Nursing diagnosis help

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Hey can anyone help me with my nursing diagnoses for my case study please? I have trouble with the "related to" parts especially, they sounds sloppy? The client is 20 years old and had ruptured esophageal varices secondary to portal hypertension.

Thank you in advance for any assistance

These are the dx I made:

1. Impaired gas exchange R/T altered oxygen carrying capacity of the blood occurring from decreased hemoglobin and anemia, and aspiration from esophageal varices A/E/B laboratory values and hematemesis.

2. Ineffective peripheral tissue perfusion R/T altered portal hypertension A/E/B skin pallor on examination, anemia, low hemoglobin and hematocrit values

3. Risk for Bleeding R/T thrombocytopenia associated with splenomegaly/hypersplenism, decreased synthesis of coagulation factors with impaired liver function and tortuosity of esophageal vessels associated with portal hypertension.

4. Risk for impaired skin integrity R/T striae, pruritus occurring from hepatic dysfunction and client's medications.

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OK, let's see if we can't tease this out. You don't have to come up with anything originally here, because, lucky for you, the profession of nursing is evidence-based and all the validated related (causative) factors are easily available in the pages of the single authority for making (not choosing: or "picking") nursing diagnoses: The NANDA-I 2015-2017 (this is the current edition-- it's updated q 2 years).

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There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/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) __(these 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. Surgery is a physical injury agent, right? So is a burn or a fracture, right? These are medical diagnoses which cause pain.

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 2015-2017 (current edition). $39 paperback, $23 for instant download to your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at 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!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilation...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! th_bf-swinging-00 If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk for� diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. Faculty often ask specifically for a ranking in Maslow's hierarchy. What are nurses for if not to protect a patient's safety, first and foremost?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Prioritizing your diagnoses: This sort of assignment is often made not only to see if somebody can recite rote information but to elicit your thought processes and see how well you can defend your reasoning.

So, you should be prepared to present the reasoning you have applied to your diagnoses and priority ranking. Why is one more important than another? There may be no one answer just remember, you are supposed to be learning how to figure this out.

Working with a hypothetical patient: If there are only medical diagnoses given, you may have a little more work to do,. But you can also exercise your creativity more, by looking in your books and seeing what kind of symptoms of nursing diagnoses someone with those medical diagnoses may demonstrate. I can't tell you what they might be. You have to have some symptoms in mind, and then identify them in the lists of defining characteristics in the diagnoses you think might apply.

So let's look at yours. Remember, "related to" means "caused by," and nothing else.

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1. Impaired gas exchange R/T altered oxygen carrying capacity of the blood occurring from decreased hemoglobin and anemia, and aspiration from esophageal varices A/E/B laboratory values and hematemesis.

Impaired gas exchange, page 204.

Definition: Excess or deficit in oxygenation and or carbon dioxide elimination at the alveolar-capillary membrane.Defining characteristics: abnormal arterial blood gases; abnormal arterial pH; abnormal breathing patterns(e.g., rate, rhythm, death); abnormal skin color(e.g., pale, dusky, cyanosis); confusion; cyanosis; decrease in carbon dioxide level; diaphoresis; dyspnea; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness; somnolence; tachycardia; visual disturbance.

Related (causative) factors: Alveolar-capillary membrane changes; ventilation-perfusion imbalance

I will give you a reasonable assumption of cellular hypoxemia due to decreased hemoglobin and anemia. However, this is not the problem with oxygenation or carbon dioxide elimination at the alveolar – capillary membrane. You have no blood gases or pH. Lab values and hematemesis are not defining characteristics for this diagnosis. In order to you need to assess your patient for one or more of the defining characteristics given. Further, impaired gas exchange for purposes of this diagnosis occurs in the alveoli and refers to problems with the lungs, as seen in the required related/causative factors.

So you cannot make this diagnosis because you have not identified defining characteristics in your patient.

Your next diagnosis, however, may be better at communicating what I think you mean, that the cells in the periphery are not getting enough oxygen.

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2. Ineffective peripheral tissue perfusion R/T altered portal hypertension A/E/B skin pallor on examination, anemia, low hemoglobin and hematocrit values

Ineffective tissue perfusion, page 237

Definition: Decrease in blood circulation to the periphery that may compromise health.

Defining characteristics: (these are your "as evidenced by" and must demonstrate at least one to make diagnosis) absence of peripheral pulses; alteration in motor functioning; alteration in skin characteristic (moisture, nails, sensation, temperature); ankle – brachial index less than 0.90; capillary refill time greater than three seconds; color does not return to lower limb after one minute leg elevation; decrease in blood pressure in extremities; decrease in pain free distances achieved in the six minute walk test; decrease in peripheral pulses; Delay in peripheral wound healing; distance in the six minute walk test below normal range; edema; extremity pain; femoral bruit; intermittent claudication; paresthesia; skin color pales with limb elevation.

