I have a 75 y/o male pt w/ an admitting diagnosis of Coronary Artery Disease. He has a past history of: HTN, diabetes mellitus type 2, hyperlipidemia, hypercholesterolemia, Gout, Degenerative joint disease, anemia, peptic ulcer disease with gastroesophageal reflux, Benign Prostatic Hypertrophy, Chronic renal insufficiency, non-Q wave MI-complication of a right total knee replacement in 2009, and a right inguinal hernia repair in 2006. He under went a cardiac catheterization on 1/28 and a CABG on 1/29. He was admitted to the telemetry unit on 1/31. His abnormal labs were: BUN 31, Creat. 1.6, Calcium 8.2, phosphorus 1.8, hemoglobin 9.5, hematocrit 27.2, platelets 90, and albumin 2.9. ABG results for 2/1 were ph 7.404, pco2 33.6, hco3 20.5, sa02 95.7, BE -3.3. total Intake 480 and total output 700 for 2/1. Physical Assessment: Alert, oriented X3, heart rate: 80 and regular w/ s1 and s2. Radial pulses and pedal pulses normal and equal. cap refill less than 3, no edema noted. Respiratory rate 20 with eupnic breathing, lungs clear bilaterally, no cough. Stomach rounded, soft and nontender, bowel sounds present in all 4 quadrants. pt complaining of constipation. last Bm 1/28. Skin: warm and dry w/ pink undertone. Dressing to chest dry and intact with slight shadowing. Dry mucous membranes. Last glucose value 109. Activity level up with assistance. ROM and strength normal for age in all extremities. pt complaining of nausea. last set of vitals: 99.0 F- 75-18-132/66 100% on 3 liters of O2 per Nasal cannula.
Some of the diagnoses I came up with were:
Risk for decreased cardiac output r/t myocardial ischemia and increased vascular resistance
Activity Intolerance r/t compromised oxygen transport system s/t cad and anemia aeb pt complaints of dyspnea with activity
Constipation r/t side effects of anesthesia aeb pt complaining of not having a bowel movement for 4 days.
Impaired Skin Integrity r/t surgical incision s/t CABG aeb disruption of skin surface
Risk for infection r/t a site for organism invasion s/t surgery
What do you think about these? and do you have any to add to this? Also im not sure what would be my top priorities. Thanks
Feb 3, '10
what are you going to do about his anemia, dry mucous membranes and nausea? did you review his list of medications and other things he is being treated for? this man has a lot of medical problems.
im not sure what would be my top priorities.
i don't know what you mean by this. are you asking how to prioritize your list of nursing diagnoses?
- - - - - - - - - - - - - - -
risk for decreased cardiac output r/t myocardial ischemia and increased vascular resistance
this is an incorrect diagnosis. if he already has cad (surgery does not cure this disease) and hypertension then he has decreased cardiac output.activity intolerance r/t compromised oxygen transport system s/t cad and anemia aeb pt complaints of dyspnea with activity
you never mentioned in your physical assessment of the patient that he had complaints of dyspnea with activity. that's kind of an important thing. when people have activity intolerance they have to stop their activities because their heart and lung functions become overcompromised. you should also have elevated heart and respiratory rates to go along with the complaints of dyspnea. you should have been able to see this activity intolerance and not just take the patient's word for it. dyspnea is also a symptom of his decreased cardiac output.constipation r/t side effects of anesthesia aeb pt complaining of not having a bowel movement for 4 days.
you should have empirical evidence in the nursing records that he has had no bm for 4 days and not just the patient's complaint that he has had no bm.impaired skin integrity r/t surgical incision s/t cabg aeb disruption of skin surface
your aeb evidence should be more specific. the cabg wound should be measured and described. was their staples or sutures? any drainage? was there a donor site on his lower leg? if so, that needs to be addressed as well.risk for infection r/t a site for organism invasion s/t surgery
just say risk for infection r/t surgical invasion.