Nursing diagnoses for MRSA

EricJRN, MSN, RN · Apr 16, 2013

The patient's medical diagnoses may suggest certain nursing diagnoses, but it's a bad idea to take a medical dx and just stick a nursing diagnosis on it. The ND should be based on the entire picture of the patient. We would need a lot more information about the patient to know whether an ND applies or whether it is a priority for the patient.

If you look through the other posts in this forum, some of our members explain this process very well. It starts with looking at the patient data though.

nurseprnRN, BSN, RN · Apr 16, 2013

MRSA is a medical diagnosis. If you are so bent on finding a nursing diagnosis that uses it as a defining characteristic or a cause, you must -- must-- look in your NANDA-I 2012-2014 to find one. Go ahead, I'll wait ....

OK, time's up. You're right, you can't find one. That's because there isn't one.

See, you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

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

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

Esme12, ASN, BSN, RN · Apr 16, 2013

Where is the MRSA? What is the patient main complaint? What do they NEED....not what they have......Simply put.......Care plans are the recipe card on how to care for someone....logically, rationally. They tell you what is important for any particular patient....and what needs to be looked at, treated, considered first. Care plans as a nurse is a standard recipe card .....you already "know" how to bloom yeast.....as a student you look up, include the how to, and "learn" how to bloom the yeast so you can remember the how to for the future.

Care plans are all about the assessment OF THE PATIENT.....the whole patient. What is the patient assessment? What do they need? Have they had any procedures? What brought them to the hospital? How long have they been hospitalized? What are their vitals signs? What is their main complaint? 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.

Tell me about your patient

mlauren · Apr 17, 2013

Quote
Where is the MRSA? What is the patient main complaint? What do they NEED....not what they have......Simply put.......Care plans are the recipe card on how to care for someone....logically, rationally. They tell you what is important for any particular patient....and what needs to be looked at, treated, considered first. Care plans as a nurse is a standard recipe card .....you already "know" how to bloom yeast.....as a student you look up, include the how to, and "learn" how to bloom the yeast so you can remember the how to for the future.
Care plans are all about the assessment OF THE PATIENT.....the whole patient. What is the patient assessment? What do they need? Have they had any procedures? What brought them to the hospital? How long have they been hospitalized? What are their vitals signs? What is their main complaint? 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.
Tell me about your patient

So I had posted this the night of my pre work, because I was having a hard time deciding how to include it. I had no assessment data other than the adm assessment that I viewed in the chart. All I knew was that the pt had mrsa, asthma, tha, osteoarthritis, hypertension, pre-diabetic. There were no VSs even charted. So of course I ended up changing a lot of my ND. I always try to review all my assessment data and number the patients problems just to get started. Then based on that I try to pick NDS that fit the patient. Sometimes the patient fits a ND, but the interventions with that diagnosis won't actually help the patient that much. That's where I get confused. Anyways, the patient had a pos. culture (nasal) for mrsa, so just colonization. My instructor said I could use infection without the risk for. I thought I should include that in my POC because the interventions are important in preventing spread of the infection. I wish I could show you guys my Finished POC. From what I'm reading here, I think I'm doing pretty good. Although I have to agree that figuring out interventions other than assessment and physicians orders is difficult, especially since sometimes I don't know exactly what to do, but hey that's what books are for. It's just a wee bit time consuming when I have to have it done the next morning. So my instructor tells us to include assessments, physicians orders, nutrition, comfort, and teaching for interventions. And so that is how I've been doing it. Do you guys have any advice for more interventions?