Related factors (causes): diabetes mellitus; hypertension; insufficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility); insufficient knowledge of disease process; sedentary lifestyle; smoking.

You will see that "altered portal hypertension" (whatever that means) does not appear on the list of approved causes for ineffective circulation to the periphery. Your assessments of evidentiary data likewise do not appear on the list of defining characteristics. So, you cannot say that this person has ineffective tissue perfusion, because you don't have the requirements to make that diagnosis.

See how that works?

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3. Risk for Bleeding R/T thrombocytopenia associated with splenomegaly/hypersplenism, decreased synthesis of coagulation factors with impaired liver function and tortuosity of esophageal vessels associated with portal hypertension.

Risk for bleeding, page 382

Definition: vulnerable to a decrease in blood volume, which may compromise health

Risk factors (remember: risk diagnoses do not have related factors, they have risk factors): Aneurysm; circumcision; disseminated intravascular coagulopathy; gastrointestinal condition(e.g., polyps, varices); impaired liver function(e.g., cirrhosis, hepatitis); inherent coagulopathy(E.g., thrombocytopenia); insufficient knowledge of bleeding precautions; postpartum and pregnancy complications ( I won't go into those here, but you can look it up); trauma; treatment regimen.

OK, now you're getting it. This patient is vulnerable to bleeding, and this is because he has deranged clotting and tortuous esophageal vessels related to cirrhosis with portal hypertension. Perfect.

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4. Risk for impaired skin integrity R/T striae, pruritus occurring from hepatic dysfunction and client's medications.

Risk for impaired skin integrity, page 400

Definition: vulnerable to alteration in epidermis and/or dermis, which may compromise health

Risk factors:

External: Chemical injury agent; excretions; extremes of age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., shearing forces, pressure, immobility); moisture; radiation therapy; secretionsInternal: alteration in metabolism, alteration in pigmentation; alteration in sensation (resulting from spinal cord injury, diabetes mellitus, etc.); alteration in skin turgor; hormonal change; immunodeficiency; impaired circulation; inadequate nutrition; pharmaceutical agent; pressure over bony prominence; psychogenetic factor

Okay then, pretty good here. I'm not seeing striae as a risk factor for changes in the skin which may compromise health (and all of us with residual stretch marks postpartum will breathe a sigh of relief over that). However, alteration in metabolism will cause itching (pruritis), and if he scratches, this will disrupt his skin.

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This is my 2nd clinical semester of writing 3 nursing diagnoses for clients, 2x a week, and not once ever gotten any feedback or corrections, and received the max amount of points on my care plans. I wish I could have known this! I do not have a NANDA book, just checked. I found one on line though until I buy my own!

"This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is" That is true for me! I was making the dx first, based on the medical dx and what I knew about that.

OK this time I'm going to take the defining characteristics..hematemesis, thrombocytopenia, splenomegaly, portal hypertension, pallor, striae (I put this as a risk for skin integrity because the nurses had a very hard time getting his veins because of it) and look for those.

Thank you so much for that very helpful response, AliNajaCat!! I appreciate your time so very much!

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Well. This is what I came up with so far

Impaired gas exchange R/T abnormal skin color (pale/pallor) (I keep going for this oxygen because he had low hemoglobin ..but no it's not fitting the definition!!)

Risk for bleeding R/T inherent coagulopathy, varices, and impaired liver function.

Risk for ineffective gastrointestinal perfusion R/T impaired liver function.

Anxiety R/T the symptoms of the disease and fear of the unknown

Risk for pressure ulcer R/T decreased albumin, decrease in mobility (bedrest), and impaired circulation

I'll ask my teacher for more help after class but at least I'm a little more on the right track.

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Make sure the one you find is the complete text from NANDA-I, not anything else. It's at Amazon, easy to find.

You're quite welcome!

(And striae might make it harder to find a vein, although I can't actually envision how, but they are not risk factors for broken skin).

?

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Impaired gas exchange R/T abnormal skin color (pale/pallor) (I keep going for this oxygen because he had low hemoglobin ..but no it's not fitting the definition!!)

Risk for bleeding R/T inherent coagulopathy, varices, and impaired liver function.

Risk for ineffective gastrointestinal perfusion R/T impaired liver function.

Anxiety R/T the symptoms of the disease and fear of the unknown

Risk for pressure ulcer R/T decreased albumin, decrease in mobility (bedrest), and impaired circulation

Abnormal skin color does not cause impaired gas exchange at the alveolar level ("related to" means "caused by" !) I tell ya, you are not looking at this through nsg dx eyes yet. It's perfusion that's the problem. Yes, perfusion carries oxygen.

Risk for ineffective GI perfusion does have impaired liver function as a risk factor... but you might think about where that impaired perfusion, and what it looks like, is so you'll know when they ask you.

The NPUAP (National pressure ulcer advisory panel) doesn't call them pressure ulcers anymore. The current accurate terminology is "pressure injury," because you can have a pretty nasty pressure injury under unbroken skin.

Doing better!

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