Nursing Dx for DKA patient

  1. 0 We finally have to start writing nursing dx and care plans, and I'm a little stuck on my second one. Doh! Here's my pt: admitted 10/29 with DKA (pH 7.30, BG >600, N/V, tremors, dizziness, SOB). I got her 10/31, the day she was to be d/c'd. She still c/o SOB, they did a VQ scan and a CXR and both were normal. All lung fields were clear to auscultation, RR, 16-18, Sp O2 97%. She described the SOB as "tight" with no to very little pain, and she didn't feel any worse when she got up to shower. So, I don't think any airway dx apply.

    No skin problems, no HEENT problems, no cardiac or GI problems, no MS problems, nothing else is wrong w/her. I did a full ROS and head to toe, no problems. Other vitals normal, BP elevated (140/74) in the morning, but down to 119/74 at lunch. Labs were mostly normal, HCT was slightly low(36.9%) but steadily rising, electrolytes all WNL, her glucose was still off a little - it had dropped to 59 overnight, back up to 132 in the morning, 135 at lunch. Still much better than >600. Hgb A1C was 7.4.

    The reason she gave for having DKA was that (at age 25) her mother (who is bipolar and schizophrenic, and she lives with) forgot to go get her 70/30. She tried to cover with just regular insulin that she had, and it obviously didn't work. She also expressed that she's a little depressed, since they recently moved here and she doesn't know a lot of people. She said she normally follows her regimen exactly, and was knowledgeable about her diet. She had trouble self-injecting in front of the nurse, but it was a different type of needle than she uses at home.

    I selected Ineffective Therapeutic Regime Management r/t social support deficit and economic difficulties aeb patient verbalized that she did not follow prescribed regime and elevated Hgb A1C.

    We're supposed to come up with "a few" dx, and I'm a little stuck on others. Should I use Deficient Knowledge? She seemed pretty knowledgeable, it was more about getting her own meds when she hasn't had to before. Social Isolation? She lives with her mom and stepdad, has a job, and applied to a college here.

    We don't get our patients the night before, we write the care plan after the fact based on what we assessed and what we did. Neither I nor my nurse had to DO much with her, I taught her how to do a breast self-exam, explained a lot of other stuff I was doing when I did my head to toe, asked her to describe her normal therapeutic regime and diet and she was right, she reminded me to get Equal for her coffee,...she had an EKG while I was there, it showed sinus tachycardia, but my nurse said that was likely anxiety. Should I use Anxiety? She wasn't that anxious...

    Sorry this is so long, and thanks in advance to anyone who can help!
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  3. Visit  MB37 profile page

    About MB37

    Joined Aug '05; Posts: 1,739; Likes: 528.

    17 Comments so far...

  4. Visit  PsychNurseWannaBe profile page
    0
    Hi,

    Don't go looking for nursing diagnosis for medical problems. It isn't how we do it. Regarldess of the diagnosis, our care plans are written for the patient and not their disorder.

    You mentioned SOB and then you overlooked it, why? You are right that it isn't an airway issue but it still is a breathing one.

    Airway
    Breathing
    Circulation

    If the patient states that she can not breathe, then apply the appriopriate nursing diagnosis. Do not NOT do it just because some tests came back. Your care plan is for the patient. Nursing is actual or perceived.

    Until you addressed ABC's, you shouldn't be entertaining Therapeutic Regimine Management. IMHO, that is more of a Maslows concern and I wouldn't do it until ABCs are done.

    Nursing assessments have to be very thorough. Sometimes its not what is said, but more of what isn't said. A client can deny having problems with let's say, breathing; however, they still exhibit sign and symptoms. Look for those!

    I know I have overgeneralized, but apparently I have to leave with my son and I have to go.

