patient is an 80yo M with a history of HTN, DM, cirrhosis secondary to Hepatitis C, blindness, and dementia. He is hypokalemic (3.3) and thrombocytopenic (26,000). BUN is 84, creatinine is 3.5. Low eGFR, low INR, high PT. Vitals are normal except for high RR of 22 and high BP which he takes Norvasc for. Blood sugar was below 150 (so no coverage) both mornings I cared for him. He is Islamic and speaks no English. His son translates for him but is not always around. No history of tobacco, alcohol, or drug use. He is on bedrest; has a peritoneal drain and a condom catheter; is incontinent of stool; has skin tears on his forearms, tops of thighs, and buttocks. He is very skinny but eats all of his food (Kosher). He is DNR. Discharge planning included hospice care but the staff was fairly certain his family would not agree to that and would want to take him home so plans were made to send him home with the peritoneal drain and possibly the condom catheter as well. So far my nursing
What is his assessment? Does he have edema? Does he make urine? He has a peritoneal catheter...what care does this have? You mention that he will be sent home with these....what teaching will be needed for the family/care givers? Depending on your instructor......You can use electrolyte imbalance but what can be caused by hypokalemia like muscle spasms, or cardiac arrhythmia. You mention that this patient is skinny....what about failure to thrive?
When you use the nursing diagnosis you need to have the supporting evidence in patient problems/symptoms to support using that particular diagnosis. Here is a list of what I think apply....you have done a great job!
Activity intolerance: he is on bedrest
Risk for Bleeding: cirrhosis, thrombocytopenia, elevated PT
Bowel incontinence: incontinent
Caregiver role strain: hows the family doing?
Chronic Confusion: dementia
Risk for compromised Human Dignity: he is a DNR but you indicated the family not prepared for hospice
Adult Failure to thrive: self explanatory
Risk for Falls: from his confusion
Risk for unstable blood Glucose level: he has diabetes
Excess Fluid volume: ascities
Risk for Infection: peritoneal catheter
Impaired physical Mobility: bedrest
Risk for impaired Liver function: hep C and cirrhosis
Impaired physical Mobility: emaciated
Imbalanced Nutrition: less than body requirements: he may be eating but continues to waste away.
Ineffective peripheral tissue Perfusion: ascites, edema?
Bathing Self-Care deficit: self explanatory
Impaired Skin integrity: skin tears.