Risk for neurovascular dysfunction

Esme12, ASN, BSN, RN · Feb 25, 2014

What ND book did you finally buy?

Are you asking about a care plan for these patients? You are picking a diagnosis first without identifying what the patient needs. Why do you want to use risk for neurovascular dysfunction related to swelling when there are better diagnosis for this patient.

As I have told you before.... 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.

So......back to square one.....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. 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.

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.

nurseprnRN, BSN, RN · Feb 25, 2014

Where is your nursing assessment of his condition? This is all medical diagnoses.

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.

In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)

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.

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 should come 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.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing 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." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad 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! Wonder where you learned that??? :)

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, 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. 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 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 and at least one of the related / caustive factors are present. 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.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, as to your specifics: There is no nursing diagnosis, "Risk for neurovascular dysfunction" in NANDA-I 2012-2104. No "diagnosis book" is free to make it up. Furthermore, the risk factors for the real NANDA-I 2012-2014 nursing diagnosis, "Risk for peripheral neurovascular dysfunction," do not include "related to swelling," although "orthopedic surgery" is a listed risk factor-- why? (HINT: how might nerves or blood vessels be affected by the mechanical aspects of surgery and its postop care, not just the fact of having had some kind of surgery?). Your diagnosis for the 91-year old would be properly stated, "Risk for peripheral neurovascular dysfunction (right leg, right wrist) due to orthopedic surgery (ORIF or whatever they were, on DATE)." Your interventions and ongoing assessments for effectiveness would be ... ? (see below for a great reference for that)

However, as to your younger patient, DVT is not a neurovascular dysfunction and is not caused by the mechanical effects of surgery, though it might occur after surgery. (WHY?)

First things first, though. DVT is a medical diagnosis, and you, the nurse, will not be in charge of preventing it, because preventative anticoagulants, sequential compression stockings, and the like are part of the medical plan of care. Nursing implements them, but they are not parts of a nursing plan of care. What are your patient's specific problems? Identify his actual or potential nursing diagnoses, not potential medical ones.

"Risk for ineffective peripheral perfusion" refers to arterial blood flow. It is defined as "at risk for a decrease in blood circulation to the periphery that may compromise health." Not a venous problem, not related to DVT.

Back away from that, and look at this guy. He's had strokes, he has brain injury, he's had major ortho surgery, and he's still on the mattress. HINTS: What other serious things could happen to hurt him? What is your assessment of his ability to understand his plan of care and his part in it? Think about those and other things, and see what occurs to you. Look in your NANDA-I 2012-2014 to see if your guesses pan out, meaning, if they have defining characteristics that apply to this patient.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence; you want the most current edition, 2011.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can’t get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.

CTrain · Feb 26, 2014

I bought Nursing Diagnosis Handbook by Betty J. Ackley. The section under peripheral neurovascular disease just confused me because my med/surge book flip flopped about compartment syndrome and DVT, so I wasn't 100% sure that DVT was represented under that diagnosis.

I apologize. I should have clarified my intention for these diagnoses. My teacher just asks for 2 diagnoses for each patient, so at that rate, most of them would be related to lungs or circulation as we have a lot of COPD pts and diabetics, so those are typical priorities. These patients have many more important actual diagnoses, I agree; however my instructor wants us now to explore other diagnoses that are not as commonly used. Both of these patients in my opinion are at risk for inadequate perfusion more so than other patients. I want to assure you, I fully assessed my patients and do realize more fitting diagnoses and other areas for concern, but that isn't what my teacher wants this time around. I just wanted to know if DVT would have better fit into the diagnosis: risk for peripheral neurovascular disease or if I as at least on the right track.

CTrain · Feb 26, 2014

Please disregard previous post. I couldn't figure out how to change it, so this is what I want to say.

Now, as to your specifics: There is no nursing diagnosis, "Risk for neurovascular dysfunction" in NANDA-I 2012-2104. No "diagnosis book" is free to make it up. Furthermore, the risk factors for the real NANDA-I 2012-2014 nursing diagnosis, "Risk for peripheral neurovascular dysfunction," do not include "related to swelling," although "orthopedic surgery" is a listed risk factor-- why? (HINT: how might nerves or blood vessels be affected by the mechanical aspects of surgery and its postop care, not just the fact of having had some kind of surgery?). Your diagnosis for the 91-year old would be properly stated, "Risk for peripheral neurovascular dysfunction (right leg, right wrist) due to orthopedic surgery (ORIF or whatever they were, on DATE)." Your interventions and ongoing assessments for effectiveness would be ... ? (see below for a great reference for that)

However, as to your younger patient, DVT is not a neurovascular dysfunction and is not caused by the mechanical effects of surgery, though it might occur after surgery. (WHY?)

First things first, though. DVT is a medical diagnosis, and you, the nurse, will not be in charge of preventing it, because preventative anticoagulants, sequential compression stockings, and the like are part of the medical plan of care. Nursing implements them, but they are not parts of a nursing plan of care. What are your patient's specific problems? Identify his actual or potential nursing diagnoses, not potential medical ones.

"Risk for ineffective peripheral perfusion" refers to arterial blood flow. It is defined as "at risk for a decrease in blood circulation to the periphery that may compromise health." Not a venous problem, not related to DVT.

Back away from that, and look at this guy. He's had strokes, he has brain injury, he's had major ortho surgery, and he's still on the mattress. HINTS: What other serious things could happen to hurt him? What is your assessment of his ability to understand his plan of care and his part in it? Think about those and other things, and see what occurs to you. Look in your NANDA-I 2012-2014 to see if your guesses pan out, meaning, if they have defining characteristics that apply to this patient.
Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes…, so you understand that he knows more about his disease.

Okay this is what I was wanting to know! Thank you, you are a godsend!

I wasn't even thinking logically about DVT. It would be due to the 52 year old patient's immobilization after surgery that would cause blood stasis am I correct? He is also at risk for falls.

Btw, I meant risk for peripheral neurovascular dysfunction. I didn't realize I left out peripheral.

I just want to clarify that there are more important diagnoses to both of these patients; however, my teacher wants our class to stop using the "given" diagnoses, and start trying new ones that apply to our patients, but this specific one threw me for a loop. I don't want you to think I do not assess my patients. I may not know everything to look for, and may have holes in my data due to lack of experience, but I do assess, and try to find their problems, prioritze them, and then make a diagnoses which Esme definately helped me with last semester.

Also, I bought Nursing Diagnosis Handbook by Betty J. Ackley. I'm going to order the Nanda DX one next.

CTrain · Feb 26, 2014

Also, the "Risk for peipheral neurovascular dysfunction related to swelling" came from my med/surg book required by my program, which is from 2010. That may have been the problem.

Esme12, ASN, BSN, RN · Feb 26, 2014

Like many things in nursing we can't assume that you assessed the patient unless you "told" us. If you are thinking compartment syndrome you are on the right track. I would think that possibly..ineffective peripheral Tissue Perfusion...might be a better fit.

I am curious...why is his wrist not splinted if it is fractured? Using older books do make a difference as the taxonomy/definition change. do you have the new Ackley? That is one of the ones I use. Your patient is at risk for DVT and they can't be anticoagulated because of the history of cerebral bleeds....and his age.

I also think about Impaired physical Mobility