Follow the steps of the nursing process in sequence:
- Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, 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)
Step #1 (assessment) - much of the physical assessment has been given to you. I sort of jumped the gun and listed the abnormal data which becomes the symptom list in Step #2:
- very diaphoretic
- mildly lethargic
- complaining of abdominal pain and nausea
- hyperventilates
- acetone breath
- Blood glucose of 450mg/dL
- pH: 6.9 (acidosis)
- pCO2: 20mmHg (low - metabolic acidosis)
- HCO3: 12mEq/L (low - metabolic acidosis)
- Na: 128 mEq/L (low)
- K+: 3.0mEq/L (low)
- pulse 88, rapid but regular
You can't do an ADL assessment on this patient because it is a case study and this is an intensive care patient who is pretty much confined to bed at the moment. However, he does have the following medical conditions:
- DKA (diabetic ketoacidosis)
- history of diabetes type I
- anxiety
- depression
and you really should be looking up the signs and symptoms as well as the tests and treatments that are ordered for these conditions as well as something about their pathophysiology. You are going to find that many of the items on the assessment list are signs and symptoms of DKA.
I'm not sure what your instructor is looking for with
assessment criteria. Maybe all the assessment data, or just the abnormal data. You probably need to clarify that with the instructor. However, I would tend to think that you need to provide
nursing assessment criteria, not medical assessment criteria. Remember, we are nurses, not doctors.
Nursing diagnoses are
ALWAYS based upon the abnormal assessment data (symptoms, or NANDA defining characteristics) that the patient has.
A nursing diagnosis is
NOT the same as a medical diagnosis. Doctors do their thing with diagnosing and we do our thing. Forget about DKA. It's nice to know that information, but it's not that relevant to a nursing diagnosis. That's why I tell you to make a list of the patient's symptoms in the first part of Step #2 of the nursing process. You need that list. Everything else from then on that you do for the care plan is dependent on what is on that list.
You know that
Mosby's Handbook of Nursing Diagnosis, 7th edition, that you have? Well, right under each nursing diagnosis is the NANDA information (from the taxonomy) about each diagnosis: definition, defining characteristics (symptoms) and related factors (etiology or causes--often the underlying pathophysiology causing the problem). The definition is the "real" problem and you should take the time to read these. The 3 and 4 word "nursing diagnoses", as we commonly call them, are actually shortened
labels that represent these definitions. You also must realize that your patient must have one or more of the defining characteristics listed for that diagnosis or you really shouldn't be using it.
The hyperventilation is contributing to the acidosis and probably anxiety as well. The nursing diagnosis to use for this is
Ineffective Breathing Pattern R/T acid-base imbalance and anxiety AEB hyperventilation.
The high blood sugar combined with the vigorous exercise probably put the patient in his DKA. He has
Imbalanced Nutrition: less than body requirements R/T failure to ingest enough food AEB blood glucose of 450mg/dL.
This patient is in metabolic acidosis and has a lot of the symptoms (medical disease symptoms) of it. He is complaining of nausea and excessive diaphoresis. His pH and CO2 are low. There's no mention of other loss of fluids, but I'm thinking that it has to be there. Without the symptoms of
Deficient Fluid Volume, however, I think the best you can go for is
Risk for Deficient Fluid Volume R/T hypermetabolic state
I wouldn't address anything else as those symptoms will go away as the blood sugar and electrolyte are brought under control. You can't care plan everything little thing going on.
The next thing you have to do is develop goals and nursing interventions for the hyperventilation, the elevated blood sugar and the potential fluid loss (I'm thinking through possible polyuria, diaphoresis and vomiting) in the three nursing diagnoses.
And that should give you some direction to go with this. Remember, we are nurses, not doctors. You have to keep the medical information separated from the nursing information in your mind.
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