Help Prioritizing nursing DX - page 2

by ALCANGEL1 1,765 Views | 11 Comments

I am need to come up with three nursing dx and I need to prioritize them and I am having problems. The patient has severe CHF, chronic renal failure, diabetes. The pt. also has some redness on a spot where they could get... Read More


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    Quote from ALCANGEL1
    Ok so the pt. was admitted with a dx of respiratory distress. Pt. has a history of renal failure, diabetes and hypertension. Pt. states she is a little out of breath especially when moving. She is overweight but does some exercise. She has a high BP, HR and RR. She has an SaO2 of 91%. She has a very high BNP which indicated heart failure. She also has a high creatinine level. She has crackles and edema. She needs assistance to walk and gets winded when walking short distances. She has some redness on her coccyx which is probably a pressure ulcer.

    When a person has CHF the heart is not pumping blood around the body like it should be and therefor tissues and organs are not getting the blood they need and oxygen is not being delivered.

    I am really trying to figure this out instead of trying to just pick care plans one of my books lists.

    I have Carpanitos handbook of nursing diagnosis and nursing care plans by gulanick and myers.
    Again and I can't stree this enough.........

    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 patient saying?. 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

    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. From what you posted I do not have the information necessary to make a nursing diagnosis.

    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.

    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

    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)

    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.

    Last edit by Esme12 on Nov 14, '12
  2. 0
    YOu are new to a program right? So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient?
    pt. was admitted with a dx of respiratory distress. Pt. has a history of renal failure, diabetes and hypertension. Pt. states she is a little out of breath especially when moving. She is overweight but does some exercise. She has a high BP, HR and RR. She has an SaO2 of 91%. She has a very high BNP which indicated heart failure. She also has a high creatinine level. She has crackles and edema. She needs assistance to walk and gets winded when walking short distances. She has some redness on her coccyx which is probably a pressure ulcer.
    Now looking at this patient. There are several clues you look at/for.

    Before prioritizing your diagnoses you need to develop them. It's all about the assessment....but unfortunately this is not a real patient. I think that is where new students get frustrated.

    Now...the patient has Renal failure. What is renal failure? Is this patients renal failure acute or chronic? You state she has a history of renal failure so it must be chronic. What does it do? What can it cause? What effect does it have on the body? You need to understand the disease before you talk about developing a plan of care.

    Renal failure.......this is a medscape link. It requires registration but it is free. As you begin your nursing journey you need good references and sources.....this is a good one. Do renal patients have an elevated B/P as a part of the disease?

    Look up HTN (hypertension) and diabetes. What impact does the diabetes have on her B/P and kidney failure? Is the patients diabeties well controlled? Did they give you any evidence of the status of the patients glucose or compliance?

    If someone is SOB from fluid over load the heart will work harder and beat faster. The patient obviously has an impaired gas exchange as evidenced by (AEB) the O2 sat of 91%. An elevated BNP isn't always an indicator of CHF (congestive heart failure)....it is an indication that the patient is fluid overloaded...........causing Pulmonary edema. What is pulmonary edema? Is the heart in failure because it can't handle the fluid? Or failing because of the heart itself? If the kidneys are failed/compromised and cannot remove fluid and toxins the build up in the body/tissues/heart/lungs.....right?

    So what would be important in the care of this patient? What complaint would be the most important to the patient? If this were your family member what would you want fixed first? The SOB (shortness of breath) right? So what nursing diagnosis would apply to this patient? I have Gulanick so I will use it......I would look at these diagnosis taxonomy and see which one/one's best fit the patients symptoms and presentation.

    Ineffective Breathing Pattern: NANDA states: Inspiration and/or expiration that does not provide adequate ventilation.

    Ineffective breathing patterns are considered a state in which the rate, depth, timing, rhythm, or chest/abdominal wall excursion during inspiration, expiration, or both do not maintain optimum ventilation for the individual. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure may be associated with changes in respiratory rate, abdominal and thoracic patterns for inspiration and expiration, and in depth of ventilation. Breathing pattern changes may occur in a multitude of conditions: heart failure, diaphragmatic paralysis, airway obstruction, respiratory infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis, uremia, or thyroid dysfunction), peritonitis, drug overdose, pleural inflammation, and chronic respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD).

    So does your patient have Ineffective breathing patterns R/T fluid over load AEB elevated BNP, edema, crackles, elevated RR rate and O2 sat of 91%?

    Decreased Cardiac Output: NANDA states:
    Inadequate blood pumped by the heart to meet the metabolic demands of the body

    Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Older patients are especially at risk because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute, ambulatory care, or home care setting.

    So does your patient have Decreased cardiac output R/T fluid overload due to the kidney's failure to filter and remove excess volume and wastes AEB a high creatinine level edema, crackles, elevated BNP, RR rate, and a low O2 sat of 91%?

    Excess Fluid Volume: NANDA States: Increased isotonic fluid retention

    Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction and the use of diuretics. For acute cases, ultrafiltration or dialysis may be required

    Impaired Gas Exchange: NANDA states:
    Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

    By the process of diffusion, the exchange of oxygen and carbon dioxide occurs in the alveolar-capillary membrane area. The relationship between ventilation (air flow) and perfusion (blood flow) affects the efficiency of the gas exchange. Normally there is a balance between ventilation and perfusion; however, certain conditions can offset this balance, resulting in impaired gas exchange. Altered blood flow from a pulmonary embolus, or decreased cardiac output or shock can cause ventilation without perfusion. Conditions that cause changes or collapse of the alveoli (e.g., atelectasis, pneumonia, pulmonary edema, and adult respiratory distress syndrome) impair ventilation. Other factors affecting gas exchange include high altitudes, hypoventilation, and altered oxygen-carrying capacity of the blood from reduced hemoglobin. Older patients have a decrease in pulmonary blood flow and diffusion as well as reduced ventilation in the dependent regions of the lung where perfusion is greatest. Chronic conditions such as chronic obstructive pulmonary disease (COPD) put these patients at greater risk for hypoxia. Other patients at risk for impaired gas exchange include those with a history of smoking or pulmonary problems, obesity, prolonged periods of immobility, and chest or upper abdominal incisions.


    See where I am going with this? This patient has an issue with skin integrity and showing signs of breakdown, they have activity intolerance in performing ADL's (self care deficit)(activities of daily living), they have imbalanced nutrition: greater than requirements........but what would be more important?

    That is where Maslows becomes important.....the ABC's is how you prioritize....what can kill the patient first.

    Are you following me? I hope this helps.


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