could list here, I won't go into great detail, but just know that part of narrowing down (or sometimes expanding) your options for applicable nursing dx, considering the systemic effect of reported symptoms or history could include or eliminate options from the list of possible dx. In this case, the most obvious effects of a fever involve increasing the body's consumption of resources/energy by way of an increased metabolism, so I take this info and I run with it..

-->increased metabolic processes lead to an increase of waste products-->waste products have to be eliminated-->elimination of this kind, for the most part, involves the kidneys. Increased metabolism also requires fuel from natural stores (water, glucose, blood cells), which is transported via a vascular system undergoing stress of the increased demand.---kinda getting my point?

Do this step with as many elements of the patient assessment you believe are the most pertinent to both the short term and long term goals of care of the patient (the goals can change anywhere throughout this process). This thinking process is what lays the foundation of choosing nursing dx's from the big list. This step obviously takes the longest, especially if you're in need of critical thinking practice or if you need to review pathophysiology.

In this case, I would consider the systemic effect of diarrhea, and then I might consider the psychosocial implications of these symptoms (like stress, embarrassment, inability to go to work...). If I had any information from a medical history, specific medication list, or other physical complaints, I'd consider them in relation to the "big picture". Remember, everything listed and considered should take into consideration not just treating the disease process but the entire patient...that's what nursing is after all, a holistic approach.

Be sure to consider risks and complications that could present throughout the case. This serves to consider preventative measures to enact, or to prepare a plan to respond. This information is particularly helpful in patient teaching.

This step is really the meat of critical thinking. It's taking knowledge that you know from studying nursing theory, combining it with the facts of the patient situation/ailment and the assessment you've done, and translating it into appropriate diagnosis and plan of care. It requires abstract thinking, objective evaluation, and consideration of both real and potential factors.

3. Scour the big list of NANDA approved nursing dx's. You can only apply them to this patient if you're able to defend it with facts from the brainstorming you did in step 2

This step should follow a format similar to this:

[Nursing Dx worded as a NANDA statement] related to [the medical diagnosis (careful, be sure this symptom is undoubtedly related to it, or it's not accepted as an appropriate defense) and the major OBJECTIVE signs and symptoms] as evidenced by [subjective symptoms (patient behavior, pt's reports, and other non quantifiable data you've collected in the assessment)]

if your nursing dx/NANDA statement is "at risk for ____" this means you are diagnosing a potential problem. Potential problems don't exist yet, therefore there can't be evidence of the problem yet. Do not include the "as evidenced by" portion of the format above for at "at risk for___" NANDA statements.After you practice developing care plans more, you'll realize that most "at risk for" diagnoses are incredibly difficult to expand into a thorough plan of care and therefore should not be prioritized. Keep this in mind in your future of nursing, actual problems will ALWAYS be higher on the list of priorities than potential (a.k.a "at risk for") problems. Your plan of care should first and foremost address actual, current patient problems.

On to the list:

These are the dx's I find most applicable to the given patient scenario it would probably include more if there was more pt information provided...

- At risk for ineffective tissue perfusion r/t hyperthermia.

- at risk for compromised human dignity r/t diarrhea as evidenced by inability to control the urge to defecate before reaching the restroom. (this dx would only work if you could prove in your assessment that the patient had no control of his bowels and was also embarrassed by it)

- Bowel Incontinence r/t GI upset as evidenced by multiple episodes of uncontrollable diarrhea. (again, this dx can only be made if you have the assessment data to support that his episodes of diarrhea are uncontrollable, and you can't relate this symptom to the fever because there isn't evidence supporting a direct relation. No assumptions allowed in nursing dx).

- Diarrhea r/t frequent bowel movements of loose stool as evidenced by patient chief complaint.

