I would like to ask for feedback on my current diagnosis. I've received very insightful information in my last request. Thank you!
I prepared this:
Excess Fluid Volume R/T decreased urine output, compromised kidney function secondary to CKD Stage V
AEB urine output of 760 mls, BP of 163/77, RR 21, general edema +1, bounding pulses
Defining characteristics that she fits: altered electrolytes, anxiety, azotemia (uremia, really), blood pressure changes, decreased H/H, edema, oliguria.
However, she doesn't have abnormal lung sounds or JVD. She also had weight loss of 4kg in two days due to dialysis (they took 2500 mls of ultra filtrate the day I worked with her and about the same the day before). Is it okay to use Excess Fluid Volume as my nursing diagnosis for the concept map if I use dialysis as one of the interventions?
What she does have: anxiety, social withdrawal (not wanting to talk much to her son), body image issues, deficient knowledge, etc are care plans
that I could write, but I wasn't sure about the priority.
If not this nursing diagnosis, what would be the priority? I sure hope I'm on the right track, because this has taken me a long time!
This is the data from my patient: 74 year old female w/ hx of DM, HTN, CKD IV now V.
Blood pressure 163/77
RBC2.92-->3.3 after 2 bags transfused
H&H of 9.9/29.5
Ca 7.9, Cl-116-->110
CSM: pale, sluggish, bounding pulse
+1 nonpitting edema
ABGs of 7.3, PaCO2 30, HCO3 15.4
quiet and withdrawn
weight loss since admission of 4 kgs (2 days).
The arrow -->) above means the first number was before dialysis, & second number was the next morning before her second dialysis treatment.
Short term goal
- patient will demonstrate an acceptable fluid balance as evidenced by: acceptable blood pressure (at least systolic of 130), fluid electrolytes within normal limits, 16-20 respirations per minute, clear lung sounds and demonstrate no edema, dyspnea or orthopneafollowing dialysis.
- Prepare patient for dialysis
- Administer antihypertensive medication as directed
- Monitor ABG levels.
- Monitor potassium levels
- Monitor for low calcium levels and
- Teach patients about nutritional needs after dialysis, specifically regarding protein intake
- Patient will decrease bounding pulses to within normal limits
- Monitor intake and output daily
- Monitor respirations every four hours to evaluate for dyspnea
Long Term goal:
- Client will remain free of effusion, anasarca and improve level of edema by end of hospitalization
- Turn or have client move at least every 2 hours to prevent skin break down from edema
- Monitor for decreased edema after dialysis
- Monitor lung sounds every four hours for evidence of crackles and of effusion
- Monitor and document blood pressure levels
- Monitor daily weights to track fluid levels
- Assess for jugular vein distention (suggesting intravascular volume increase) with HOB elevated to 30-45 degrees twice a day
- Teach patient importance of participation in fluid management through fluid and sodium restrictions
- Teach patient to avoid medications that may cause fluid retention, such as over-the-counter nonsteroidal anti-inflammatory agents, certain vasodilators, and steroids.
- Teach patient for signs and symptoms of fluid overload
ok, so here's my hints. it's hard to know what to put in a care plan when you are just learning the difference between a nursing intervention and something a nurse does to carry out aspects of the medical plan of care. it is assumed that you will do that-- legally, that's part of what nurses do. you are in school to learn nursing (in addition to a good amount of medicine), so when your faculty wants you to do a nursing plan of care, they want to know what you have learned about nursing assessments and nursing interventions. that's why "carry out thus and such aspects of medical plan of care" like "give meds/fluids as ordered" (gawd, i hate that word) doesn't belong in a nursing plan of care. any time you are tempted to write "as ordered" in a nursing plan of care, imagine me glowering over there in the corner challenging you to look at nursing, not physicianing, at the moment.
this lady is a hemodialysis patient because her kidneys are not doing their job at regulating her internal environment. she's making some pee but not enough, and her electrolytes are out of whack too. medicine will figure out why that is and write the medical plan of care to address that diagnosis: hemodialysis, meds for bp and electrolyte regulation, minimal iv fluids, perhaps a po fluid restriction, etc., and timetables by which to monitor the progress of these medical interventions (and you are always free to check vs, breath sounds, etc. more often as you feel important).
