Trouble with relating medical dx to nursing dx

JustBeachyNurse, LPN · Jun 17, 2014

Yes it is an acceptable intervention to teach safer IV drug use, refer for clean needles. I believe in all states now

Esme12, ASN, BSN, RN · Jun 17, 2014

hi, thank you for your response! i believe it is, i am just looking in my book and the other nursing diagnoses listed for thrombophlebitis are ineffective peripheral tissue perfusion, which doesnt really apply because they have no edema, normal cap refill, normal skin color.. the other ones are acute pain (they are not in pain), and risk for impaired physical mobility (not applicable because the thromboplhebitis is in their arm).

Care plans are all about the patient and the patients problems. 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.

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.

What is suppurative thrombophlebitis? Septic thrombophlebitis is a condition characterized by venous thrombosis, inflammation, and bacteremia.

So your problem is sepsis. What complications can someone get with septic thrombophlibitis? What is their WBC's? Are the febrile? It sounds like they are at the end of their treatment. Has their addiction been addressed? Have they been seen by social services/psych?

Here are a few of the top of my head.

Anxiety

Ineffective Health Maintenance

Risk for Infection

Deficient Knowledge (specify)

Self-Neglect

idialyze, BSN, RN · Jun 17, 2014

Wouldn't think sending a known IV drug abuser home with a PICC would be a good idea!

Guest 360983 · Jun 17, 2014

Wouldn't think sending a known IV drug abuser home with a PICC would be a good idea!

So this might be part of the care plan :)

AQEELSMOM · Jun 17, 2014

What did your assessment show? What did the nurse spend most of her time doing with the patient? Why is the patient hospitalized and not getting antibiotics via PICC at home?

the patient is a homeless iv drug user. the nurse spent most of her time on the patient monitoring their ins and outs, and informally assessing them on return to the floor for evidence of drug use. they were supposed to have DAU tests every time they return, but they are not really doing that for this patient.

my personal assessment of the patient revealed no redness, drainage, inflammation or edema at the surgical site or on the affected limb or at the iv site, no reduced rom of aff limb, aaox3, lucid and able to meet their self care needs vitals in normal range for the patient, denies pain. sometimes dilated pupils upon return to the floor, a lot of commentary about how the patient wanted to leave, a lot of pacing and standing outside of their room with their arms crossed, staring at the nurses station.

AQEELSMOM · Jun 17, 2014

suppurative thrombophlebitis can lead to septic thrombophlebitis but they werent septic yet, they had an abscess and purulent drainage d/t bacteremia at the site where they were injecting drugs, which was surgically removed.

i went with deficient knowledge r/t lack of interest in learning aeb (statements made by the patient). where i fell short was in my subjective and objective info, as i had included in my interventions a teach intervention about safe injecting, but my instructor said there was nothing about iv drug use in my subj/obj. she told me to make up stuff for subj obj that fits my interventions so that everything gets tied together, and that only reporting what i personally see isnt enough for subj/obj observations.

Care plans are all about the patient and the patients problems. 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.
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.
What is suppurative thrombophlebitis? Septic thrombophlebitis is a condition characterized by venous thrombosis, inflammation, and bacteremia.
So your problem is sepsis. What complications can someone get with septic thrombophlibitis? What is their WBC's? Are the febrile? It sounds like they are at the end of their treatment. Has their addiction been addressed? Have they been seen by social services/psych?
Here are a few of the top of my head.
Anxiety
Ineffective Health Maintenance
Risk for Infection
Deficient Knowledge (specify)
Self-Neglect

smf0903 · Jun 17, 2014

suppurative thrombophlebitis can lead to septic thrombophlebitis but they werent septic yet, they had an abscess and purulent drainage d/t bacteremia at the site where they were injecting drugs, which was surgically removed.
i went with deficient knowledge r/t lack of interest in learning aeb (statements made by the patient). where i fell short was in my subjective and objective info, as i had included in my interventions a teach intervention about safe injecting, but my instructor said there was nothing about iv drug use in my subj/obj. she told me to make up stuff for subj obj that fits my interventions so that everything gets tied together, and that only reporting what i personally see isnt enough for subj/obj observations.

I mean no offense by this (hopefully this doesn't seem that way), but I think your instructor is doing you a huge disservice by telling you to make up stuff to fit/support your dx. The data you collect and what you observe is what drives your dx, not the other way around. The opportunity to come up with the right (priority) dx for your patient can be easily missed when making a dx first and then trying to make data fit. We were always taught to cluster our data first, then those clusters drive what diagnoses we think would fit that data. Then we look up each of the diagnoses and see if our "as evidenced by" data fits the data support under the NANDA diagnosis. If not, we move on to the next possible dx and repeat. I think my jaw would hit the floor if I had an instructor tell me to make up data to support my diagnosis and interventions :bored:

Good luck to you! :)

Esme12, ASN, BSN, RN · Jun 17, 2014

the patient is a homeless iv drug user. the nurse spent most of her time on the patient monitoring their ins and outs, and informally assessing them on return to the floor for evidence of drug use. they were supposed to have DAU tests every time they return, but they are not really doing that for this patient.
my personal assessment of the patient revealed no redness, drainage, inflammation or edema at the surgical site or on the affected limb or at the iv site, no reduced rom of aff limb, aaox3, lucid and able to meet their self care needs vitals in normal range for the patient, denies pain. sometimes dilated pupils upon return to the floor, a lot of commentary about how the patient wanted to leave, a lot of pacing and standing outside of their room with their arms crossed, staring at the nurses station.