mlauren · Apr 17, 2013

This patient was admitted for a THA (Lt) and was 1 day post op. I have no idea what her vitals were, because they had not been charted or maybe were in a different system, I don't know. But her History included asthma, staph Lt lung, pleural effusion (2009), high cholesterol, hypertension, osteoarthritis, DB pain BLE, chronic back pain, n/t Bilateral feet, and she had a left pelvic fracture last year. The MRI from 2/13 said "findings characteristics of avascular necrosis", and differential diagnosis included septic arthritis. Her vital signs during clinical were 0800: T 98.3 P 117 R 15 BP 112/73 O2 sat 100 Pain 8. 1200: T 96.9 P 114 R 14 BP 118/68 O2 sat 97 Pain 10. When I gave meds with the RN at around 0800 the patient was tachycardic (up to 145) and had low BPs for the past hour. A NS bolus was ordered 1000ml/90 min. (I thought that was an awful lot, but the RN said they're just trying to get her BP up) Lung sounds were clear. I checked all of her pulses and they were equal, regular, and thready, especially pedal. But her carotid was bounding. Cap. refill, color, temp, sensation all good. H&H was 11.1 & 33.6, red cell count 3.79, lymp 9.5, neut 8.4. So anyways, her heart rate stayed up around 115-145 between 0800 and 0900 and BP was 144/74 at 0930 when the bolus finished. So then the RN gives her the ordered antihypertensive. But her HR was still staying at 114-120. Rn also administered 4 mg morphine around 0845. She vomited probably 300ml an hour or so after that. After the bolus finished (0930)the RN had me hang a new bag of D51/2 at 75ml/hr. Her incision was covered w/microfoam and I seen no drainage. Urine output was 300 dark yellow. The patient was extremely fatigued, stated she was tired, could not move without crying, and when PT came she stood for 5 min. w/walker and sat on the edge of the bed for about 10. She was on a clear liquid diet, but they were trying to advance her to reg. She had no appetite and drank very little when I encouraged it. I'm trying to understand why her HR stayed up even after her BP dropped back down. Pain? This is my first patient that actually had problems or changes in baseline data during my shift. I was concerned about her HR, but the RN I worked with did not seem to be.

Anyway, I ended up using acute pain as #1, fatigue rt tachycardia and pain as #2, Infection as #3, and Risk for ineffective airway clearance for #4. I was going to put risk for ineffective tissue perfusion as #4, because she has so many of the risk factors associated w/that. But, I thought since she was getting morphine, wasn't moving a lot, and had asthma that I would use the other. I also had Chronic pain, disturbed sensory perception, Risk for injury, risk for impaired skin integrity, risk for peripheral neurovascular dysfunction, risk for unstable blood glucose levels, risk for constipation, risk for fluid volume overload, risk for ineffective breathing pattern.

Thank you guys for the advice by the way.

MendedHeart · Apr 18, 2013

You have a ton of data there...perfusion looks like the highest priority here...it doesnt seem that this patient has active infection. .most nurses have it in their nose too..I prolly do lol...but wbc norm and no temp..

Also...what about fluid and electrolytes...this patient is vomiting right? Not eating much...needing fluid boluses?

Esme12, ASN, BSN, RN · Apr 18, 2013

Quote
Her vital signs during clinical were
0800: T 98.3 P 117 R 15 BP 112/73 O2 sat 100 Pain 8.
1200: T 96.9 P 114 R 14 BP 118/68 O2 sat 97 Pain 10.
When I gave meds with the RN at around 0800 the patient was tachycardic (up to 145) and had low BPs for the past hour. A NS bolus was ordered 1000ml/90 min. (I thought that was an awful lot, but the RN said they're just trying to get her BP up) Lung sounds were clear. I checked all of her pulses and they were equal, regular, and thready, especially pedal. But her carotid was bounding. Cap. refill, color, temp, sensation all good. H&H was 11.1 & 33.6, red cell count 3.79, lymp 9.5, neut 8.4.
So anyways, her heart rate stayed up around 115-145 between 0800 and 0900 and BP was 144/74 at 0930 when the bolus finished. So then the RN gives her the ordered antihypertensive. But her HR was still staying at 114-120. RN also administered 4 mg morphine around 0845. She vomited probably 300ml an hour or so after that. After the bolus finished (0930)the RN had me hang a new bag of D51/2 at 75ml/hr.
Her incision was covered w/microfoam and I seen no drainage. Urine output was 300 dark yellow. The patient was extremely fatigued, stated she was tired, could not move without crying, and when PT came she stood for 5 min. w/walker and sat on the edge of the bed for about 10. She was on a clear liquid diet, but they were trying to advance her to reg. She had no appetite and drank very little when I encouraged it.
Anyway, I ended up using acute pain as #1,
fatigue rt tachycardia and pain as #2,
Infection as #3,
and Risk for ineffective airway clearance for #4.
I was going to put risk for ineffective tissue perfusion as #4, because she has so many of the risk factors associated w/that.
But, I thought since she was getting morphine, wasn't moving a lot, and had asthma that I would use the other. I also had Chronic pain, disturbed sensory perception, Risk for injury, risk for impaired skin integrity, risk for peripheral neurovascular dysfunction, risk for unstable blood glucose levels, risk for constipation, risk for fluid volume overload, risk for ineffective breathing pattern.
Thank you guys for the advice by the way.

