Please help with Dx for nursing care plan!

Esme12, ASN, BSN, RN · Feb 13, 2013

HI! welcome to AN! The largest online nursing community!

First of all it's Heroin. NOT Heroine .

Heroin is a narcotic opiate drug ...diacetylmorphine or morphine diacetate , also known as diamorphine or by the street names H, smack, horse, brown, black, tar

A Heroine is :

a : a mythological or legendary woman having the qualities of a hero

b : a woman admired and emulated for her achievements and qualities

c : the principal female character in a literary or dramatic work

d : the central female figure in an event or period

Cellulite is: Cellulite (also known as adiposis edematosa, dermopanniculosis deformans, status protrusus cutis, gynoid lipodystrophy, orange peel syndrome and cottage cheese skin) is the herniation of subcutaneous fat within fibrous connective tissue that manifests topographically as skin dimpling and nodularity.

Cellulitis is: Cellulitis is a localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin.

I'm sorry :shy: .....I just couldn't resist. But spelling is a BIG deal in nursing for the misplacement of one letter can mean something completely different.

What semester are you? What care plan books do you use? What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:). I have to ask is this a real 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.

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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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.

So tell me about your patient.......What do they need? What do they c/o? ? What is your assessment......What does this tell me about the patient?

26yo homeless male. Heroin user, smoker, and alcohol abuse. Was kicked out of home because of his lifestyle. First time he came in about month ago with an infected rash. He was given a prescription for antibiotics because he had no insurance or money to fill it.

Was admitted yesterday for tx of cellulitis. Pt c/o pain usually 8-10/10. No hx of other medical conditions or disease. Lungs, heart normal. Bowel tones present. Labs are normal.

You talk about a rash..where is the rash? He has cellulitis..where is the cellulitis? Is it from IV use of Heroin? How is his nutrition? Personal Hygiene? Are the febrile? What does he NEED?

These are some of the potential NANDA I diagnosis that this patient has or might have from the little information you gave me.

Hopelessness
Hyperthermia
Risk for Infection
Deficient Knowledge (specify)
Risk for impaired Liver function
Self Neglect
Impaired individual Resilience
Impaired Skin integrity
Impaired Tissue integrity
Acute Pain
Chronic Pain
ineffective self Health management

What "evidence" do you have to prove he has any of these issues.....

julienurse2b · Feb 13, 2013

Thanks for the reply! I'm in second quarter and we use the Davis's Nurse's Pocket Guide 12edition.

Yes it's heroin and cellulitis, thanks, I was tired and typing at 2am :shy:

This is actually a real patient. You said:

"You talk about a rash..where is the rash? He has cellulitis..where is the cellulitis? Is it from IV use of Heroin? How is his nutrition? Personal Hygiene? Are the febrile? What does he NEED?"

He came in a month ago with a rash to his thighs and groin area and was given a prescription for antibiotics. He couldn't fill the prescription because he didn't have any money. Now he came back and was admited for treatment. The "rash" got worse and now they are calling it cellulitis. It i red and dry, no drainage. It is due to drug abuse ( that's what his chart said).

He's been homeless for about 2 months. He grabs a quick bite to eat at a fast food place. At the hospital he eats 100% of his meals. He is fit and muscular. He does not want to to go a shelter because he doesn't want to follow the rules they have. He is able to do everything on his own (ADLs, activity). He is dirty, but he does live on the streets so he really doesnt have a place to clean up. His vital signs are stable, no febrile. His WBC was elevated when he came in the first day but by the second day they went down to normal. He complains of sharp pain to his thigh and groin area.

He copes with stress by smoking and drug use. His freinds are in the same boat as him. He also has a family hx of alcohol, drug abuse and depression. (Based on the assessment, he does not appear to be depressed).

He is on Vancomycin for the cellulitis, on a nicotine patch, and on oral pain medications.

He had a 18gauge SL in RAC but c/o pain at the site during the seconda day so it was removed and placed in the RFA.

You ask "what does he need?" He needs pain control and he needs to manage his health better by getting off drugs. He also needs social support and find a better way of coping with stress.

His neuro, cardio, pulmonary, and GI assessments show no problem. He did have clear diminished lung sounds but he did not c/o CP, SOB, dyspnea or anything else. He was given an insentive spirometer (sorry for spelling again :sorry: ) to do deep breathing.

nurseprnRN, BSN, RN · Feb 13, 2013

We might think he needs to get off drugs, but if he doesn't think so, he has that right. How about you assess him for something like "Readiness for Enhanced Comfort," or "Social Isolation," or "Readiness for Enhanced Self-health Management"? He might say no all the way across the board, but they are possibilities. Differential diagnoses, if you will. "Risk-Prone Health Behavior"? "Ineffective Protection"? Do you have the NANDA-I 2012-2014? Free 2-day shipping for students from Amazon and you'll never lack for this sort of thing again.

