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by RStudentRN

o.k here was another question that I got stumped on...

Your patient has End Stage Renal Disease, with a 30 year HX of Type 1 DM. She has a 2-cm dry, ulcerated circular area on the lateral outer aspect of her right great toe and an AV fistula in the right forearm. You have adminisered her AM NPH insulin at 0730 and you are waiting for her dialysis treatment. At 1130 you do a fingerstick and the results are 236, According to the Sliding Scale you administered 10 units of Regular insulin.
Which of these Nursing Diagnosis is a priority at this time.
Risk for infection
Altered patterns of elimination
Fatique
Excess fluid volume
Deficient Fluid Volume
Imbalance Nutrition:Less than body requirements

I choose Fluid volume excess, because she is now hyperglycemic. Wouldn't there be a fluid shift from intracellular to intravascular because of the high concentration of glucose in the vascular system.

F&E confuses me...Anyone have any ideas. Thanks

[Agnus]

Re: ESRD Nursing Diagnosis

I'm going for risk for infection. These are diabetic foot ulcers you are talking about. Risk for infection is alway a VERY high priority when you have diabetic foot ulcers. Why do you think we make such a HUGE deal over diabetic foot unlcers and diabetic foot care.

Fluid volume over load or deficit refers to total fluid volume on board. Not just what is in the vasculature. There is no way you can determine just from a glucose fingerstic as to the osmolarity of her blood.

ANd being a dialysis pt. she may or may not be in fluid overload at this time. There is no mention of overload symptons so she is probably not in over load.

She is fatigued so what that is a minor symptom. And if you think she is fatigued now wait until dialysis. As for nutrition imbalance. well there is a glucose imbalance in that at this moment it has not moved into the cells but you just fixed that with the insulin (what else would you do about it)
Generally less than body requirements means she is not taking in enough which is not the case here.

So you took care of the insulin. The volum excess will be taken care of shortly in dialysis. Fatigue is a minor sympton but the foot ulcers have not been addressed. What do you think?
Think this out a bit more rationally. These questions are never so complicated or esoteric as you are trying to make it.

[RStudentRN]

Re: ESRD Nursing Diagnosis

I always make the questions out to be complicated : ) My teacher said that we were not very good critical thinkers at this point. Hopefully after I graduate and have some years of practice behind me I will look back and laugh at all these questions that I had as a student. Thanks for your help

[lovemyjob]

Re: ESRD Nursing Diagnosis

Sounds to me like you might want to read up on the s/sx of fluid volume excess. That is usually ther answer whe the question includes words like "course lung sounds (or whatever they want to call it..rhonchi, rales..whatever!)," difficulty breathing, edema, wt gain, increased bp, etc. Look at in the most simpl terms...look at each answer and say to yourself "what are the signs if this..."
You will find throughout nursing school that there are certain "hot button" questions..and diabetics and feet are one of them. Cant think of any others at the moment (only been out 2 years....) but try and recognize them in test questions and not be distracted by small minor issues. Look for your abc's (as they are ALWAYS priority) and then look for those hot button questions.

HTH...

[lovemyjob]

Re: ESRD Nursing Diagnosis

Originally Posted by RStudentRN

I always make the questions out to be complicated : ) My teacher said that we were not very good critical thinkers at this point. Hopefully after I graduate and have some years of practice behind me I will look back and laugh at all these questions that I had as a student. Thanks for your help

When you graduate, you wont even remember this question!!

[Daytonite]

RStudentRN. . .The answer to this is Risk for Infection. The patient has symptoms that fit the description for this NANDA diagnosis (i.e.: inadequate primary defenses--broken skin, chronic disease). Your knowledge of diabetes should also tell you that an elevated blood sugar in a diabetic is reason for concern of possible infection if the diabetes is supposed to be under control. The heart of this question is getting at the symptoms of each diagnosis. In actuality, the information given in the question only supports two of the diagnoses given: Risk for Infection and, surprise!, Deficient Fluid Volume (the dry skin on her toe), and your knowledge of ESRD tells you that can't be right! So, of all 6 nursing diagnoses listed, only one fits the symptoms given and can be your answer.

Do you have a care plan book that lists the diagnoses in alphabetical order as well as the symptoms (defining characteristics) that go with each? This is what you need to be looking at with each of these nursing diagnoses. Like a medical diagnosis, each nursing diagnosis has specific signs and symptoms that have to be present in the patient in order to use that particular nursing diagnosis. If the symptoms aren't there, then you can't use the diagnosis. This is a concept that you must hammer in to your head about nursing diagnosis.