- At risk for electrolyte imbalance r/t diarrhea (claiming an actual electrolyte imbalance problem would require patient labs like a CBC/Chem 10 panel, to quote as "as evidenced by")

- at risk for fluid volume deficit r/t diarrhea (not an actual problem until vital signs, labs, and physical s/s can prove it)

- at risk for fluid imbalance r/t fever

- at risk for acute confusion r/t fever

- Impaired comfort r/t diarrhea as evidenced by patients report that "[iNSERT QUOTE ABOUT THE DISCOMFORT BROUGHT ON BY DIARRHEA EPISODES]"

-Imbalanced body temperature r/t diagnosis of fever of an unknown origin as evidenced by temperature reading of 101.9

- Hyperthermia r/t temperature of 101.9 as evidenced by patient reports of heat flashes and chills.

- At risk for impaired skin integrity r/t diarrhea (this, like many of the other "at risk"s listed above can be converted into actual problems [so you can drop the "at risk" at the beginning] if you can use collected data/evidence to support the presence of the subject. In this case, if you assessed the perineum/orifice/butt as being red, swollen, tender to the touch, chapped, bleeding, etc, then you have evidence to support the presence of an actual skin integrity problem.)

- Ineffective thermoregulation r/t fever as evidenced by patient reports of "chills".

As you can see a couple of these are repetitive, but that's only because I was only given 2 symptoms and an active therapy to work with while considering the list of dx's. Because you have no further assessment data provided, a lot of them have to remain "at risk" problems until you can provide data that supports the presence of the actual problem (vital signs, lab work, history, pt complaints, etc)

Where you went wrong on your initial list is on your number 1: "infection r/t disease process as evidence by temp 101.9 and patient received with antibiotics". You made some common fundamental errors.

First, you cannot claim that there is an actual problem of infection. Nothing in the patient summary you provided supports that claim, especially not the medical diagnosis you reported was made as: "fever of unknown origin". Claiming infection would be an example of you using the symptoms (fever and diarrhea) to diagnose a medical condition. While it isn't necessarily wrong to associate the presence of fever and diarrhea as probable indicators of an infection process, the correlation of these symptoms to that conclusion is not in your scope of practice as a nurse.

This infection claim would need to remain an at-risk diagnosis until a medical diagnosis or positive lab culture confirms a bacterial colonization (which would be an infection with or without the need for a doctor to confirm it as a diagnosis).

Secondly, even if we were to ignore the fact that the infection claim was invalid, relating it to a "disease process" does nothing to provide evidence of the claim. Mostly because an infection IS a disease process. A disease process is also not an objective finding (unless it is specifically named by a doctor officially making a medical diagnosis).

Lastly, and probably the biggest thing wrong with the entire statement is the fact that you included "patient received with antibiotics" (which I'm sure is meant to read "pt treated with antibiotics") as evidence. You cannot use a treatment/therapy as evidence to the claimed PRESENCE of a problem especially in the form of a prescription of antibiotics being evidence of the presence of infection, most simply because if you just look at the issue rationally, the wrong drugs get prescribed all the time, or drugs sometimes get prescribed for off-label purposes, simply possessing a prescription for any drug doesn't definitively mean you have the ailment said drug is meant to treat...but I guess that's really not the point. In nursing care plans, you really don't use the prescribed therapies to a problem as evidence to the existence of problem itself ever. It wouldn't make much sense.

In this specific case, the only useful way we could use the information regarding the patient being prescribed an antibiotic in relation to a nursing care plan would be to associate it with a RISK of infection r/t prescribed antibiotic therapy...the rationale behind this would be reasoning like: the risk antibiotic therapy poses on hospitalized patients for c-diff, the risk of a super infection from bacterial resistance or opportunistic infection exposure. The beauty of nursing diagnoses is that if you collect enough information from your patient, you could potentially qualify SEVERAL NANDAS. The key is having the information/data to back up any claim you make, especially if you're going to attempt to claim an issue as an active on-going problem, and always remember that we aren't doctors, we, as nurses, can't diagnose medical conditions/diseases, but we can come really really close.