Wherein blazes is this patient going that they should have DAU upon return. Is he actively using in the hospital?

Your instructor told you to make it up? YOu ahve data the patient IS an IV drug user. They are actively looking to leave for more drugs. They patient had an abcess that had to be surgically removed....so they did have an infection. they are at risk for further infection due to drugs and the surgical procedure alone.

What NANDA resource are you using? What semester are you?

la_chica_suerte85, BSN, RN · Jun 17, 2014

I'm not quite sure that the instructor is just telling the student to spoof the info. In my last care plan format, if, for whatever reason (i.e. the pt was a new admit and we didn't get to see the labs at any point during the clinical day or for some reason they weren't able to be drawn yet), we had to list what lab abnormals we would be expecting for the Dx. There is a utility for this, particularly at one site where we were carted around all over the place without having pts assigned to us (i.e. assignments in GI lab, cath lab, OR, etc.) and we were so busy we did not have time to actually look over charts or find lab specifics (this was a particular issue at one hospital -- it seemed to take ages to get new labs).

In this situation, the instructor may be just demonstrating the backwards way of making connections. The emphasis on theory drives the rationale for this -- but, it's definitely not reality. Because the OP did not assess any of these things and only had the pt's motivation to leave for more drugs, there isn't much to extrapolate from there so it needed to be buffed up a bit. I know for actual nursing practice this would not be the case at this point in time for this particular pt but, had she been there when the infection was active and very visible, then there would be something much more to do and I think that is what the instructor is trying to get at. Again, not at all ideal for real practice but at least the OP now has in her "nursing knowledge foundation" that it is appropriate to instruct on safe IV drug use, how to assess for readiness to learn, how to deal with infection risk, and how to deal with a pt that really is absolutely, 100% non-compliant. I would hope this would be useful for the OP down the line.

AQEELSMOM · Jun 17, 2014

no offense taken (and i agree with you). thank you for your explanation of how you come up with dxes, i am going to try your method.

every clinical instructor i've had thus far has explained careplans differently and had different expectations, and its a little frustrating to get my careplans to a point where my instructor is saying, "great!" and then i start with a new instructor, and they say "wrong wrong wrong!" :/

I mean no offense by this (hopefully this doesn't seem that way), but I think your instructor is doing you a huge disservice by telling you to make up stuff to fit/support your dx. The data you collect and what you observe is what drives your dx, not the other way around. The opportunity to come up with the right (priority) dx for your patient can be easily missed when making a dx first and then trying to make data fit. We were always taught to cluster our data first, then those clusters drive what diagnoses we think would fit that data. Then we look up each of the diagnoses and see if our "as evidenced by" data fits the data support under the NANDA diagnosis. If not, we move on to the next possible dx and repeat. I think my jaw would hit the floor if I had an instructor tell me to make up data to support my diagnosis and interventions
Good luck to you! :)

AQEELSMOM · Jun 18, 2014

i think they are just going outside and meeting friends - i am at a county hospital in an urban area, not very far from a neighborhood well known for procuring a wide variety of illegal drugs.

i cant say for sure that they are actively using because i have never asked the patient personally, and i havent seen any urine tests in his medical record, however based on my personal experience i would say the patient is, based on my observation of their behaviors.

the text that i have is: Nurses Pocket Guide, 12th ed, Doenges, Moorhouse, Murr, but I am quickly realizing that its kind of lousy. if you have a suggestion for a better resource for me i would appreciate it, as I want to get something better but dont know which to pick. I am in 2nd semester of a 4 semester ADN.

I put in my objective supporting data: patient attempts to leave the floor at every opportunity, and in the rest of the careplan it does state that he is there because he got the infection because of IV drug use, but she said i needed to actually write: "patient is an iv drug user" "patient has track marks", that kind of stuff in my objective in order to include an intervention about teaching safe injecting... I thought it was kind of obvious from the rest of the careplan, but that is what she requested I do.

she also directed me to change the language of my interventions, and put them into laymans terms; i didnt understand why. shouldnt the language be one that others nurses can understand, not a layman?

Wherein blazes is this patient going that they should have DAU upon return. Is he actively using in the hospital?
Your instructor told you to make it up? YOu ahve data the patient IS an IV drug user. They are actively looking to leave for more drugs. They patient had an abcess that had to be surgically removed....so they did have an infection. they are at risk for further infection due to drugs and the surgical procedure alone.
What NANDA resource are you using? What semester are you?

AQEELSMOM · Jun 18, 2014

we had to list what lab abnormals we would be expecting for the Dx. There is a utility for this, particularly at one site where we were carted around all over the place without having pts assigned to us (i.e. assignments in GI lab, cath lab, OR, etc.) and we were so busy we did not have time to actually look over charts or find lab specifics (this was a particular issue at one hospital -- it seemed to take ages to get new labs).

My instructor had us eliminate all labs from our careplans, which i was kind of sad about, because it was helping me learn about them. is this a common occurrence? she is my fourth clinical instructor, and the first one to do this. i still do them just for my own learning, but dont include them in what i submit to her. she also glosses over our patho (she told us to reduce it to a paragraph, i still write a whole page just for my own learning), diagnostic tests and meds, and focusses exclusively on our nursing dx and interventions.