Need help with nursing diagnosis for care plan

mustbcrazy · Oct 22, 2010

Someone please help!! i'm really stressed about this, need advice!

Guest27531 · Oct 22, 2010

I'm at a loss and need help coming up with a nursing diagnosis for my patient I will be caring for tomorrow. Here is the info on the patient:
89 year old Female who was going to the hospital for an evaluation for a PEG tube but had a high WBC due to a UTI, patients family states she has a constant UTI, it will get better then come right back. She has a fever and her WBC is 14.9 and her I&O for the last 24 hrs is I5457and O750. The patient has had a low oral intake for some time now and is having trouble swallowing food and has had some weight loss. Patient is nonverbal, has a history of hypertension, dementia, stroke, CHF, thrombocytosis, leukocytosis aspiration pneumonia, and has edema of the lower extremities. She is incontinent and has a foley cath.
I would like my nursing diagnosis to be something to do with her UTI or her WBC but I can't find it. I found risk for infection, but she already has the infection. Or would it be one of the Urinary incontinence? Or should I worry about her nutrition? I think it would be best to take care of the infection first so that she can be evaluated for a PEG tube and then that will help her nutritional state. Please help, I'm really not sure what is best for this patient.
Thanks
MUSTBCRAZY

So, it's been a long time since I had to complete a Nursing Diagnosis assignment. I looked at the current list of NursingDiagnosis and found a few that would pertain to your patient. You should first relax...take a deep breath and just do your best. Think about your patient...

I would likely use:

1. Risk for infection - Although she already has an infection it could worsen and lead to sepsis. Is it possible to describe your rationale in your assignment?

and

2. Failure to thrive - This seems appropriate to me, although technically it may not be acceptable for an 89 year old. Consider this one

or

3. Nutrition: less than body requirements, imbalanced - This one speaks for itself although our nursing care plans always required an explanation

and

4. Fluid volume, risk for deficient - Again, this one speaks for itelf although you will need to elaborate as required by your nursing instructor

Hope this helps...

Guest 360983 · Oct 23, 2010

Immediate problems I see in your patient:

1) Look at the imbalance between the intake and output. Where is the fluid going? What does the edema tell you? Does fluid volume excess fit?

2) Weight loss and limited eating might support nutrition: less than body requirements.

3) UTIs are painful. What signs and symptoms would support a diagnosis of Acute Pain?

You need to focus on the signs and symptoms of the patient instead of the medical diagnoses. My program has us write down the cellular changes caused by medical diagnoses to use as signs/symptoms in nursing diagnoses. It's also a good idea to look at the meds. You can sometimes get a diagnosis out of the side effects and if you aren't sure what is going on with the patient, figure out why each med has been prescribed. I find meds tell me more about what the doctor is thinking (or the direction he is going) in an unclear case than his notes.

mustbcrazy · Oct 23, 2010

Thank you so much! great advice and both helped very much!

ImThatGuy, BSN, RN · Oct 23, 2010

The scenario patient is holding a lot of fluid in. That's not good. With what you've already given you need to make that your focus. Put a CBC, lytes, BUN/Cr on your interventions. The results should tell you lot. You might even run a strip to check out her heart function. You may even go sterile and pull a urine sample. If you get her renal function going you'll start pushing fluids through her system which will help her UTI and probably aid the antibiotic therapy to kill out her UTI completely. I don't know if she's still got the pneumonia, but you don't want that fluid backing up in her lungs on top of it. I don't have a list of diagnoses with me, and I make no effort to memorize them. Go with the fluid and/or renal insufficiency.

NP Sam · Oct 23, 2010

Here are my two suggestions...1) impaired urinary elimination: frequency r/t uti OR 2) risk for ineffective renal perfusion. I got these from my nursing diagnosis book

Unknown member · Oct 23, 2010

the advice above is great.. i think it's best to write EVERY nursing diagnosis you can think of with the information you have... then when you meet your patient, you will find that some may no longer be appropriate while you missed significant ones i.e based on her self-esteem? depression? role relationships? things that the data above won't give you. also, after meeting your patient, it will be MUCH easier to prioritize based on pain, what they feel is important, new findings, etc.

also if you have a care plan book (which you should) USE IT! it lists all the nursing diagnoses with etiology and s + s. it also gives things to assess as well as nursing interventions.