Do you have any suggestion on the priority nursing diagnosis for this case study? Your input would be greatly appreciated.
At 9:10 pm, a 47-year old Hispanic male with severe mental disability, cerebral palsy and seizure disorder was transferred from skilled nursing facility to a hospital emergency dept. with suspected aspiration pneumonia and sepsis. Patient has severe chronic contractures, was non-communicative and had a history of aspiration pneumonia and dysphagia, for which he as a long-standing orders of nothing to be given by mouth. Although the gastrostomy tube was functioning normally and the pt. was tolerating feedings well, his breathing had recently become labored, with alternating episodes of tachypnea and apnea. At admission, his oxygen saturation level measured by pulse oximetry while breathing 50% oxygen by mask was 92%. Auscultation revealed bilateral rhonchi. His heart rate varied from normal to tachycardia, while his blood pressure fluctuated between 80/65 and 138/52. His rectal temp was 104.5F. The emergency dept collected blood cultures, administered IV piperacillin and tazobactam and requested a chest x-ray. Dehydration was recognized but IV access, initially established in a thumb (because of severe contractures and dehydration) was soon lost. His laboratory findings were:
Carbon Dioxide 31
Urea nitrogen 38
Glucose (non-fasting) 109
The patient was transferred to you unit at 2:30 am. What is you PRIORITY nursing diagnosis? Write a careplan following that nursing diagnosis.