Help! Hypotension care plan!

  1. I am trying to figure out what to put as my "related to" and "as evidenced by" for my nursing diagnosis of Risk for altered tissue perfusion. The patient was a trauma patient that sustained 8 fractured ribs and a pneumothorax. Once the epidural catheter was placed and test dose of 1% lidocaine was infused, his blood pressure dropped to critical values (down to 57/35 at one point) and we ended up pushing neo a few times and narcan eventually. He had 5mg of dilaudid and 4 mg of morphine previously in the ER. I am trying to work out how to write about how the hypotension is related to the narcotic administration and test dose of lidocaine (plus additional BP drop once pain was relieved). The reason I am using "risk for" is because his O2 sats remained at about 97%. Thanks!!!
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    Joined: Apr '12; Posts: 2


  3. by   nurseprnRN
    you don't make a decision on a nursing diagnosis and then try to make a rationale by cramming your facts into it (common nursing student error, though). you take your facts and assessment data and look at them, and that's where your nursing diagnosis comes from. data first, diagnosis second.

    so. you have:

    a trauma patient with 8 fractured ribs and a pneumothorax
    epidural catheter, test dose of 1% lidocaine
    blood pressure dropped to critical values (down to 57/35 at one point)
    given neo and narcan (had 5mg of dilaudid and 4 mg of morphine previously)

    if you're looking for a nursing diagnosis, i don't think you have to look much further than that. he had an actual (not risk-for) episode of decreased perfusion, as evidenced by a bp of 57/35. this was related to vasodilation from his opioids and epidural. does that make sense? what makes you think he's at risk for doing it again, what data support that conclusion? am i missing something? (and spo2s don't have much to do with this)
  4. by   rademily
    ok, thanks. I guess I thought that because his oxygen saturation remained normal that he was perfusing well enough. I was really just not sure how to word the diagnosis correctly. That makes sense though. Thanks!
  5. by   Esme12
    the young, without pre-existing disease, will compensate with their spo2 a long time. when that is compromised with a critical value you have missed something and are in serious trouble.

    think about the pain. think about ineffective breathing patterns becasue of the splinting from the rib fractures is the patient deep breathig enough? willl this place them at risk for pneumonia? look up flail chest. look up epidural and side effects and narcotics and side effects. how many days post trauma? is the patient adequately hydrated? is there a skin integrity issue? any abrasions?

    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?

    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 them as a recipe to caring for your patient. your plan of how you are going to care for them.

    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:
    1. 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)
    2. 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)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)

    a dear an contributor daytonite always had the best advice.......check out this link.
    nursing diagnosis

    Last edit by Esme12 on Apr 17, '12
  6. by   AndrewCraigRN
    I just wanted to elaborate on the previous post's discussion on the O2 saturation and low BP. There are situations when a person may have low O2 saturation because of low BP. For instance, a person with a significant blood loss. O2 saturation is the measurement of how much O2 is attached to hemoglobin at any given moment. Or, O2/hemoglobin. That's why O2 saturation is expressed as a percentage. Like, 97% in this case. Now, in your patient's case, his vasculature dilated, dropping the BP, related to the vasodilation effects of the test. However, pulseOx remained okay because there wasn't a O2/Hgb issue but a vasculature issue. In your patient's case, you addressed the issue with narcan and such. It terms of ABCs or maslow, the pneumothorax is likely priority. Could be a number diagnoses related to this. Risk for Injury r/t loss of negative pressure in the lungs. As well as others mentioned above. The folks above sound much more seasoned than myself. Just my two cents. Good luck!
  7. by   KD_bluelnwife
    Well impaired tissue perfusion related due decrease mobility since trauma. Without mobility blood does not flow as with an active patient and when blood sits blood clots so secondary risk for clots.

    Are you wanting to focus on tissue integrity or the rx route?

    Also if he is a heavy guy with large body fat percentage then remember that the fat can cause drugs such as narcotics to linger or have a longer rebound time.