nursing, while doing all those actions by which nurses implement the medical plan of care (we don't take chest x-rays or do surgery, for example), looks at the effect the condition of excess fluids has on this lady, includes data from diagnostics to inform a nursing understanding of what goes on, and writes a nursing plan of care for what nursing does independent of physicians. i know that's a really huge concept to wrap your arms around when you're just starting out, but hey, that's how nurses get to be strong autonomous partners in patient care, not just handmaidens.
so, a good start. here are some things to think about.
excess fluid volume r/t decreased urine output, compromised kidney function secondary to ckd stage v (what is it about ckd stage v that is in the related factors? hint: how do kidneys promote homeostasis?)
aeb urine output of 760 mls (in what time period? input? i/o is a defining characteristic for this dx, need both to communicate why there is an excess of intake over output)
bp of 163/77 (changes are a defining characteristic-- what was it before/after hd?)
rr 21(changes are a defining characteristic-- what was it before/after hd?)
general edema +1, (yep)
bounding pulses (i don't see this on the list of defining characteristics for this diagnosis)
short term goal
- patient will demonstrate an acceptable fluid balance as evidenced by: acceptable blood pressure (at least systolic of 130), fluid electrolytes within normal limits, 16-20 respirations per minute, clear lung sounds and demonstrate no edema, dyspnea or orthopnea following dialysis. good medical outcomes. wht would a nurse like to see? wht would a nurse like to hear the patient say?.
- prepare patient for dialysis (this action does not promote fluid balance-- dialysis does, but that's part of the medical plan of care. just because a nurse does it doesn't make it part of the nursing assessment and plan of care.)
- administer antihypertensive medication as directed (not a nursing intervention, part of the medical plan of care. how about looking to see how well it's working, side effects, patient teaching?)
- monitor abg levels. }
- monitor potassium levels }
- monitor for low calcium levels and }how are these 3 monitoring activities interventions and how do they relate to your goals? hint: what do they tell you?
- teach patients about nutritional needs after dialysis, specifically regarding protein intake (why? and what about fluid i/o? how does this relate to the stg above?)
- patient will decrease bounding pulses to within normal limits (this is not a nursing intervention, it is an evaluation criterion but doesn't appear as a goal so why is it here? or why isn't it there?)
- monitor intake and output daily (this is not a nursing intervention, it is an evaluation criterion but i&o doesn't appear as a goal so why is it here? or why isn't it there?)
- monitor respirations every four hours to evaluate for dyspnea (resps aren't enough. what else happens to the lungs when there is fluid overload? how would you know? how would you check? would the patient tell you anything in addition to that? what would you instruct her to tell you, and why?)
long term goal:
- client will remain free of effusion, anasarca and improve level of edema by end of hospitalization. (this is a great medical treatment endpoint. i don't see where nursing interventions (not nursing carrying out the medical plan of care) facilitates this. what are the endpoints of nursing actions to address fluid excess-- teaching, skin protection, comfort, anticipating / assessing for complications)
- turn or have client move at least every 2 hours to prevent skin break down from edema (good idea, i'd put it under a risk for tissue (skin) injury dx, is not an intervention for edema per se)
- monitor for decreased edema after dialysis (how does this influence effusion/anasarca/edema? not an intervention, not a goal. isn't long term, either-- you would do this from the beginning. edema takes some time to leave the extravascular space so it might be awhile before you see a real difference. what's the best assessment to check fluid balance?)
- monitor lung sounds every four hours for evidence of crackles and of effusion (aha! also related to the breathing problem you noted; do from the beginning, not a goal)
- monitor and document blood pressure levels (how does this influence effusion/anasarca/edema? not an intervention. not a goal.)
- monitor daily weights to track fluid levels(how does this influence effusion/anasarca/edema? not an intervention. not a goal.)
- assess for jugular vein distention (suggesting intravascular volume increase) with hob elevated to 30-45 degrees twice a day(how does this influence effusion/anasarca/edema? not an intervention. not a goal.)
- teach patient importance of participation in fluid management through fluid and sodium restrictions (now you're getting closer. what does she need to know, and how will you know she does? hint: self health management section, domain 1)
- teach patient to avoid medications (or maybe better to discuss with her physician any meds she takes to help her avoid...)that may cause fluid retention, such as over-the-counter nonsteroidal anti-inflammatory agents, certain (certain? which?) vasodilators, and steroids.
- teach patient for signs and symptoms of fluid overload (what will that entail? daily weight q am before breakfast will yield the first sign)
Last edit by nurseprnRN on Jun 9, '12