What is a nursing diagnosis for fever

NANDA nursing diagnostics using the case study of a multimorbid patient

Table of Contents

1 Introduction

2. First impression
2.1 Master data of Mr. H.
2.2 Reason for outpatient care
2.3 Medical diagnoses and drugs
2.4. Assessment guide for adults according to Gordon 2013
2.4.1 Perceiving and dealing with one's own health
2.4.2 Diet and metabolism
2.4.3 Elimination
2.4.4 Activity and movement
2.4.5 Sleep and rest
2.4.6 Cognition and perception
2.4.7 Self-perception and self-image
2.4.8 Roles and Relationships
2.4.9 Sexuality and reproduction
2.4.10 Coping behavior and stress tolerance
2.4.11 Values ​​and Beliefs
2.5 Assessment instruments, criteria-based questionnaires, screening

3 Derived nursing diagnoses

4 Prioritized nursing diagnoses

5 Planning the goals and measures

6 Discussion and Outlook

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1 Introduction

The assignment of the housework was to carry out a case presentation on a selected patient and to derive nursing diagnoses. The nursing diagnoses were then prioritized, and measures and goals were formulated. The measures were justified on the basis of scientific or criteria-based literature.

2. First impression

Mr. H. opened the door for the student and greeted him with a firm handshake. He said, “You are the young man I spoke to on the phone. Please come in."

He shows the student his big house. He proudly presents his fireplace and added more wood. Its bathroom, kitchen and bedroom is on the ground floor. It was rebuilt to make it suitable for care when his wife fell ill with cancer. He accompanied her through her illness until she died.

2.1 Master data of Mr. H.

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Housing situation: alone, wife died 11 years ago

Children: 2 daughters Grandchildren: 3

Weight: 90kg Height: 186cm BMI: 26.01kg / m2

Contacts: 2 daughters, 3 neighbors, 4 friends, nursing staff

Aids:

-Glasses
-Compression stockings (class 2) with pull-on aid
- Dentures above and below
-Bathtub lifter

2.2 Reason for outpatient care

According to his own statement, Mr H. has been using outpatient care for about 3 years. Since that time, the outpatient nursing service came and provided help with the insulin injection. Mr. H. had poor eyesight and was afraid of injecting too many insulin units. He also suffered from a venous ulcer on his left lower leg, which the nursing staff took care of 3 times a week. He put his ulcer compression stockings on himself with a pull-on aid.

2.3 Medical diagnoses and drugs

Medical diagnoses according to the medical documentation:

Chronic venous insufficiency (CVI)

Venous leg ulcer left US lateral

Renal insufficiency stage 2

Essential hypertension

Type 2 diabetes mellitus requires insulin

Lumbar pain

Disc prolapse 1998

myopia

Hyperlipidemia

CHD

Hypothyroidism

Vital signs collected from the student:

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Laboratory parameters from December 9th, 2014 inquired by phone:

Figure not included in this excerpt

Long-term medication:

-Ramipril 5 mg tablets 1 0 0 0

Mechanism of action: ACE inhibitors, inhibit ACE so that less angiotensin 2 and aldosterone are formed. NW: dizziness, headache, taste disturbances, angioedema (swelling of the throat and mucous membranes), dry, irritating cough (usually subsides after a few weeks), hyperkalemia, risk of falling is increased Ingestion: regardless of meals cf. (Jelinek 2013, 180-182)

-Metformin 1000mg tabl. 1 0 0 1

Indication: Type 2 diabetes mellitus, reduces intestinal absorption and the formation of new sugar in the liver

NW: gastrointestinal complaints, diarrhea, nausea, vomiting, is taken after eating

KI: Lactic acidosis WW: with alcohol, beta blockers, anticoagulants Cf. (Jelinek 2013, 231-233)

-Simvastatin 20mg tabl. 0 0 1 0

Indication: lowers cholesterol and triglycerides, taking in the evening NW: gastrointestinal complaints, skin reactions, damage to the liver, muscles

KI: Liver, kidneys and muscle damage WW: Warfarin, Ciclosporin Cf. (Jelinek 2013, 234-235)

-Euthyroxin 75 mg tabl. 1 0 0 0

Indication: for hypothyroidism, same effect as thyroid hormone L-thyroxine (T4), is taken on an empty stomach in the morning (30 min before meal), no dairy products at breakfast NW: if the dose is too high, tachycardia, tremors, insomnia

See (Jelinek2013, 150)

-ASS 100mg tabi. 0 1 0 0

Indication: Acetylsalicylic acid is a platelet aggregation inhibitor (inhibits the agglomeration of platelets). Mostly used for prophylaxis against insults or myocardial infarctions. NW: gastric discomfort and bleeding as well as ulcers. KI: in gastrointestinal ulcers, asthmatic / allergic reactions.

