HELP!!!

Apr 01, 2009 01:25 PM

by lovelysmile83

OKAY, ugh so I have this instructor who put a target on my back and I have to be flawless with my careplan and I could use some help. I am stuck on the diagnosis. My patient was admitted with septic shock and severe dehydration. Her H&H are normal but her BUN was 104 and creatinine was 5.4, so should it be altered tissue perfusion: renal? or what about fluid volume deficit. I know that perfusion would be the best one but I am having a difficult time coming up with realistic interventions that I would implement. Any, any suggestions or feedback would be great.

thanks

laura

*Daytonite* · Apr 01, 2009, 02:35 PM

I can offer very little help as far as nursing diagnoses because the only information you gave was the patient's medical diagnoses and that she had an abnormal BUN and creatinine level. Nursing diagnoses need clues (evidence) to support their existence. It is why we assess our patients. To write a care plan you should follow the nursing process in the sequence of the steps as they occur. . .

Step 1 Assessment - Assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - BUN was 104 and creatinine was 5.4. Look up the significance of this in shock and dehydration.
- http://www.merck.com/mmpe/sec06/ch068/ch068a.html - Sepsis and Septic Shock, includes the pathophysiology, signs/symptoms and treatment
- http://www.webmd.com/a-to-z-guides/dehydration-adults - Dehydration in Adults
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered

Step #2 Determination of the patient's problem(s)/Nursing diagnosis - diagnosis is done by gathering together the abnormal data that was collected in Step #1 during assessment and matching them with the defining characteristics of nursing diagnoses to which they apply. Every nursing diagnosis has a list of defining characteristics that describes what that nursing problem is. The abnormal data that you collected in Step #1 is the proof of the various nursing problems that this patient has. Your task is to sort it all out and put names (nursing diagnoses) with them. You need that pathophysiology information about sepsis and dehydration in order to help in composing those 3-part diagnostic statements and explain why these nursing problems occurred.

Step #3 Planning (write measurable goals/outcomes and nursing interventions) - now you can begin to develop your goals/outcomes and nursing interventions. Nursing interventions target that abnormal data you found back in Step #1 of the nursing process when you were assessing this patient. You are now going to do something about them. For as many of the abnormal pieces of data as you can, you will develop some kind of action plan. Nursing interventions are of four basic types:

Assess/monitor/evaluate/observe (to evaluate the patient's condition)
Care/perform/provide/assist (performing actual patient care)
Teach/educate/instruct/supervise (educating patient or caregiver)
Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

--------------------------------------

You can see examples of this care planning process in constructing diagnoses on this sticky thread: http://allnurses.com/general-nursing-student/help-care-plans-286986.html - Help with Care Plans. However, I cannot assistant you any further with the little information you have provided. An elevated BUN was just discussed on this thread yesterday if you need information about this test: http://allnurses.com/nursing-student-assistance/increased-bun-381400.html

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HELP!!!

HELP!!!

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