    I hope my post doesn't sound bad, it wasn't meant to be that way. Good Luck
  5. Visit  MB37 profile page
    0
    What else should I have looked for? I'm still really new at this. So you didn't offend me or anything, but I'm no closer to knowing what I should have done... Also, the care plan book that our school made us buy (Gulanick/Myers) has one chapter that describes about half the nursing dx in general, and the rest are organized by medical dx. If your patient doesn't exhibit the textbook S/S of whatever medical dx they have, it's a little hard to find things for me at least in this book. I would like to get another one, but haven't had the time to go page through a ton of them yet. Any suggestions? Thanks
  6. Visit  Conrad283 profile page
    1
    DKA is a problem related to dehydration (among other things), so that could be one as well. Fluid status.
    MB37 likes this.
  7. Visit  MB37 profile page
    0
    Thanks! Maybe Excess Fluid Volume, since she has dyspnea...her Na was 131 when she came in, but 138 on the day I had her. Her hematocrit was still low, and her BP was a little high. Awesome, thanks a lot!

    Oh, is r/t maybe excessive fluid intake? (IV) Since she was getting NS, which is isotonic? My nurse stopped her IV while I was there, although she didn't explain why. Maybe they overhydrated her. Her skin WAS tight - when I went to pinch for skin turgor, I couldn't even really get any skin between my fingers.
    Last edit by MB37 on Nov 3, '07 : Reason: another question
  8. Visit  PsychNurseWannaBe profile page
    0
    But has the patient exhibited signs of fluid excess?? or fluid loss?? You can't just look at the typical signs of a med disorder and then slap a nursing dx on it. The nursing dx is for the patient. Yes, it will help greatly if you know pathophys and understand the physiological aspects of things... but we use nursing dx for the patients response to actual or perceived events.
  9. Visit  MB37 profile page
    0
    I get that...but she does have some S/S of FVE. I took patho last semester, but our book didn't have much to say about DKA (I just looked it up for the "patho" part of my care plan). This is only the second set of nursing diagnoses I've ever had to come up with, so I was hoping for a few suggestions. My care plan book is organized by medical dx, unfortunately, so that's what I have to work with. It doesn't fully describe every nursing diagnosis by iteslf, just how they relate to common medical dx. I understand that we don't have "standard" nursing dx that go with the medical ones, but I'm a beginning student and I tried to provide as much assessment data as I could in my opening post. Our instructor told us to focus on vitals and lab values, and any abnormalities in our head to toe assessment. I'm just looking for a place to start...all I have is the list of NANDA dx on the back cover, then I've been individually looking up some that sounded relevant. Most that I've looked up didn't really seem to fit my patient's S/S, but FVE seemed to, and could be the explanation for her SOB...I thought...
  10. Visit  cardiacRN2006 profile page
    0
    Quote from Conrad283
    DKA is a problem related to dehydration (among other things), so that could be one as well. Fluid status.

    Yep! When we get DKAs, we just start IVF and open them wide-bolus after bolus.

    How did they treat her initially? You can say she is at risk for FVE r/t her treatment, or FVD if she is still dehydrated. What was her NS running at?

    What was her initial K+ level at? Was she ever placed on an insulin drip?

    Also, I've never seen someone go into DKA for missing one insulin dose. You mentioned that she is 25, but she is relying on her mother who has psych issues to obtain insulin, so you can address her inability to take control of her own disease process as well.

    I may sound cynical here-but when a 25 year old comes into us with DKA, we always do a tox screen. Did they do one of those, or get an alcohol level in the ED?
  11. Visit  cardiacRN2006 profile page
    0
    Quote from PsychNurseWannaBe
    But has the patient exhibited signs of fluid excess?? or fluid loss?? You can't just look at the typical signs of a med disorder and then slap a nursing dx on it. The nursing dx is for the patient. Yes, it will help greatly if you know pathophys and understand the physiological aspects of things... but we use nursing dx for the patients response to actual or perceived events.

    She mentioned that the pt was tachycardic in her initial post. This could be due to dehydration-which is a very common situation in DKA.

    At the very minimum, I would say, Risk for FVD just based on her MEDICAL diagnosis alone.

    The OP knows what a nursing diagnosis is...she just needed help incorporating that into practice. But, just because it's a nursing diagnosis doesn't mean that you ignore the medical diagnosis...
    Last edit by cardiacRN2006 on Nov 3, '07
  12. Visit  PsychNurseWannaBe profile page
    0
    My main point with this med vs nursing dx... is do your own assessment and plan the care accordingly. By looking for a nursing dx from a medical one does not address the patient. I have been seeing this all over the boards... I need a nursing dx for XXXX disorder. WHY? You saw the patient...and you can only formuate your nursing dx from a well done assessment, from what you actually saw.

