Am I on the right track?

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So here are my ques and a couple dx so far....

Age - 68

Admitting dx: septicemia

On continuous TPN, although the day I treated her, her doctor allowed regular diet. I believe eating or not, she is always on TPN.

CV line left upper arm

Ileostomy RLQ

Hx of severe protein calorie malnutrition

Hx of chronic kidney disease

Hx of hyperlipidemia

CMP4/14/14: BUN high @ 53, Creatinine high @ 2, Albumin low @ 2.3, Bilirubin high @ 1.3, AST high at 41, GFR abnormal at 26.3

CBC 4/14/14: WBC low @ 3.7, RBC low @ 3.2, Hemoglobin low @ 9.4, Hematocrit low @ 28.1, PLT low @ 128, Eosinophils high @ 9

Vitamin b-12 4/13/14: >1000 high

CMP 4/13/14: Na low @ 135, Potassium high @ 5.3, BUN high @ 49, Creatinine high @ 1.8, Albumin low @ 2.2, GFR abnormal @ 29.7

CBC 4/12/14: RBC low @ 3.43, Hemoglobin low @ 9.8, Hematocrit low @ 29.7, PLT low at 110, Neutrophils high @ 69, Lymphocytes low at 20, Monocytes low @ 5, Eosinophils high @ 4

Foley catheter

Red area noted on sacrum

T 97.2 HR 81 R 13 BP 148/81

Appeared confused aeb stated, "My friend is 5 years younger than me. She is 57 and I'm 68 so, let's see, she is 11 years older than I am." Also repeatedly asked who the night nurse that took care of her last time she was at Kindred and was confusing names.

Medications: Fentanyl patch, fluticasone propionate, meropenem, vancomycin, piperacillin, zolpidem tartrate, morphine, Ipratropium, hydrocodone/acetaminophen, diphenhydramine

DX:

1. Risk for confusion r/t septicemia, polypharmacy, decreased hemoglobin, electrolyte imbalances, increased BUN/creatinine, malnutrition, over 60 years of age

2. Risk for electrolyte imbalance r/t chronic kidney disease.

3. (possibility) Risk for impaired skin integrity.

or

4. (possibility) Risk for infection r/t Foley catheter.

Any guidance is appreciated!

What about your head to toe?

Neuro status? Lung sounds? Heart sounds? Bowel sounds? Skin integrity? Cap refill? Pain assessment? Edema? ROM? Urine - appearance? Quantity? Quality?

She's on respiratory medications... Yet I didn't see anything about respiratory related issues in the Hx.

Is she on HD?

Why is she lacking protein?

Specifically ... albumin?

What does albumin do?

What about the TPN... is she on 50 TPN and 50 PO?

What do you know about TPN and glucose?

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You are still missing the point. What ACTUAL problems does your patient have? If she only has risks then she should be at home. If sh actively is confused...then that is not a risk is it? She actually is confused and has confusion...therefore no longer a risk.

If she has severe calorie malnutrition then she HAS Imbalanced Nutrition: less than body requirements

If she has a reddened area on her coccyx then she is no longer AT RISK for this she actually has....Impaired Skin Integrity

You are still focused on medical diagnosis and finding a diagnosis and then trying to force your patient into that diagnosis. This is the exact opposite of what you should be doing.

Why are you only using at an risk diagnosis when she has real problems?

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

takingcare19

56 Posts

Neuro - she was alert & oriented to time, place, person, situation. I just noticed while talking to her through the day, she was a little confused and forgetful.

She complained of headache, she c/o pain in her abdomen.

She has full ROM, but stays in bed b/c she is weak. She was able to move from bed to wheelchair with assistance.

Her skin was dry and clean except for the spot on her sacrum. So even though it's just a reddened area, she out of risk for and it is impaired....She has a wound on her clavicle from the removal of her Mediport.

Pulse 81 regular, capillary refill was

Resp was 13, no abnormal lung sounds, no cough, room air.

She has an ileostomy. She had a gastric bypass that went wrong and has had issues ever since.

She has a foley. Clear, yellow urine, no odor.

Afebrile, bp 148/81, c/o pain throughout the day, even after receiving morphine. Was requesting dilaudid.

H&P - she was admitted to the hospital with sepsis, fever, acute renal failure. Infection came from mediport which was removed. She is in need of TPN b/c of short gut syndrome. She was transferred to the rehab where I was seeing her for continued therapy. She has a significant amount of discharge from her ileostomy bag.

I honestly couldn't tell you why the resp medications.

Would her protein be low b/c she has short gut syndrome? There is no gut...food goes from her stomach then out the ileostomy. She eats, but I think that is why she is on TPN also, to help supply her with the nutrients her body needs.

Albumin is made in the liver - it transports medications and keeps the osmotic pressure in the blood stream. Low albumin can be caused by kidney disease, which she has.

As far as I know, she was on continuous TPN only on admit. Monday when I saw her, she requested normal food and the doctor allowed. There was no report of lowering TPN.

Esme - I know, I can't seem to grasp the concept of thinking like a nurse. My grades and my posts are clear of that! It's very frustrating; I feel like I'm on the right track and I'm totally off.

