case study

Nursing Students LPN/LVN Students

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Specializes in Clinicals.

Hello,

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:

Sodium 156

Potassium 3.6

Chloride 118

Carbon Dioxide 31

Creatinine 0.9

Urea nitrogen 38

Glucose (non-fasting) 109

PH 7.56

WBC 11,690

Hemoglobin 18.6

Hematocrit 58.5%

The patient was transferred to you unit at 2:30 am. What is you PRIORITY nursing diagnosis? Write a careplan following that nursing diagnosis.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

What is your thinking as to what some of the nursing problems (nursing diagnoses) here might be before I begin to show you how to pick this apart and show you how to figure out what the priority problem is?

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Specializes in Clinicals.

At first I was thinking about the possible aspiration pneumonia and sepsis, so I thought At risk for Sepsis r/t history of aspiration pneumonia m/b increase wbc & temp, tachypnea, and apnea... am i targeting it wrong?

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Specializes in MICU, SICU, CRRT,.

i wouldnt say at risk for sepsis because apparantly he is already septic. Because sepsis is a medical diagnosis you cant use that. I would go with one of these.

1. Ineffective airway clearance

2. Risk for aspiration

3. Impaired gas exchange

4. Risk for infection

5. Impaired skin integrity

6. Impaired swallowing

7. Impaired spontaneous ventilation

8. Deficient fluid volume

9. Decreased cardiac output

10. Risk for ineffective breathing pattern

All of these are from the NANDA list of nursing diagnosis, and you can find care plans all over the internet. When you decide which one you want to use, I will help you develop a care plan if i can, if you need!!

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Specializes in Clinicals.

Would this priority nursing diagnosis work:

Fluid volume deficit related to NPO status or inadequate fluid intake?

What interventions can I do for this pt. on NPO status beside Administering IV fluids as ordered, monitoring I&O, weight, B/P, heart rate and respiratory status, and skin turgor, provide daily oral care?

He has a gtube and he is on NPO status. Please help. Thanks much.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

well, aspiration pneumonia and sepsis are medical diagnoses and not nursing diagnoses or nursing problems. risk for sepsis r/t history of aspiration pneumonia m/b increase wbc & temp, tachypnea, and apnea is a potential (as in does not exist yet) problem. risk for sepsis is not an official nanda nursing diagnosis and sepsis is a medical diagnosis. nanda and most nursing programs won't let nurses use a medical diagnosis in a nursing diagnostic statement. in a "risk for" diagnosis, the r/t part of the diagnostic statement lists the risk factors that lead to the problem and there can never be any m/b's which are the signs and symptoms that prove the existence of actual nursing problems because "risk for" diagnoses are not actual nursing problems. if you have signs and symptoms of sepsis, then the patient has sepsis and not a risk for sepsis. if the patient has sepsis, a nurse cannot diagnose it because a nurse does not have a license to do that. do you see the problem you have run into?

to determine this patient's nursing problems you have to apply the nursing process. you can see other examples of how this is done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

step 1 assessment - assessment consists of:

  • a health history (review of systems) - this is a 47-year old hispanic male that was admitted to the er from a skilled nursing facility with suspected aspiration pneumonia and sepsis. he was also found to be dehydrated. he has a severe mental disability and cerebral palsy, seizure disorder, dysphagia, severe chronic contractures and is non-communicative (doesn't speak?). he has a history of aspiration pneumonia.
  • performing a physical exam - since this is a case scenario the physical assessment data has been provided for you: labored breathing with alternating episodes of tachypnea and apnea, o2 sat 92% on 50% o2 by mask, bilateral rhonchi, tachycardia at times, blood pressure between 80/65 and 138/52, and rectal temp was 104.5f.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - all we really have been told is that he has dysphagia, is non-communicative and has contractures, but a lot of conclusions can be drawn from this.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you should be looking up aspiration pneumonia, sepsis, dehydration, and cerebral palsy. sepsis, in particular, has specific symptoms, as does pneumonia.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - the gastrostomy tube is a medical treatment for his dysphagia. the iv piperacillin and tazobactam is a combination antibiotic probably given for the fever and elevated wbc count (http://www.drugs.com/ppa/piperacillin-sodium-tazobactam-sodium.html). other abnormal labs included sodium 156 (normal is 136-145), chloride 118 (normal is 90-110), urea nitrogen 38 (normal is 10-20), ph 7.56 (normal is 7.35-7.45), and hematocrit 58.5% (normal 42%-52%).

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data.

  • labored breathing with alternating episodes of tachypnea and apnea
  • bilateral rhonchi
  • tachycardia
  • blood pressure between 80/65 and 138/52
  • rectal temp of 104.5f
  • dysphagia
  • contractures
  • non-communicative
  • gastrostomy tube
  • sodium 156 (normal is 136-145)
  • chloride 118 (normal is 90-110)
  • urea nitrogen 38 (normal is 10-20)
  • ph 7.56 (normal is 7.35-7.45)
  • wbc 11,690 (normal is 5,000-10,000)
  • hematocrit 58.5% (normal 42%-52%)
  • history of seizures

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. every nursing diagnosis has a set of signs and symptoms just as every medical diagnosis has a set of signs and symptoms. prioritization is done according to maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). the priority nursing diagnosis based on the data is

  • ineffective airway clearance r/t infection and neuromuscular dysfunction aeb (m/b) alternating episodes of tachypnea and apnea, bilateral rhonchi and no cough.

an equally important problem on the same level is

  • ineffective breathing pattern r/t neuromuscular impairment aeb (m/b) labored breathing with alternating episodes of tachypnea and apnea.

these are the two top nursing problems. there are others.