    I was trying to help her explore the patient and not the medical diagnosis.
  13. Visit  Daytonite profile page
    2
    in doing a care plan, the first thing you do is a thorough assessment of the patient. the second step is to list out the abnormal data that you collected. from what you posted, this is what i came up with:
    • dka (ph 7.30, bg >600, n/v, tremors, dizziness, sob)
    • her glucose was still off a little - it had dropped to 59 overnight, back up to 132 in the morning, 135 at lunch
    • the reason she gave for having dka was that (at age 25) her mother forgot to go get her 70/30. she tried to cover with just regular insulin that she had, and it obviously didn't work
    • sob - described the sob as "tight" with no to very little pain
    • bp elevated (140/74) in the morning
    • hct was slightly low(36.9%)
    • she also expressed that she's a little depressed, since they recently moved here and she doesn't know a lot of people
    this patient was admitted for dka and the reason for it is a major problem if it isn't addressed because it may happen again. she used the wrong insulin to control her diabetes at home. both she and her mother need teaching about proper use of insulin. that's a biggie for these two. also, a b/p of 140/70 in a young person is not normal, i don't care that it was early in the morning. hypertension is a complication of diabetes. and, what's with this low hct that is going on. some kind of anemia? or, an underlying renal problem, also a potential complication of diabetes? is this patient a type i diabetic? and, yes, you should address the patient's statement of depression. i see a couple of nursing problems here that you could be addressing and i've put them in priority order:
    • activity intolerance r/t imbalance between oxygen supply and demand aeb shortness of breath, tightness and pain upon exertion and low hct levels [physiological need]
    • grieving r/t moving to a new home aeb patient statement that she feels depressed because she doesn't know a lot of people since she moved here [role-relationship need]
    • risk-prone health behavior r/t [either inadequate comprehension of disease state or negative attitude toward health care] aeb administration of incorrect type of insulin after forgetting to purchase the correct type necessary that resulted in dka and patient being hospitalized (teaching needs related to diabetes can be included as nursing interventions under this diagnosis) [note: this diagnosis was previously titled impaired adjustment.] [coping-stress need]
    • risk for injury: seizures r/t low fasting blood sugars
    puresass and MB37 like this.
  14. Visit  emtb2rn profile page
    0
    You mentioned that the pt's Hgb A1C was 7.4, so I think there's a knowledge deficit and overall compliance issue going on as well. How long was she missing the 70/30 and covering with regular? Good opportunity for some teaching.
  15. Visit  MB37 profile page
    0
    Thanks Daytonite! My book calls that 3rd one Impaired Adjustment. However, it's not in the index. I really need a new care plan book. She is type I, went into a coma at age 5 when she moved to mainland US (from PR). She said she was in the coma for 6 months, and when she came out of it she had a lot of mental issues - biting people, growling at them, etc. Her HCT was 39.5 when she was admitted, then dropped to 34.5 the next morning, 35.2 5 hours later, and 36.9 when I saw her. I'm only supposed to write interventions and evals for one diagnosis, the highest priority - so you say this would be the activity intolerance? Of course, I'm also supposed to write what I actually did during my 6 hours, to address the needs that I perceived while I was there, and all I did was teach and chat with her, made sure the HOB was elevated, rechecked vitals, etc. - only what I've learned in Fundamentals. My nurse had 4 other students (no idea why, I was on a new floor, it was always 1:1 on my previous one - maybe she was the only RN?) and they were all passing meds, so she didn't have time to talk to me or my patient really, unless I came and got her for something. I asked my instructor for ideas for interventions when she came around, and all she suggested was to make sure she knew how to get meds if her mother forgets again. None of the interventions in my book for activity intolerance really apply to a young person, especially one who has a job where she's on her feet for 8 hours a day, and we have to provide a rationale for everything we use, with a reference (supposed to be from our care plan book).


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