Nursing Diagnosis

Hey m&m! Nursing diagnosis focuses on potential risks or actual conditions as a result of the related disease or symptoms. Below are a list of 5 nursing diagnosis related to Ebola. I choose one to go into detail (I have highlighted) about goals, outcomes, and interventions.

To understand a little bit about how Ebola works in the body I’ll give a short summer below. Also go back to my blog post “Ebola Treatment” and watch the video at the bottom of the post of how Ebola works in your body. Or click here to go directly to the video.

Ebola doesn’t stay at the initial place of infection; it migrates to nearby lymph nodes and then travels to the liver, spleen, and adrenal gland. Liver cells die off and clotting factors that help clot your blood so you don’t bleed out, become abnormal. This can cause prolonged or excess bleeding. Ebola can also result in Adrenocortical death which causes low blood pressure and makes it hard to make steroids. The Ebola virus also initiates a release of cytokines that are associated with inflammation which can cause impairment of clotting and result in multi-organ failure.  

Nursing Dianogsis

1. Risk for bleeding related to impaired clotting factors.
2. Risk for electrolyte imbalance related to decreased oral intake, vomiting and diarrhea.
3. Risk for shock related to progressive multi-organ failure.
4. Pain related to musculoskeletal and abdominal aches.   
5. Risk for fluid volume deficit related to restricted oral intake, bleeding, vomiting and diarrhea.  

Risk for fluid volume deficit related to restricted oral intake, bleeding, vomiting and diarrhea. 

Goal and outcomes: Patient will maintain fluid volume balance as evidenced by

• Normal skin turgor
• Weight stable at baseline
• Moist mucous membranes
• Heart rate within normal baseline
• Blood pressure within normal baseline
• Mental status within baseline
• Balanced intake and output

Assessment

• Check for tenting: decreased skin turgor (look to the figure at the right)
• A: pinching the skin
• B: skin remains elevated = dehydration 
• Sudden weight loss of at least 2%
• A low B/P or high B/P upon standing
• A rapid and weak pulse
• Change in mental status from baseline
• Decreased urine output

Implementations

• Administer prescribed anti nausea medications to reduce vomiting episodes
• Administer prescribed antidiarrheal medications to reduce watery stools
• Maintain fluid intake through IV if oral intake is contraindicated  
• Weigh patient daily to monitor for fluctuations

Resources:  

Chertow, D.S., Bray, M. (2015). UpToDate: clinical manifestations and diagnosis of Ebola virus disease. Wolters Kluwer. Retrieved May 20, 2015 from http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-ebola-virus-disease 

Ebola (Ebola Virus Disease). (April 1, 2015). Retrieved May 20, 2015 from http://www.cdc.gov/vhf/ebola/healthcare-us/preparing/clinicians.html 

Nanda International (2015). Retrieved May 20, 2015 from http://www.nanda.org/nanda-international-nursing-diagnoses-defintions-and-classification-2015-17.html