I like the rest of your diagnoses and rationales. Gold star, :yes: and tell your faculty one of the meanest old bats on AN says to thank them for teaching you well.

lucki_star7 · Feb 14, 2013

Here are a couple possibilities:Noncompliance r/t denial of illness AEB (any statements he makes to you about not having a drug problem). Compromised family coping r/t codependency issues AEB family kicking pt out of house. Dysfunctional family processes r/t substance abuse AEB lack of familial support.

nurseprnRN, BSN, RN · Feb 14, 2013

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.

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).

So, for example, if you use "neonatal jaundice" as your nursing diagnosis, you discover that the support you need for that includes the following in the NANDA-I 2012-2014:

Defining characteristics (must have at least one): abnormal blood profile (a number of lab results given...look in the NANDA-I to see what they are); abnormal skin bruising; yellow mucous membranes; yellow-orange skin; yellow sclera

"As evidenced by" means "these are the defining characteristics I observed/learned about in the chart." The related factors are in the NANDA-I too.

When developing and using nursing diagnosis it's important-- no, it's required-- that you use the NANDA-I diagnoses with their defining characteristics and related-to factors. Just because it sounds like it ought to be in there, or "it works for me," doesn't let you do it. If you don't have the NANDA-I 2012-2014 in your hands right now, you're cheating yourself out of the best resource there is to help you learn to think like a nurse. Free 2-day shipping for students from Amazon, and it's not that much.

In the above examples, the Noncompliance nursing diagnosis doesn't include "denial of illness" as a related factor, so you can't use that, but one or more of the others might apply-- the OP can assess for them.

I'm not seeing "codependency issues" as a related-to factor for Compromised Family Coping, nor is "kicking the pt out of the house" a defining characteristic. Look again.

I'm not seeing "lack of familial support" in the list of defining characteristics for Dysfunctional Family Processes, either, but, again, look to see if your patient evidences any other(s).

lucki_star7 · Feb 14, 2013

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.
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).
So, for example, if you use "neonatal jaundice" as your nursing diagnosis, you discover that the support you need for that includes the following in the NANDA-I 2012-2014:
Defining characteristics (must have at least one): abnormal blood profile (a number of lab results given...look in the NANDA-I to see what they are); abnormal skin bruising; yellow mucous membranes; yellow-orange skin; yellow sclera
"As evidenced by" means "these are the defining characteristics I observed/learned about in the chart." The related factors are in the NANDA-I too.
When developing and using nursing diagnosis it's important-- no, it's required-- that you use the NANDA-I diagnoses with their defining characteristics and related-to factors. Just because it sounds like it ought to be in there, or "it works for me," doesn't let you do it. If you don't have the NANDA-I 2012-2014 in your hands right now, you're cheating yourself out of the best resource there is to help you learn to think like a nurse. Free 2-day shipping for students from Amazon, and it's not that much.

In the above examples, the Noncompliance nursing diagnosis doesn't include "denial of illness" as a related factor, so you can't use that, but one or more of the others might apply-- the OP can assess for them.

I'm not seeing "codependency issues" as a related-to factor for Compromised Family Coping, nor is "kicking the pt out of the house" a defining characteristic. Look again.

I'm not seeing "lack of familial support" in the list of defining characteristics for Dysfunctional Family Processes, either, but, again, look to see if your patient evidences any other(s).

While I do understand your concern. We use the ninth edition Nursing Diagnosis Handbook, and I got all of these from the book relating to substance abuse. In my book the first 100 or some odd pages have examples of nursing dx for different medical diagnoses and other health concerns and these were all listed under substance abuse. However, in my program we were told to use our assessment data as the evidence. Which is what I did above. I am sure this is probably an ongoing issue with different people because not every school teaches it the same way, and not every book probably words everything exactly the same either. Believe me I am not saying that I know more than you because, I certainly don't as I am only in my first year of NS. I guess I am just trying to figure out if we HAVE to use a defining characteristic that is exactly as it is in the book, then how are we able to use statements from the pt as the evidence?

nurseprnRN, BSN, RN · Feb 15, 2013

Nursing diagnosis is not something that kinda popped out of someone's imagination. The NANDA-I (formerly the North America Nursing Diagnosis Association, then -International) is an international nursing organization that researched and formulated nursing diagnosis. They are the authority, the be-all, end-all of nursing diagnosis. I am not familiar with your book, but I would bet you dollars to doughnuts that they are not using nursing diagnosis as it is designed and validated if this is what they give you.

NURSING DIAGNOSES DO NOT DERIVE FROM MEDICAL DIAGNOSES. Sorry to shout. It's such a common misconception and we see it here all the time. "My patient has congestive heart failure, what are his nursing diagnoses?"

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.

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. 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.

Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. There are more. These are all things you often see in diabetics who come in with complications. And there may be more that this patient exhibits that might not have anything to do with the fact that he is living with diabetes, but that might impact his care. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could hav, and the only definitive one that would stand up in court besides, because it is the product of a validation process. 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 mutilization...)

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

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

Now, if you are ever again tempted to make (or adopt) 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. 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.

