Care plan help - need help with 2 nursing dx

[pinkiepie_RN]

Sooo I have to do a mini careplan for my patient tomorrow and I'm a little stuck when it comes to nursing dx. I haven't done an assessment on her yet; we go to the hospital the night before just to pick up the Kardex and introduce ourselves to the patients, nothing more. Her reasons for admittance to the hospital are as follows "tele (anyone know what that means?), febrile, hypotensive". The medications my instructor highlighted for me to know for tomorrow are artificial tears, rivastigmine, escitalopram, tamsulosin, risperidone, lisinopril, neutra-phos, magnesium sulfate, calcium gluconate, vancomycin, and piperacil. She's on a pureed diet, which makes me think that risk for aspiration is a good one but I want to write one related to her medical dx or reason for admittance. I think risk for aspiration related to impaired swallowing ability might work. She also had +2 edema when I did see her today. She was unresponsive and the nurse said she had been lethargic all day, to not worry that should was not waking up when I called her name and shook her gently.

I'm going to look these up to see if I can get some more hints, but I would be greatly appreciative if anyone who knows of these medications or dx related to this patient's medical dx's could give me a hand.

[Daytonite, BSN, RN]

what you need to do is look up the symptoms you would see with fever and hypertension and develop nursing diagnoses from those. "tele" is a shortened term for "telemetry". this patient is having her ekg continuously monitored, so she must have some kind of arrhythmia they are worried about. you need to look up the drugs she is on. she's on two antibiotics which matches with the fever, so she's got some type of infection going on. there are other reasons for being on pureed diets--like having no teeth.

[pinkiepie_RN]

what you need to do is look up the symptoms you would see with fever and hypertension and develop nursing diagnoses from those. "tele" is a shortened term for "telemetry". this patient is having her ekg continuously monitored, so she must have some kind of arrhythmia they are worried about. you need to look up the drugs she is on. she's on two antibiotics which matches with the fever, so she's got some type of infection going on. there are other reasons for being on pureed diets--like having no teeth.

well i certainly had a fun day with this patient. based on my assessment and data gathered, i'm going to picking "risk for aspiration" as a primary dx since she's got dysphagia and serious exhaustion, to the point where she would fall asleep before swallowing her food this morning.

thanks!

[Daytonite, BSN, RN]

Please remember what I've told you before. . .the patient's symptoms are what drive and are the foundation of any care planning. The nursing diagnoses are not as important as determining those symptoms. They are merely labels that get attached to groups of symptoms that can be collected together to form one particular problem you can attach a name to. You are still going to treat the symptoms--not the nursing diagnosis. The nursing diagnoses as well as the goals and nursing interventions will fall into place very nicely as long as you have the patient symptoms straight in your mind (and on a list). Just make sure that you exhaust every resource you can think of to gather the abnormal data (symptoms) and that includes a thorough scrutiny of the patient's medical record.

[pepperann35]

Based on her medications, like risperidone, she must have a behavioral issue. Her lethargy could be a side effect of some of her meds. She could be confused. A fall risk, fall precaution care plan would be good. A care plan for her antibiotic would be good also--to monitor for medication side effects etc. Just of couple of ideas:rolleyes:

[nursin09]

Have you thought about activity intolerance? It sounds like your patient might have an issue with that...

[pinkiepie_RN]

Have you thought about activity intolerance? It sounds like your patient might have an issue with that...

*nod* Thanks! I ended up picking risk for aspiration because she showed signs of coughing while swallowing, inability to swallow food efficiently and difficulty staying awake during feeding. This was my primary dx because the only time I could keep her awake was during breakfast and even that was a challenge. We only had to pick one dx and it could be anything related to her symptoms. It turns out that the abx had already been d/c'ed when I was there and her infection was gone.