See (Jelinek 2013, 188-196)

Reliever medication

-Pantoprazole 20mg Kbs. 1 tablet in the morning when taking painkillers Proton pump inhibitors: inhibit the formation of hydrogen protons and

thus suppress stomach acid production, for stomach protection take: 30-60 min before eating on an empty stomach.

See (Jelinek 2013, 211-212)

-Ibuprofen 800mg tablets, max. 2 x daily. One tablet for pain CAVE: Never take ASA 100 at the same time. Cancels its effect. Always take ASA one hour in advance. NW: stomach pain, nausea, risk of addiction cf. (Jelinek2013, 82-84)

-Novamine sulfone drops max. 3x20 drops daily for pain

Metamizole: Phenazone: good tolerance, against colic, fever, pain, inflammation CAVE: shock, agranulocytosis Cf. (Jelinek2013, 83-85)

-Actrapid insulin by value

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2,4, Assessment Guide for Adults according to Gordon Cf. (Gordon 2013)

2.4.1 Perceiving and dealing with one's own health

Self-assessment:

Mr H. said that he did not catch colds that often. He puts on thick clothes in winter so that he doesn't get sick easily.

He also said that alcohol and smoking were not an issue for him. He never smoked, except as a teenager. He seldom drank alcohol and in moderation.

Mr. H. mentions that he has been diabetic for about 10 years. Back then he was always thirsty and very tired. The family doctor then diagnosed diabetes.

Observation:

In the morning, Mr H. squeezed his pills out of the blisters. He succeeded in doing this very well despite his visual impairment. The medication taken was checked and was in line with the medication schedule.

2.4.2 Diet and metabolism

Self-assessment:

Mr H. said he got meals on wheels three times a week. Sometimes he cooked himself too. Sometimes he says he just eats bread for lunch. He liked hearty and well-seasoned dishes best. He liked fish, meat, poultry and soups. He was very fond of dairy products and eggs. As a side dish, he said he had rice or noodles and often salads. He mostly avoided sweet dishes because of his diabetes. For breakfast he liked to eat bread with cheese spread or sausage. Mr. H. said that he eats an apple or a green banana every day. He said that he had attended a diabetic training course. He knew his way around an adapted high-fiber diet. He mentioned that his long-term sugar level was good and that he had no problems with over or under sugar.

He drinks coffee, tea and juice diluted with water. His daily drinking amount is around 2.5-3 liters.

According to his own statement, Mr. H. used to be always thin. Mr H. said his body weight had increased slightly over the years since he was diabetic.

Observation:

Mr. H. showed his two prostheses on instruction. The mouth and prosthesis status could be ascertained. There were no abnormalities. See Kayser-Jones Assessment

External assessment:

The nursing staff said that Mr H. had a very balanced diet that was adapted to his diabetes.

2.4.3 Elimination of self-assessment:

Mr H. admitted having soft stools every other day. There were no unusual changes in urine or stool. Mr H. said that he was the urinary and stool continent.

2.4.4 Activity and movement self-assessment:

Several times a day, Mr H. announced that he had to walk short distances around his house. Then his legs became heavy and tired. Sometimes my legs itched too. Mr H. put his legs up in between when he was resting on his couch. He complained of leg pain after walking long distances. His maximum walking distance was less than 200 meters. Mr H stated that he was safe in motion and did not fall.

Objective data: See BWA

His gait was safe. Mr. H.'s steps were symmetrical and he was able to keep his balance. According to Mr. H., the joint mobility in the pelvis was restricted due to the current pain in the lumbar vertebrae area. Wound pain occurred when moving the left ankle. The leg ulcer was 3 cm above the left outer ankle.

See checklist skin observation:

Mr. H. bathed independently with the help of a bathtub lifter. He held his left leg out of the water to prevent the bandage from getting wet. He used curd soap and a washcloth to clean it. Recommendation: A washing lotion that does not dry out the skin (e.g. seba med washing lotion).