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Specializes in MICU, SICU, CRRT,.
well, aspiration pneumonia and sepsis are medical diagnoses and not nursing diagnoses or nursing problems. risk for sepsis r/t history of aspiration pneumonia m/b increase wbc & temp, tachypnea, and apnea is a potential (as in does not exist yet) problem. risk for sepsis is not an official nanda nursing diagnosis and sepsis is a medical diagnosis. nanda and most nursing programs won't let nurses use a medical diagnosis in a nursing diagnostic statement. in a "risk for" diagnosis, the r/t part of the diagnostic statement lists the risk factors that lead to the problem and there can never be any m/b's which are the signs and symptoms that prove the existence of actual nursing problems because "risk for" diagnoses are not actual nursing problems. if you have signs and symptoms of sepsis, then the patient has sepsis and not a risk for sepsis. if the patient has sepsis, a nurse cannot diagnose it because a nurse does not have a license to do that. do you see the problem you have run into?

to determine this patient's nursing problems you have to apply the nursing process. you can see other examples of how this is done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

step 1 assessment - assessment consists of:

  • a health history (review of systems) - this is a 47-year old hispanic male that was admitted to the er from a skilled nursing facility with suspected aspiration pneumonia and sepsis. he was also found to be dehydrated. he has a severe mental disability and cerebral palsy, seizure disorder, dysphagia, severe chronic contractures and is non-communicative (doesn't speak?). he has a history of aspiration pneumonia.
  • performing a physical exam - since this is a case scenario the physical assessment data has been provided for you: labored breathing with alternating episodes of tachypnea and apnea, o2 sat 92% on 50% o2 by mask, bilateral rhonchi, tachycardia at times, blood pressure between 80/65 and 138/52, and rectal temp was 104.5f.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - all we really have been told is that he has dysphagia, is non-communicative and has contractures, but a lot of conclusions can be drawn from this.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you should be looking up aspiration pneumonia, sepsis, dehydration, and cerebral palsy. sepsis, in particular, has specific symptoms, as does pneumonia.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - the gastrostomy tube is a medical treatment for his dysphagia. the iv piperacillin and tazobactam is a combination antibiotic probably given for the fever and elevated wbc count (http://www.drugs.com/ppa/piperacillin-sodium-tazobactam-sodium.html). other abnormal labs included sodium 156 (normal is 136-145), chloride 118 (normal is 90-110), urea nitrogen 38 (normal is 10-20), ph 7.56 (normal is 7.35-7.45), and hematocrit 58.5% (normal 42%-52%).

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data.

  • labored breathing with alternating episodes of tachypnea and apnea
  • bilateral rhonchi
  • tachycardia
  • blood pressure between 80/65 and 138/52
  • rectal temp of 104.5f
  • dysphagia
  • contractures
  • non-communicative
  • gastrostomy tube
  • sodium 156 (normal is 136-145)
  • chloride 118 (normal is 90-110)
  • urea nitrogen 38 (normal is 10-20)
  • ph 7.56 (normal is 7.35-7.45)
  • wbc 11,690 (normal is 5,000-10,000)
  • hematocrit 58.5% (normal 42%-52%)
  • history of seizures

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. every nursing diagnosis has a set of signs and symptoms just as every medical diagnosis has a set of signs and symptoms. prioritization is done according to maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). the priority nursing diagnosis based on the data is

  • ineffective airway clearance r/t infection and neuromuscular dysfunction aeb (m/b) alternating episodes of tachypnea and apnea, bilateral rhonchi and no cough.

an equally important problem on the same level is

  • ineffective breathing pattern r/t neuromuscular impairment aeb (m/b) labored breathing with alternating episodes of tachypnea and apnea.

these are the two top nursing problems. there are others.

i agree..i think that both the ineffective airway should be priority, but i personall would go with the first one because it provides more depth and information.

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Specializes in Clinicals.

Thank you very much Daytonite and Mommyof3 for all your reply. You were a great help. Have a great weekend.

smile.png

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Specializes in med/surg, telemetry, IV therapy, mgmt.
would this priority nursing diagnosis work:

fluid volume deficit related to npo status or inadequate fluid intake?

what interventions can i do for this pt. on npo status beside administering iv fluids as ordered, monitoring i&o, weight, b/p, heart rate and respiratory status, and skin turgor, provide daily oral care?

he has a gtube and he is on npo status. please help. thanks much.

fluid volume deficit related to npo status or inadequate fluid intake

the problem with the construction of this diagnosis is that the etiology doesn't physiologically explain why the patient is dehydrated.
npo status
is a medical order.
inadequate fluid intake
merely restates the nursing diagnosis.

the construction of the 3-part diagnostic statement follows this format:

p(problem)- e(etiology) - s(symptoms)

  • problem- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.


  • etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  • symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

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Specializes in Clinicals.

wow you should really consider teaching. You are very good. I wish I had teachers like you in our school. Thanks again.

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I agree with Zyraal.

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