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.
.......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.