The condition of his skin all over his body was dry. He mentioned that he never creams his body. Student recommendation: A care product containing urea (e.g. seba med 10% urea)

Edema was found in the area of ​​the wound. Why? Is the compression insufficient? Why not a diuretic? The conversation with the family doctor revealed that diuretics were not used because Mr H. had already lost a lot of fluid through his wound. The general practitioner did not trust himself to be capable of tighter compression because the current vascular status was not yet available.

Objective data:

The following data were taken from the nursing wound documentation:

-Cause: venous leg ulcer
-Location: 3 cm above the left outer ankle
- Creation time: for approx. 10 weeks
-Size: 5.4 cm long, 3.9 cm wide, 0.4 cm deep
-Wound reason: granulation tissue, fibrin coverings, subcutaneous tissue
-Wound edge: macerated, reddened, swollen
-Wound environment: macerated, reddened, edematous
Exudate: a lot
- Smell: foul smelling
- Pain when changing bandages and at rest, see cognition and perception
-3x weekly dressing change with Suprasorb P and gauze bandage, cleaning with sterile compress and Octenisept, over dressing ulcus stocking
-Symptoms: itching, pain, maceration, odor
- Signs of inflammation in the wound bed, wound edge and surrounding area

Why signs of inflammation and edema around the wound? Why so much

Exudate and bad smell? Why not autolysis of the fibrin layers? wound

infected? Possibly a smear? A conversation with the family doctor revealed that a smear had been arranged. 9.2.2015

External assessment:

According to the nursing management, both daughters helped Mr. H. by doing the shopping and cleaning his apartment. The grandson always brought him wood for his fireplace. Mr H. went to the nearby butcher himself to go shopping.

Observation:

Mr. H. wore neat clothes. He wore a long-sleeved shirt, over it a sweater and suit trousers. In the apartment he walked with sturdy slippers. Underneath had on wool socks.

There were many books on the shelves in the living room. When asked, Mr H. said that he reads books often and with pleasure.

2.4.5 Sleep and rest

Self-assessment:

Mr. H. said that he could fall asleep well and sleep through the night. He usually went to bed around 11.30 p.m. and got up at 7.30 a.m. because the nursing staff came. Then he had breakfast and afterwards began to calmly carry out his personal hygiene. During the day, Mr. H. often rested on the couch.

2.4.6 Cognition and Perception

Self-assessment:

Mr. H. said that he heard very well.

He can see very poorly short distances, says Mr. H. His visual acuity and the glasses had not been checked for a long time. He read with a magnifying glass. Here the student recommended to consult an ophthalmologist to have a more detailed diagnosis, visual acuity and glasses checked.

Mr H. stated that he sometimes forgot things. He said: "But I'm not demented!"

External assessment:

Mr. H. heard whispers from about a meter away.

Objective data requested with VRS:

Mr H. stated that he often had stabbing and burning pains in both legs. At rest on the couch, the pain was 2-3 / 10 at the time of the query on the VRS. After prolonged running, the pain was 3-4/10 on the VRS. When the dressing was changed, the pain on the VRS was 4/10. He stated that the leg pain was not always present. At times he also had pain-free intervals. He couldn't quite say what made the pain worse or worse. Mr. H. described his leg pain as chronically recurring with pain-free intervals.

Mr. H. also described his pain in the lumbar region as stabbing and burning. Here, too, there was a chronically recurring character with phases of complete freedom from pain. At the moment he gave a 5/10 on the VRS for movement and 4/10 at rest. Mr H. was of the opinion that the pain had a lot to do with the cold weather and that he had to dress warmly. For pain relief, he used a warmed cherry stone pillow for the lumbar region and took his on-demand medication.

2.4.7 Self-perception and self-image

Self description:

Mr. H. mentioned that he was quite satisfied with his body. His wound on his left leg, however, bothered him massively. Sometimes the wound got so wet that the wound fluid ran through the compression stockings, he said. The bad smell also limited him a lot. He couldn't go on birthdays because he didn't want to bother other people. Short times, he said, can be bridged well. He couldn't be out of the house for long. He said he had the situation under control at home. He often put his legs up so that the wound would not get too wet. Sometimes his legs are very itchy, said Mr. H. The pain in his legs also prevented him from covering long distances. Then he always had to rely on someone driving him.

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