How does this sound? Please help!

Nursing Students Student Assist

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Hi Super Nurses,

My fellow students and I try to help each other with evaluating our ND's and patho each week, but we miss a lot because...well, because none of us know what we are REALLY doing!

How does this sound?

Nsg Dx # 1

Deficient fluid volume related to blood loss and third

spacing loss as evidenced by ascites, edema and impaired

GI absorption as evidenced by bloody stool, 20 inch

protuberant abdomen with fluid wave, +1 edema in hands

and feet and less than 600 mL input/day.

Nsg Dx #2

Altered Tissue Perfusion: renal related to impaired organ function as evidenced by low blood pressure, hematuria, decreased and concentrated urine output

Nsg Dx #3

Imbalanced nutrition less than body requires related to impaired GI absorption as evidenced by height of 5'11, 145 lbs and BMI of 20.2, loss of 15 lbs in 3 weeks, signs of muscle atrophy in neck and arms and NG tube return of feeding 60 mL at rate of 15 mL/ hour.

Presentation- Syncope and partial LOC related to GI bleeding due to rupture of gastric and esophageal varices.

Pathophysiology- Gastric and esophageal varices are small collateral veins that dilate fully due to blood diverted from the liver as the body tries to compensate for hepatic portal hypertension. The continual high-pressure environment makes the vessels enlarged and prone to rupture at the sight of comminuting or easily ruptured by gastric acid, rough food and increased pressure from vomiting, sneezing or coughing. The increase in liver vessel pressure is a result of Cirrhosis. Cirrhosis refers to the replacement of normal hepatocytes with fibrous scar tissue. The combination of fewer liver cells and scar tissue blocking the normal flow pattern causes blood to back up increasing the hepatic pressure as more blood volume processes in a smaller area by fewer cells. Inflammation of hepatocytes from cirrhosis is due (In Mr. TE"s case) to the Hepatitis C virus. Hep C is an RNA virus in the Flaviviridae family, genus Hepacivirus. It is a small double enveloped single-strand RNA virus. HCV replicates in the liver and is present in the serum during acute and chronic infections. More than 60% of HCV patients will progress to chronic status with approximately 20% leading to cirrhosis. Serum ATA levels best reflect hepatocellular injury and may fluctuate with the viral load.

Do you think the 3 nd's are in the right order?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

do you think the 3 nursing diagnoses are in the right order?

no, and that is prioritizing by maslow.

nursing diagnosis #2 (need for oxygen)

altered tissue perfusion: renal related to impaired organ function as evidenced by low blood pressure, hematuria, decreased and concentrated urine output

doesn't the hepatic hypertension also create the renal problems? where's your pathophysiology for the renal problems? didn't see anything mentioned about impaired kidney function in your pathophysiology presentation. this diagnosis is about oxygen deprivation/circulation problems in the organs addressed by this diagnosis. why isn't the kidney getting proper circulation/oxygen/nutrients in this patient? "impaired organ function" is a pretty general etiology. in your reading of cirrhosis did you run across kidney involvement with cirrhosis and why it occurs? or, is there something separate from the liver going on here? this kidney is not working because it isn't getting perfused or getting nutrients it needs.

nursing diagnosis # 1 (need for fluid)

deficient fluid volume related to blood loss and third spacing loss as evidenced by ascites, edema and impaired gi absorption as evidenced by bloody stool, 20 inch protuberant abdomen with fluid wave, +1 edema in hands and feet and less than 600 ml input/day.

you've used "as evidenced by" twice. the use of the word "ascites" is questionable as being a medical diagnosis. it can be described by using factual terms--you can do abdominal girth measurements. i would be more descriptive of the stools by listing amounts and numbers of them per day. there is a specific nursing diagnosis for diarrhea if they are watery in nature. not taking in enough fluid is evidence of
imbalanced nutrition less than body requirements
. this diagnosis is about
loss
. it is, as described in its definition, about
dehydration
. his low blood pressure and urine output

better:
deficient fluid volume related to fluid loss, blood loss and third spacing of fluid as evidenced by bloody stools, 20 inch protuberant abdomen with fluid wave, +1 edema in hands and feet, low blood pressure and urine output

nursing diagnosis #3
(need for nutrition)

imbalanced nutrition less than body requires related to impaired gi absorption as evidenced by height of 5'11, 145 lbs and bmi of 20.2, loss of 15 lbs in 3 weeks, signs of muscle atrophy in neck and arms and ng tube return of feeding 60 ml at rate of 15 ml/ hour.

the item of "less than 600 ml input/day" that you had for deficient fluid volume belongs here. i would re-write "height of 5'11, 145 lbs and bmi of 20.2" as "low bmi (20.2) for height and weight" and "loss of 15 lbs in 3 weeks" as "15 pound weight loss in 3 weeks". what are the signs of muscle atrophy? ng tube feeding returns that are aspirated are called
gastric residuals
.

better:
imbalanced nutrition: less than body requirements related to impaired gi absorption as evidenced by low bmi (20.2) for height and weight [ideal: ___], loss of 15 pounds in 3 weeks, signs of muscle atrophy in neck and arms and gastric residuals of 60 ml (tube feeding at 15 ml/ hour).

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wow!! You should be a professor! Or a tutor!! Since I can't send you real brownies, I will just say THANK YOU!!!!:yeah::bowingpur:monkeydance:

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Does Maslow have sub-levels? In our school they teach us the Hierarchy of Needs, but it seems very general. Physiological, Safety, love Self esteem, self actualization- we never went into what goes on within a level. So I know you don't talk about relationship issues with a patient who is in physical pain, but how do you prioritize between needs in the same category?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

does maslow have sub-levels? yes. here you go, including the website where i got it from.

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

  1. physiological needs (in the following order)
    • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
    • the need for food and water
    • the need to eliminate and dispose of bodily wastes
    • the need to control body temperature
    • the need to move
    • the need for rest
    • the need for comfort

[*]safety and security needs (in the following order)

  • safety from physiological threat
  • safety from psychological threat
  • protection
  • continuity
  • stability
  • lack of danger

[*]love and belonging needs

  • affiliation
  • affection
  • intimacy
  • support
  • reassurance

[*]self-esteem needs

  • sense of self-worth
  • self-respect
  • independence
  • dignity
  • privacy
  • self-reliance

[*]self-actualization

  • recognition and realization of potential
  • growth
  • health
  • autonomy

so i know you don't talk about relationship issues with a patient who is in physical pain, but how do you prioritize between needs in the same category?

the ones i have that question with are the respiratory, safety and self-esteem ones. usually i resolve it by deciding which one kills you first. if they are so close in need, i don't think it matters which comes first, but i'm not in school anymore so i don't have the anxiety of a grade hanging over my head either. pain is a comfort issue. skin integrity is usually a safety need, but sometimes it can be classified as a nutrition need. i struggle with them too. the appendix of
nursing diagnosis handbook: a guide to planning care
by betty j. ackley and gail b. ladwig classifies the diagnoses according to maslow and gordon's functional health patterns. the appendix of
taber's cyclopedic medical dictionary
classifies the nursing diagnoses by gordons's functional health patterns and by doenges & moorhouse's diagnostic divisions (these are similar to the nanda taxonomy).

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