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Risk for vs Actual

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by carolgodfrey86 carolgodfrey86 (New) New

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I am working on a care plan for my pt admitted with urosepsis. Assessment information I have includes: Dyspnea, crackles bilaterally, SpO2 88-92% on 5L/min NC, intermittent generalized weakness, fever upon admission (10 days prior to my shift) but afebrile during shift, NSR (average rate 90). Labs: Normal WBC (8.71), initial platelet (1) which came up to 21 after administration of 2units platelets, 1 dose IV IGG, and 3rd unit of platelets. Then Hgb dropped to 7.9 and Hct to 23.6. Neutrophils 80.3. Foley is in place.

During my shift, pt was given 1unit packed RBC's and another dose of IV IGG with Tylenol 500mg PO and 50mg Benadryl PO prophylactically for transfusion. Also IV daptomycin for infection.

I have a few questions: can I use "infection r/t presence of bacteria in urinary system s/t UTI? AEB cultures positive for Staph, dark tea-colored foul smelling urine with sediment, and febrile upon admission"? (can you used admission criteria?)

I've noticed my books have infection listed as "risk for" and not actual... does that mean you can't use the actual?

Also, with this particular pt, I am having a hard time coming up with a short term goal (short term for our class is during shift). I was trying to think of something regarding urinary output (ie maintain urinary output at least 30ml/hr during shift), would that be relevant to infection?

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Double-Helix has 9 years experience as a BSN, RN and specializes in PICU, Sedation/Radiology, PACU.

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"Infection" is not a NANDA nursing diagnosis. It's a medical diagnosis. "Risk for infection" is a NANDA nursing diagnosis. It has goals and interventions for management specific to the nurse's scope of practice.

Here's a link to the list of all approved NANDA diagnoses, if you need some ideas: http://faculty.mu.edu.sa/public/uploads/1380604673.6151NANDA%202012.pdf

In urinary output related to infection? You tell me. What other organs involved in the production of urine can be affected by urosepsis? What laboratory results do you have that might help tell you if the function of those organs is normal? Does adequate urine output suggest that the infection is resolving? Would decreased urine output be a sign that the infection was getting worse? Does the patient have a problem with urinating? Is there frequency, urgency, oliguria, dysuria or hematuria? Is there another nursing diagnosis you could use if any of those symptoms are present?

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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I am working on a care plan for my pt admitted with urosepsis. Assessment information I have includes: Dyspnea, crackles bilaterally, SpO2 88-92% on 5L/min NC, intermittent generalized weakness, fever upon admission (10 days prior to my shift) but afebrile during shift, NSR (average rate 90). Labs: Normal WBC (8.71), initial platelet (1) which came up to 21 after administration of 2units platelets, 1 dose IV IGG, and 3rd unit of platelets. Then Hgb dropped to 7.9 and Hct to 23.6. Neutrophils 80.3. Foley is in place.

During my shift, pt was given 1unit packed RBC's and another dose of IV IGG with Tylenol 500mg PO and 50mg Benadryl PO prophylactically for transfusion. Also IV daptomycin for infection.

I have a few questions: can I use "infection r/t presence of bacteria in urinary system s/t UTI? AEB cultures positive for Staph, dark tea-colored foul smelling urine with sediment, and febrile upon admission"? (can you used admission criteria?)

I've noticed my books have infection listed as "risk for" and not actual... does that mean you can't use the actual?

Also, with this particular pt, I am having a hard time coming up with a short term goal (short term for our class is during shift). I was trying to think of something regarding urinary output (ie maintain urinary output at least 30ml/hr during shift), would that be relevant to infection?

Nope. Can't use infection as that is a medical diagnosis. Only risk for infection is a nursing diagnosis which your patient does not meet the criteria.

There are some risk for that have actual impaired skin integrity and risk for impaired skin integrity for example.

Your diagnostic statement is a medical diagnosis and out of the scope of a nurse.

There are others that are applicable to this scenario. To get you started, your patient has adventitious breath sounds what nursing diagnoses might apply.

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3 Posts; 422 Profile Views

Ok, now I am frustrated. I just typed out a long reply and it deleted and wouldn't post. So here's to trying again :)

My priority nursing dx is ineffective breathing pattern r/t fatigue s/t anemia AEB dyspnea, crackles, low SpO2, and low Hgb & Hct (I'm paraphrasing). I hope that one is okay.

Other info included: pt came to ER for urinary retention after being on and stopping abx for UTI (he stopped taking them when he felt better). BUN is low (6) and creatininine is normal (0.97). Output is average 50mL/hr and input (IV and PO) is about the same average over 24hrs.

Urinary output is often decreased if the infection is involving other organs (ie kidneys) so monitoring is important, however it could be dehydration as well.

Other diagnosis' I have for my concept map include:

Activity intolerance

Imbalanced nutrition: less than... (pt reports frequent nausea, dietary intake is >10% average, presence of infection requires more)

Risk for impaired tissue perfusion (renal or cardiopulmonary depending on which book I look in) r/t anemia, low SpO2, pale skin (but cap refill is good)

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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What are you using as your defining characteristics don't exactly match the current NANDA-I requirements?

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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Care plans are all about the patient assessment...of the patient. 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.

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 from our Daytonite

  1. 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)

  2. 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)

  3. Planning
    (write measurable goals/outcomes and nursing interventions)

  4. Implementation
    (initiate the care plan)

  5. 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.

Another member GrnTea say this best......

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

"Related to" means "caused by," not something else.

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Esme12 has 40 years experience as a ASN, BSN, RN and specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

6 Followers; 4 Articles; 20,908 Posts; 148,956 Profile Views

Dyspnea, crackles bilaterally, SpO2 88-92% on 5L/min NC, intermittent generalized weakness, fever upon admission (10 days prior to my shift) but afebrile during shift, NSR (average rate 90). Labs: Normal WBC (8.71), initial platelet (1) which came up to 21 after administration of 2units platelets, 1 dose IV IGG, and 3rd unit of platelets. Then Hgb dropped to 7.9 and Hct to 23.6. Neutrophils 80.3. Foley is in place.
What is the patients blood pressure? What is the respiratory rate? What are the patients vitals?

The patient has a low O2 sat....they have rales. The Hct is low...are they bleeding? What is IVIG? why are they administering IVIG? Why are the platelets low (platelet count of one an admission? (WOW!) A patient with sepsis can actually have a low or normal WBC..what is sepsis? Treating Septic Shock Is this patient on other drips? Why is the BUN low? Is there edema? What blood condition can develop from sepsis? What co-morbidities are present?

Rales indicate the lungs are "wet" IMPAIRING GAS EXCHANGE. Is the cardiac output affected by sepsis? How many IV lines does this patient have? Are they central lines? Is the patient alert? What does the patient say? what does the patient NEED? Low platelet count could this cause bleeding?

Tell me the assessment of your patient.....

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