Direction with Care Plan....please

  1. Hi, I am working on a care plan and having a difficult time coming up with nanda's. My pt. came in with complaints of SOB. He was diagnosed with pneumonia, which I used for my 1st nanda. His co-morbidities are BPH, Chronic renal failure, hypertension, COPD, Lung Cancer, peripheral artery disease. He had a AAA stent put in last year. He had a transthoracic echo which stated "all normal" but as I read further into the report it stated he had mild mitral regurgitation, a trace of tricuspid regurgitation, borderline aortic stenosis, Left atrium mildly dilated, EF of 55-60%. He also has a foley catheter.
    We are only allowed to use one nanda per system.
    Besides the pneumonia, I have Fatigue r/t low RBC production aeb the patient stating "I am always so tired and have no energy" His RBC's are 3.11
    I have a risk for infection due to the indwelling foley catheter which they were discussing having him wear at home. I have a psych one because he is on two anti-psychotics and is anxious b/c he does not want them to take the foley out.
    My last one I was going to do on the chronic renal failure.....Chronic urinary retention r/t obstruction aeb inability to empty bladder completely
    Do these areas sound right? I was going to use decreased cardiac output but the professor said no.....any direction would be greatly appreciated...thanks

    Labs.. Creatinine 2.93, BUN 71, GFR 21, RBC 3.11, WBC 10.9, Hgb 8.9, Hct 27.3, his Ca, K and Na are all within normal limits...although they put him on a low K diet(5.3)
    BP 153/73, P 70, RR 20 O2 95% room air
    Last edit by ekka on Feb 9
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    About ekka

    Joined: Feb '18; Posts: 2

    3 Comments

  3. by   KrCmommy522
    They sound good to me. Except for pneumonia. That is not a nursing diagnosis. That's a medical diagnosis. You are on the right path with wanting to use pneumonia as your first diagnosis - that is the issue causing problems right now. However, you need to come up with a nursing diagnosis for it. Like ineffective airway clearance or impaired gas exchange. Do you have a nursing diagnosis book? If so, the front part of the book should have an area with medical diagnoses, where you can look them up and it will list nursing diagnoses that go along with it. Of course, you need to figure out which one fits your pt based on your assessment of the pt.

    Risk for infection is good with the indwelling cath and the fact that he might be wearing it at home.

    Is chronic urinary retention a nursing diagnosis? Urinary retention is but I don't think it says anything about being chronic. You could use impaired urinary elimination or urinary retention. Your post didn't say anything about an obstruction. I would probably use impaired urinary elimination r/t CKD. He has ability to empty bladder some, but all doesn't come out? If so, I would use the impaired urinary elimination.
  4. by   ekka
    Thank you so much for replying. I used Impaired gas exchange r/t decreased functional lung tissue and accumulation of fluid AEB crackles in mid right lobe, increased respiratory rate and patient complaining ofs shortness of breath.

    Also, on the urinary retention we just received a new nanda list and I think the chronic is on there but I will check. I used obstruction because he has BPH and I was thinking his prostrate was the obstruction....am I off there? But I like the impaired urinary elimination r/t CKD so will probably use that. Thank you again
  5. by   KrCmommy522
    Quote from ekka
    Thank you so much for replying. I used Impaired gas exchange r/t decreased functional lung tissue and accumulation of fluid AEB crackles in mid right lobe, increased respiratory rate and patient complaining ofs shortness of breath.

    Also, on the urinary retention we just received a new nanda list and I think the chronic is on there but I will check. I used obstruction because he has BPH and I was thinking his prostrate was the obstruction....am I off there? But I like the impaired urinary elimination r/t CKD so will probably use that. Thank you again
    For the impaired gas exchange AEB, don't put increased RR, put the actual RR: RR 20 breaths/min.

    You're right on the BPH causing obstruction. I didn't see the BPH sorry! You can use impaired urinary elimination r/t mechanical obstruction (which would be from the BPH) and effects of CKD. So you would put "impaired urinary elimination r/t mechanical obstruction and effects of CKD.

    Do you have a nursing diagnosis handbook? If not, I would recommend Nursing Diagnosis Handbook by Betty Ackley and Gail Ladwig. It is a great book! It helped me do all my care plans in nursing school and I never had any issues making them with it!

    The Nursing Diagnosis Handbook Says:
    Impaired Urinary Elimination
    Defining characteristics - Dysuria; frequency; hesitancy; incontinence; nocturia; retention; urgency
    Related factors - Anatomic obstruction; multiple causality; sensory motor impairment; urinary tract infection

    Urinary Retention
    Defining characteristics - Absence of urine output; bladder distention; dribbling; dysuria; frequent voiding; overflow incontinence; residual urine; sensation of bladder fullness; small voiding
    Related factors - Blockage, high urethral pressure, inhibition of reflex arc, strong sphincter

    I would use impaired urinary elimination based on the fact that you said he was unable to empty the bladder completely. Thus, his elimination is impaired. He does not have retention unless he has absence of output, bladder distention, etc. (I'm not sure why the defining characteristics for urinary retention has "frequent voiding," I would think it would be infrequent voiding based on the fact it also has absence of urine output - That's the first time I ever saw something I had to wonder about in that book! LoL!)

    I didn't see chronic urinary retention in the NANDA 2018 - 2020 nursing diagnoses, but I could have missed it.

    Nursing Care Plan BPH with Diagnosis and Interventions >> NANDA NURSING

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