So, in answer to your question, " I guess I am just trying to figure out if we HAVE to use a defining characteristic that is exactly as it is in the book, then how are we able to use statements from the pt as the evidence?" the answer is yes, you do have to use the defining characteristics in NANDA-I because they are, well, the defining characteristics. However, if you read them, you will find ample opportunities to use statements from the patients as evidence. Let's see, I'll just flip mine open to a random page for an example....

OK, here's Readiness for Enhanced Nutrition. I didn't pick it because of the DM example above, honest, I just flipped open the page. Some of the defining characteristics include "expresses willingness to enhance nutrition; expresses knowledge of healthy food / fluid choices." There are more.

Let's try Post-Trauma Syndrome. Defining characteristics include alienation, altered mood states, depression, guilt, intrusive dreams, reports feeling numb.... all of these, and more, you will observe because the patient tells you.

Hypothermia: some related-to factors are illness, inactivity, inadequate clothing, malnutrition, pharmaceutical agents, and trauma. Your patient may be able to tell you about these, right?

So of course you can use things your patient tells you...but you use them to establish a nursing diagnosis because they are known, validated defining characteristics of the diagnosis, the same as an abnormal blood smear is diagnostic of leukemia.

I hope that helps.

lucki_star7 · Feb 15, 2013

Thanks for that long winded response, but I really think you misunderstood what I said or that I wasn't clear in my response. I wasn't saying that they derived the nursing dx from the medical dx. What I was getting at was they wrote nursing dx that could be possible for someone with a certain medical dx. Obviously you would have to base your nursing dx off of facts and your findings in their assessment. I wasn't giving the OP a definitive nursing dx. She didn't include much info to start off with, I was just giving possible ones provided that they matched her assessment data and could be used. However, Let me give you an example from my book. Lets say I have a pt with Parkinson's a possible nursing dx could be Risk for injury r/t tremors and altered gait. Would this work for every single pt with Parkinson's? It would seem so, but possibly not if their tremors are kept under control, but if upon doing the assessment you notice tremors and an altered gait then it can definitely be used. What you are trying to get at is that I am just making up nursing dx with fake information. There was hardly any information given to begin with and I didn't perform this assessment. As I said before, I was just giving examples of what could be used if the data matches. Thank you for the recommendation and advice, but honestly I am not about to confuse the crap out of myself when it comes to writing a nursing dx. I get where you are coming from, but I really think you are misunderstanding me. I may just have a hard time explaining myself because I haven't been at it as long as you have. Anyways thanks again.

Esme12, ASN, BSN, RN · Feb 15, 2013

He came in a month ago with a rash to his thighs and groin area and was given a prescription for antibiotics. He couldn't fill the prescription because he didn't have any money. Now he came back and was admited for treatment. The "rash" got worse and now they are calling it cellulitis. It is red and dry, no drainage. It is due to drug abuse ( that's what his chart said).
He's been homeless for about 2 months. He grabs a quick bite to eat at a fast food place. At the hospital he eats 100% of his meals. He is fit and muscular. He does not want to to go a shelter because he doesn't want to follow the rules they have. He is able to do everything on his own (ADLs, activity). He is dirty, but he does live on the streets so he really doesn't have a place to clean up. His vital signs are stable, no febrile. His WBC was elevated when he came in the first day but by the second day they went down to normal. He complains of sharp pain to his thigh and groin area.
He copes with stress by smoking and drug use. His friends are in the same boat as him. He also has a family hx of alcohol, drug abuse and depression. (Based on the assessment, he does not appear to be depressed).
He is on Vancomycin for the cellulitis, on a nicotine patch, and on oral pain medications.
He had a 18gauge SL in RAC but c/o pain at the site during the second day so it was removed and placed in the RFA.
You ask "what does he need?" He needs pain control and he needs to manage his health better by getting off drugs. He also needs social support and find a better way of coping with stress.
His neuro, cardio, pulmonary, and GI assessments show no problem. He did have clear diminished lung sounds but he did not c/o CP, SOB, dyspnea or anything else. He was given an incentive spirometer (sorry for spelling again ) to do deep breathing.

Hopelessness
Risk for Infection
Self Neglect
Impaired individual Resilience
Impaired Skin integrity
Impaired Tissue integrity
Acute Pain
ineffective self Health management
Risk for impaired Liver function

These are what I think could apply. You have done a good job. I do recommend that you look into the NANDA I that Grntea talks about it isn't THAT expensive and it is a WEALTH of information.....it will help you to see things clearer

julienurse2b · Mar 3, 2013

Thank you everyone for your help! In the end, this is what I ended up with:

Ineffectivecoping related to disturbance in pattern of tension release as manifested byusing drugs, tobacco and alcohol to relieve stress.

.AcutePain related to right lower extremity cellulites as manifested by facialexpression, guarding behavior and verbal report.

Ineffectiveself health management related to economical difficulties as manifested bybeing homeless and lack of financial resources.

Also, I know I didn't include a lot of information about the assessment but the information that I did include was all of the ABNORMAL data I found. Thanks again! :)