This is a link to a sticky thread entitled "Desperately need help with careplans" in the Nursing Student Assistance Forum.
http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html Please check it out. There is a lot of information there to help you. You can also PM (Private Message) me if you have questions about this.

Is there some reason why you are not posting your questions in the nursing student forums? No offense to my fellow licensed nurses. The only reason I happened to find this post of yours is because I did a search for the word "diagnosis".

http://allnurses.com/forums/f205/ - Nursing Student Assistance Forums
http://allnurses.com/forums/f50/ - the General Nursing Student Discussion forum

In case I haven't responded to any of your other posts, welcome to allnurses!

[flyingbaby]

Re: ESRD Nursing Diagnosis

how about if you patient is on antibiotics, can i still go my Nursing diagnosis with rish for infection?

[Daytonite]

how about if you patient is on antibiotics, can i still go my Nursing diagnosis with rish for infection?

Hi, flyingbaby, and welcome to allnurses!

The answer to your question is No. If the patient is on antibiotics, then they have an infection, don't they? Risk for Infection is an anticpated problem, so you can only use it if the patient does not have an infection, but you anticipate that they will get an infection. If they already have an infection, then you have to find another diagnosis to use.

This is how nursing diagnoses are chosen:

(From page 4 of Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig)

"When the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate Nursing Diagnosis label using critical thinking skills.

• Highlight or underline the relevant symptoms.
• Make a short list of the symptoms.
• Cluster similar symptoms.
• Analyze/interpret the symptoms.
• Select a Nursing Diagnosis label that fits with the appropriate related factors and defining characteristics.

The process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."

You will find help in determining nursing diagnoses and writing care plans on these two websites in the nursing student forums of allnurses:

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)

[flyingbaby]

Re: ESRD Nursing Diagnosis

I am on my first semester of nursing school, my pt is on antibiotics and glucoma meds(right eye legally blindness, and hydrochlorothiazide for chronic kidney disease.

His main problem is Diabetic foot unlcer with mycosis, canllus, metartarsalgia and cyst infected on the back.

I have not found the possible Nursing Diagnosis for him, and which make me upset.

[Daytonite]

And you are going to continue having a problem finding nursing diagnoses for him as long as you keep focusing on his medical problems. Please re-read the information I posted for you on the previous reply. You need to go through your assessment information that you got on this patient from his medical record and from doing your physical assessment. You need to make a list of the symptoms (abnormal data) that you found. It is from that list of symptoms that you will look for nursing diagnoses that have the same symptoms. You need a nursing diagnosis reference to help you do this. You cannot choose nursing diagnoses based upon the medical disease that a patient has. It's like trying to make a square peg fit in a round hole--it isn't going to happen.

Give me a list of your patient's symptoms. I know he is blind and cannot see well. That gives you:

• Disturbed Sensory Perception: visual
• possibly, Risk for Injury
• possibly, Self-care Deficits of some sort, but it depends on what you found during your assessment of his ability to perform his ADLs

What was your assessment of this foot ulcer? What were its measurements? What did the wound look like? Did the nurses already assign a Stage to it (there are 4 stages for skin ulcers)? Was there any drainage present and what did it look like (serosanguinous or purulent)? How much drainage was there? Was there any odor? What is the treatment being done for the ulcer and how often? How bad is the pain in patient's foot? What rating was used to assess it? Is the patient receiving any kind of treatment for the pain? What's going on with this cyst on his back? What is the assessment for it--size, any drainage, treatment for it? Just why is the antibiotic being given to this patient anyway? The doctor would have detailed this in his progress notes. What are the patient's symptoms of his kidney disease? What did his labwork (electrolyte) look like? Any pain in the flank? What was his output like? Does he have any output? Is he on dialysis? What medications is the patient on? Sometimes the medications a patient is on will backtrack you to clues as to what is going on with the patient.

Do you understand what I am trying to do here? You need to investigate what is going on with the patient and why the doctor is ordering certain things. The doctor is treating the patient's symptoms just as you are going to develop nursing interventions for some of the patient's symptoms as well. However, you can't even begin to do that until you figure out what those symptoms are. You have to investigate (assess) first. Then, we can work on nursing diagnoses. The fact is that your care plan and the goals and outcomes are going to be based on these symptoms you find. A nursing diagnosis is nothing more than a label (a name) that you put on the problems that you have found and nothing more than that. Don't get so hung up on it. You need to be clear about what the symptoms are first.