Looking at her ques, I would say she needs intervention for her skin integrity so it doesn't get worse. I would say she needs to be closely watched for delirium (so the nurse isn't hit with failure to rescue), or confusion r/t her kidney disease and multiple medications, and electrolyte status. I would say she needs improved nutrition, although with eating a normal diet, TPN, and her short gut syndrome, I'm not sure what else we could do.

Please, help.

takingcare19

56 Posts

I'm not sure how Imbalanced nutrition is appropriate, she eats, she is overweight (although her extremities are fairly normal, a majority of her weight is her abdomen. There are no guts, but it is filled with fat.), her capillary refill is normal, no diarrhea (well, I guess she doesn't, she has an ileostomy), no bowel sounds, she eats fine, her mucous membranes are pink, she eats all of her meals. I'm just looking in my book at defining characteristics.

In electrolyte imbalance (well, book has risk for), renal dysfunction and medication side effects are listed, as well as impaired regulatory mechanisms (although she isn't diabetic, she is dx by physician with hypoglycemia and is on a sliding scale.)

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

See here is the problem I didn't see the patient. You indicated she has short bowel and has chronic nutritional needs. You did not include in your initial post that she was obese.....Then it is imbalanced nutrition: more than body requirements.

I don't know what your grades are...((HUGS)) and I am trying my very best to help.

Impaired Skin Integrity is described by NANDA as an Altered epidermis and/or dermis

Related Factors (r/t)

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

NO where in this definition does it mention lines.

Her albumin is low and therefore that will increase healing time and make her more likely to have skin breakdown.

I am confused that she is diagnosed with HYPOglycemia yet has insulin coverage. Does she receive coverage? Waht is the implication of TPN and the patient glucose?

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

  1. Activity Intolerance
  2. Impaired Comfort
  3. Risk for Infection
  4. Impaired Memory
  5. Impaired physical Mobility
  6. Acute Pain
  7. Chronic Pain
  8. Impaired Skin Integrity
  9. Risk for unstable blood Glucose level

From what you have given me these are the few that I see. Look them up and see which might apply.

I also think you might not be getting necessary information when you are there....I have on my sig line a critical thinking sheet for assessment for patients made by a dear member Daytonite.

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm not sure how Imbalanced nutrition is appropriate, she eats, she is overweight (although her extremities are fairly normal, a majority of her weight is her abdomen. There are no guts, but it is filled with fat.), her capillary refill is normal, no diarrhea (well, I guess she doesn't, she has an ileostomy), no bowel sounds, she eats fine, her mucous membranes are pink, she eats all of her meals. I'm just looking in my book at defining characteristics.

In electrolyte imbalance (well, book has risk for), renal dysfunction and medication side effects are listed, as well as impaired regulatory mechanisms (although she isn't diabetic, she is dx by physician with hypoglycemia and is on a sliding scale.)

does this patient take steroids?

takingcare19

56 Posts

I am just as confused about hypoglycemia and insulin...my classmate said last time that the patient argued with her that she wasn't diabetic, but my classmate was under the impression she was. But that may be b/c of the fact they have her on a sliding scale. Something I accidentally skipped when listing meds, she has orders for dextrose IV push unscheduled prn. The day I was with her, she did not receive insulin.

I'm sorry, I can't grasp what this means? 'NO where in this definition does it mention lines." About skin integrity?

Implication of TPN and her glucose? Possibly she isn't receiving enough glucose?

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I am just as confused about hypoglycemia and insulin...my classmate said last time that the patient argued with her that she wasn't diabetic, but my classmate was under the impression she was. But that may be b/c of the fact they have her on a sliding scale. Something I accidentally skipped when listing meds, she has orders for dextrose IV push unscheduled prn. The day I was with her, she did not receive insulin.

I'm sorry, I can't grasp what this means? 'NO where in this definition does it mention lines." About skin integrity?

Implication of TPN and her glucose? Possibly she isn't receiving enough glucose?

That is Ok...you mentioned...
Her skin was dry and clean except for the spot on her sacrum. So even though it's just a reddened area, she out of risk for and it is impaired....She has a wound on her clavicle from the removal of her Mediport.
Impaired skin integrity s from mechanical shearing forces.e.g., friction, shearing forces, pressure, restraint not from invasive lines as pper the definition for NANDA I. YOur statement in your care plan has to match the definition provided by NANDA I
Implication of TPN and her glucose? Possibly she isn't receiving enough glucose?
Read what you said carefully.....what is TPN? What percentage of glucose does it normally contain? Why is patient on TPN frequently on insulin coverage? Could it be from the 50% Dextrose on the TPN solution?

takingcare19

56 Posts

So, impaired skin integrity r/t pressure, obesity, low albumin aeb redness on sacrum, weight of 212, albumin level low at 2.3.

TPN has amino acids, fats, glucose, minerals. Her order says custom so I'm not sure how much is glucose (good ol' google says about 10%)...she has the dextrose 50% IV push prn. Possbily the insulin is in case they glucose gets too high?

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