nursing diagnoses, which are merely names for the nursing problems the patient has, are always based upon the signs and symptoms of these nursing problems that the patient has. therefore, they are dependent on the nurse having done a thorough assessment of the patient.
i usually approach care planning from a nursing process viewpoint, but with a dying patient, in particular, the nurses overall goal is to support the deterioration of the patient's condition
. that doesn't always sit well with some people, but there it is. nanda doesn't really have a nursing diagnosis for this, but there has been one that has been used unofficially for a long time. i don't know if your instructors will allow it, but i will provide it for you for your consideration and you can run it by the instructors and see if they will let you use it.
- impaired comfort r/t physical deterioration aeb listlessness and lethargy - and any other observations you remember that the patient seemed in discomfort, uncomfortable or restless
otherwise, you use the symptoms you observed:
- irregular heart rate
- respirations are 10, shallow and irregular
- expiratory wheezes in both lungs
- edema in both arms
along with knowledge of the pathophysiologies of her medical diseases (chf, hyperkalemia and the renal insufficiency) to diagnose these 2 nursing problems in this order of priority (heart then lungs):
- decreased cardiac output r/t altered heart rate and rhythm and elevated potassium levels secondary to chf and hyperkalemia aeb irregular heart rate and peripheral edema in arms
- ineffective airway clearance r/t retained secretions aeb respirations of 10 that are shallow and irregular with expiratory wheezes in both lungs
her heart will probably stop first because her potassium level is elevating so high. high potassium levels cause heart block so that the heart will stop beating. i am not really sure about that edema in her arms being of cardiovascular origin. it's puzzling that she doesn't also have edema in her legs. did she have mastectomies?
as far as doing knowledge deficit (for the family) i wouldn't advise that with the physical evidence that you do have on the patient. the focus of a care plan is always
about the patient--not the family. when you start turning to the family you still need to make the patient the focus. and as i started out, although it is uncomfortable, there are a lot of things we can do to support the deterioration of someone who is dying. i worked in long-term care and took care of many dying patients. they shouldn't get swept under the rug because they are at the end of their days. see these weblinks for ideas for care of dying patients:
good luck with the remainder of your care plan.