This poor patient needed some pain relief. I am not so sure(personal opinion) about a liter of fluid for a B/P of 112-114/72-68 but orthopedic surgeries are notorious for blood loss. But this patient's pain started at an 8/10 and only got 4mg of morphine and 4 hours later it's a 10/10 and crying.....this poor patient is being made to suffer unnecessarily. Did she not have a PCA pump? any other pain Rx ordered?

They are also having issues with volume....why would you think about volume overload? Because of the IVF bolus? But the bolus was because she had a deficit...right? You also sad her po intake is almost non existent and she vomited and voided dark yellow urine.....all signs of volume deficit.....right?

Was the reason she had poor pain control because she had a B/P that was too low to medicate her?

Looking at this patient what would be the first priority? You decide which will hurt her the most first.

That problem is the low B/P due to deficient volume and a decreased cardiac output....right? NANDA defines decreased cardiac output as.....Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body.

I know we have talked about this before......I use a care plan book called.......Ackley: Nursing Diagnosis Handbook, 10th Edition. Every student nurse should have a good care plan book(not a pocket guide) with interventions/definitions/NANDA and goals....TRUST ME your life will become SO much easier.

Defined by.......

Quote
Defining Characteristics
Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
Behavioral/Emotional: Anxiety; restlessness;fatigue;weakness
Related Factors (r/t): Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

You must have at least one of the defining chracteristics to support your diagnosis

decreased cardiac output:

tachycardic (up to 145) and had low BPs for the past hour

they were equal, regular, and thready, especially pedal

NANDA describes deficient volume: Decreased intravascular, interstitial, and/or intracellular fluid.

Defining Characteristics

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; Increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Related Factors (r/t)

Active fluid volume loss; failure of regulatory mechanisms

deficient volume:

vomited probably 300ml

Urine output was 300 dark yellow

drank very little

extremely fatigued, stated she was tired

Now you can address her pain......Acute Pain: NANDA describes......

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 1979); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is whatever the experiencing person says it is, existing whenever the person says it does (APS, 2008; McCaffery, 1968).

Some other thoughts.....

Nausea

Imbalanced Nutrition: less than body requirements

Activity Intolerance

Risk for unstable blood Glucose level

Risk for Electrolyte Imbalance

Risk for Infection

Risk for Falls

Do you see where this is going?

abeaty · Apr 20, 2013

Ackley is the nursing diagnosis book that was required for my program. I was a life saver!!! Like everything she said above, a nursing diagnosis and interventions are something you as a nurse can do something about without needing an order.

abeaty · Apr 20, 2013

it was a life saver, not I.

nurseprnRN, BSN, RN · Apr 23, 2013

Fatigue isn't caused by tachycardia and pain. Neither appears on the list of related factors fr the nursing diagnosis of fatigue, so you can't use them as support for your choice of that diagnosis. You might want to check that before you turn it in ... page 229 in your handy NANDA-I 2012-2014. There are plenty of others that would likely apply to this scenario.