I know this was a really really really long post, but I remember how frustrated I was in nursing school with trying to construct quality nursing care plans. If this helps you, great. If it doesn't, maybe someone else will benefit from some of the explanations. If you have any problems with formulating the rest of the care plan, let me know (I promise I won't be as long winded), after you make solid diagnoses, the plan of care is easy to blow through, at that point it's just listing the steps you'd take to solve or prevent the actual or potential problems (and in some cases citing literature to back you up, yaknow, evidence based practice), and then explaining how you would evaluate if you were successful in doing it...it all comes back to the basics of the nursing process. Have fun! I promise it will get easier to do this the more you are assigned to do it, and it doesnt mean they ever become less annoying to complete.

Esme12, ASN, BSN, RN · Nov 16, 2013

I have a pt who diagnosis with fever of unknown origin. chief complain: fever, diarrhea.
pt's temperature 101.9 and received with antibiotics.
for my nursing intervention i have are
1, infection r/t disease process as evidence by temp 101.9 and pt received with antibiotics.
2, risk for electrolyte imbalance r/t diarrhea
what other nursing intervention that i can use, thanks all.

Welcome to AN!

The largest online nursing community!

What care plan book do you use? Do you have the NANDA I for current nursing diagnosis terminology and characteristics?

You are falling into the same trick bag that all students fall into.....picking you diagnosis and trying to fit the patient into it......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.

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.

Every nursing diagnosis needs to be an approved diagnosis statement from NANDA I.....GrnTea says it best....

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

While your patient has an infection....they have a fever. So you would choose hyperthermia. I use NANDA I and Ackley: Nursing Diagnosis Handbook, 10th Edition

Hyperthermia NANDA-I Definition: Body temperature elevated above normal range

Elevated body temperature can be either fever (pyrexia) or hyperthermia. Fever is a regulated rise in the core body temperature to 1° to 2° C higher than the client’s normal body temperature as an innate immune response to a perceived threat and is regulated by the hypothalamus. Hyperthermia is an unregulated rise in body temperature that occurs when a client either gains heat through an increase in the body’s heat production or has developed an inability to effectively dissipate heat. Hyperthermia is not adaptive and should be treated as a medical emergency.

Defining Characteristics:

Flushed skin; increase in body temperature above normal range; tachycardia; tachypnea; warm to touch; seizures in children

Related Factors (r/t): Anesthesia; decreased perspiration; dehydration; exposure to hot environment; inappropriate clothing; increased metabolic rate; medications; illness; trauma; neurological disorder/injury; strenuous physical activity in hot climates.

Your patient also has diarrhea so you would choose the nursing diagnosis of diarrhea.

Diarrhea NANDA-I Definition

Passage of loose, unformed stools

Defining Characteristics

Abdominal pain; at least three loose liquid stools per day; cramping; hyperactive bowel sounds; urgency

Related Factors (r/t)

Psychological: Anxiety; high stress levels

Situational: Adverse effects of pharmaceuticals; alcohol abuse; contaminants; travel; laxative abuse; radiation; toxins; tube feedings

Physiological: Infectious processes; inflammation; irritation; malabsorption; parasites

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.

Now......Tell me about your patient.......What do they need? What do they c/o? What is your assessment? What is your patient saying? 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.

nurseprnRN, BSN, RN · Nov 19, 2013

"Infection" is not a nursing diagnosis. Period. Even if it were, the patient having been prescribed antibiotics is not evidence of it.

motay68 · Nov 19, 2013

I don't know where my other post went so I'll post it again....

I can not tell you how much these replies have helped me with my own care plan. I've been so worried about getting all of the information in, not diagnosing the patient, and grouping things together that I've been going nuts.

I'm going to need to start a book on all of the information that has helped me get through this semester alone

Thank you!

Esme12, ASN, BSN, RN · Nov 19, 2013

I have an assessment organization sheet that may help you gather the information you need from a former contributor here...Daytonite...(rip)

You can always post here and we will help lead you....we love helping!

critical thinking flow sheet for nursing students

student clinical report sheet for one patient