facial edema and difficulty breathing

CP2013 · Jan 20, 2013

I would think that facial edema and allergic reaction could potentially impair her airway, right?

Look along the lines of how you would go about protecting her airway - interventions may be the things you need to do in order to protect it.

Look through your list of diagnosis again and lets see where you land.

BloomNurseRN, ASN, BSN, RN · Jan 20, 2013

I was actually thinking the same thing as CP2013. One thing you will find out VERY soon is that priority is everything and when it comes to priority the ABC's are the gold standard. If there is ever the risk of airway being affected, you want to look at diagnoses for that. Once you do, then focus on how to protect the airway.

Also, I highly recommend a nursing care plan book. I have one but don't think you need to look for anything specific. It's not to quit doing your own work but to start learning the types of things you should be looking for. Good luck!

nursingstu14 · Jan 20, 2013

I cannot use the diagnoses of airway obstruction since its the most obvious diagnoses (according to my professor). That is the reason why i chose risk for impaired skin integrity. Thanks though =)

Since she has facial edema, excessive fluid retentions of the face, Im thinking for an intervention would be drug therapy on removing the excess fluid retention. My rationale would be if diuretics were prescribed it will increase kidney water and sodium excretion. Another intervention could be nutrition therapy, which can involve restrictions of both fluid and sodium intake to control fluid volume. And since she has itching and red swollen blotches an intervention can be some sort of ointment/medication to reduce the itching which will prevent the patient from scratching and making her blotches worse. If patient continues to scratch they can tear skin which will increase chance of skin infection/ integrity.

What do you guys think?

CrufflerJJ, BSN, RN, EMT-P · Jan 20, 2013

It sounds like she's having a significant allergic reaction to a med.

Research anaphylaxis.

Besides blotchy skin and facial edema, what are some other significant potential problems encountered by that type of pt?

OK, so you can't choose the highest priority diagnosis, per your instructor.

Why does she experience facial swelling? Is it due to too much sodium in her diet? Answer: no. Look into why the swelling occurs.

On a systemic level, if the mechanism that causes localized (facial) edema occurs body-wide, what might happen. Hint: fluid being where it's not supposed to be can cause the swelling. If the fluid is not where it's supposed to be, what other highly important issue might happen, due to a lack of fluid?

Risk for....(fill in the blank)

nursingstu14 · Jan 20, 2013

Yes, she's having an allergic reaction to the medication cefazolin. And sorry for not mentioning it but cant do anaphylaxis either. So, heres the whole case:

A 69 yr old Mexican American woman is admitted for total knee replacement surgery. Following surgery, an order was written for cefazolin sodium (Ancef) 2 gm intravenous piggybank every 8 hrs for 24 hrs. She received her first dose after surgery. Thirty mins after the medication was started, the patient calls the nurse and reports "itching all over" and difficulty breathing. The nurse notes facial edema and audible wheezing. The skin is red with large swollen blotches over her arms, trunk and back. Patient states, "I had this happen to me before when I took a drug called amoxil. The doctor said i am allergic to amoxil."

I believe she is experiencing swelling to the face because of the allergic reaction from the medication not from sodium in her diet. So, it doesn't make sense when i wrote for one of my interventions to be nutrition therapy. I chose that for when she goes home she would be educated in what not to eat so swelling doesn't get worse. Maybe the sodium in her med order is adding to the swelling too. Cefazolin is meant for bacterial infection so maybe she has an infection which is contributing to her swelling. But that wouldnt cause swelling to her face because its her knee....Swelling is the body's reaction to an injury, which in the patients case is her knee surgery. =/ im not sure what to say.

risk for dehydration??

Im sorry if i miss it. I don't really know. Im completely new to this i have no medical background what so ever? Im researching all of this as I'm going in my textbooks and internet.

nursingstu14 · Jan 20, 2013

I do have a nursing all in one care plan book but it doesn't really give much information on edema. In the book they have it more as a side effect or symptom to a greater disease...=/ thanks for your advice though =)

LadyFree28, BSN, LPN, RN · Jan 20, 2013

Risk for ineffective tissue perfusion...anaphylatic shock, edema, leaking in the tissues NOT NORMAL...

Like what PPs said, ABCs...you instructor said airway was obvious, so she took away AB, C=circulation is left...ineffective tissue perfusion is a BIGGIE as a nursing diagnosis in shock...sorry, I had to answer the question! :-/

psu_213, BSN, RN · Jan 20, 2013

I cannot use the diagnoses of airway obstruction since its the most obvious diagnoses (according to my professor).

Excuse me?? I usually take the instructor's side when I hear about student/teacher conflicts. However, this is the silliest thing I have ever heard! Risk for impaired skin integrity could become bad if they scratch open an area and it becomes infected. However, this is not going to be an issue if the pt dies first because they don't have patent airway!

While you may not be able to use an airway diagnosis, this is no doubt that airway is going to be the first issue to be 'dealt with.'

livRN2012 · Jan 20, 2013

Think about what is happening to her systemically if her airway is closing. She can't breathe so her o2 intake is decreasing. If her o2 is decreasing, her tissues aren't being perfused. What will you do to help her with this. Give o2, focus on reducing swelling-diuretics, etc. I would recommend getting a nursing diagnosis book. They help a lot with getting good interventions and helping you think things through.

psu_213, BSN, RN · Jan 20, 2013

Give o2, focus on reducing swelling-diuretics, etc.

I have to respectfully disagree on the use of diuretics. The swelling is going to "go down" with meds that stop the allergic reaction (epi, antihistamines, etc.) not diuretics. In fact, a pt with a anaphylactic reaction is going to receive a large volume of IV fluids...a diuretic would only counteract the administration of such fluids (according to an emergency medicine journal, sometimes more than 5 L of NS).

To the OP, why would a patient having an anaphylactic reaction need that volume of fluids? (I know we have been hammering the airway issue, but think beyond the airway...what does anaphylaxis do to the body, specifically that vasculature? BTW, this may direct you towards another nursing dx.)

Esme12, ASN, BSN, RN · Jan 20, 2013

Yet again.... I sit here shaking my head. You are brand new to school and given this scenario...You know nothing about allergic reactions nor anaphlyaxis ......AND care plans are all about assessment.......the patients assessment and needs...yet you may not explore ANY OF THESE even though nursing is all about priority you are not to follow that protocol.

Here is what I know that usually applies......Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

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.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.