NEED HELP ASAP!! DKA

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    OK...So I observed a patient in the ICU, came in through the ER with DKA and Right ankle osteomyelitis/abscess, complicated by sepsis. Experienced respiratory depression after desating to 80s on face mask, failed bipap trial, persistant tachypnea with increased agitation and poor mental status--so patient was intubated. Vitals-107/60, Resp 29, Pulse 82, O2 97%.... Patient was dong really well, he was on medication to keep him sedated, on bronchodilators, on tylenol prn, on insulin drip to control the DM, on pepcid, cipro and s/p 2U PRBC. Had ETT in place, foley, colostomy, NG tube, on mechanical vent and wound vac for abscess on right ankle..

    I NEED SOME NURSNG DIAGNOSES....I was thinking ineffective tissue perfusion r/t swelling on ankle...
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  3. 6 Comments so far...

  4. 0
    Ineffective airway clearance related to increased mucous production due to presence of tube in trachea......Powerlessness related to dependency on ventilator.......Impaired verbal communication related to ETT and ventilator.....But wha diagnosis can i put for the DKA if the patient is not having any complications ? Can i put risk for infection related to the tube if the patient is already in sepsis?
  5. 0
    could you use knowledge deficit, related maybe noncompliances with treatment (check hemoglobin A1c) ??? that would even be a psychosocial diagnosis.
  6. 1
    a care plan is based upon the nursing problems that a patient has. care planning follows the steps of the nursing process. it all begins and is based upon the abnormal data that is found during the initial assessment of the patient. the first step is assessment. a good nursing assessment consists of the following:
    • a health history (review of systems) - admitted to icu with dka and right ankle osteomyelitis/abscess complicated by sepsis.
    • performing a physical exam - the only physical assessment data you provided (and i am only interested in abnormal data) is that the patient has persistent tachypnea and a respiratory rate of 29, is agitated and has poor mental status. with so many respiratory problems i would expect to see lung sounds. the patient was not put on a ventilator because of excess secretions in the airway. there should also be an assessment of this abscess of the right ankle. one of your diagnoses suggests there is swelling of that extremity and that is abnormal. sepsis is a very serious infection of the blood stream and there are specific symptoms that you should be looking for:
      • an acute inflammatory reaction occurs with systemic manifestations associated with release into the bloodstream of numerous endogenous mediators of inflammation. the inflammatory reaction typically manifests with 2 or more of the following
      • temperature > 38 c or < 36 c
      • heart rate > 90 beats/min
      • respiratory rate > 20 breaths/min or paco2 < 32 mm hg
      • wbc count > 12,000 cells/μl or < 4000 cells/μl, or > 10% immature form
      • severe sepsis is sepsis accompanied by signs of failure of at least one organ. cardiovascular failure is typically manifested by hypotension, respiratory failure by hypoxemia, renal failure by oliguria, and hematologic failure by coagulopathy
    having a colostomy suggests there has been some previous disease of the colon of some sort. there should be an abdominal assessment. why is there an n/g tube now?

    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what needs to be done for the patient? what can the patient do and not do for themself? nurses are the people that help patients perform their adls.
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition the pathophysiology of the dka and sepsis are needed in order to construct the related factors (etiologies) for some of your nursing diagnostic statements. you also need to know the signs and symptoms of these conditions to double check that you didn't miss seeing any of them in the patient. this is part of your learning experience.
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - a ett, foley, colostomy, ng tube, ventilator, wound vac and blood transfusion are medical treatments. so are medications (sedation, bronchodilators, tylenol, insulin drip, pepcid and cipro). side effects and complications of these procedures and medications need to be reviewed.
    the second step is to determine what nursing problems the patient has and name them (give them nursing diagnoses). these problems are based upon the abnormal data that falls out from the assessment information done in the first step. this abnormal data now becomes the evidence proving that problem(s) exist. they will also be the target for your goals and nursing interventions you will develop in the third step of the nursing process.
    abnormal data:
    • abscess right ankle
    • respiratory depression
    • persistent tachypnea
    • increased agitation
    • poor mental status
    • resp 29
    diagnoses:
    • impaired tissueintegrity
    • impaired gas exchange
    • acute confusion
    but what diagnosis can i put for the dka if the patient is not having any complications?
    but, the patient is having complications. the abscess, for one. it probably wouldn't have gotten infected and had difficulty healing if the patient didn't have diabetes. this is delayed surgical recovery if any sterile procedures have been done on the abscess. also ineffective tissue perfusion, peripheral is going on as a complication of the diabetes. the dka itself is imbalanced nutrition: less than body requirements r/t body's ability to use nutrients.
    can i put risk for infection related to the tube if the patient is already in sepsis?
    no. the patient already has been diagnosed with sepsis which is an infection of the blood.
    - - - - - - - - - - - - - - -
    there are problems with some of the nursing diagnoses you propose. the construction of the 3-part diagnostic statement follows this format:

    p (problem) - e (etiology) - s (symptoms)
    • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    • etiology- also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
    • symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
    ineffective tissue perfusion r/t swelling on ankle
    • the diagnosis is named incorrectly. it is ineffective tissue perfusion, peripheral. as of the 2009-2011 nanda taxonomy this has been changed to ineffective peripheral tissue perfusion.
    • swelling on ankle is a symptom of this problem and not a cause, or etiology of it. the etiology is the patient's diabetes, for sure. does the patient smoke or are they sedentary and immobile? they are also related factors for this diagnosis.
    ineffective airway clearance related to increased mucous production due to presence of tube in trachea
    • increased mucus and the presence of a foreign body in the airway (the et tube) are both related factors for this diagnosis
    powerlessness related to dependency on ventilator
    • this is a psychosocial diagnosis and is about the patient's feelings and what is causing their lack of control over the current situation.
    impaired verbal communication related to ett and ventilator
    • related to (the presence of) ett and ventilator
    NRSKarenRN likes this.
  7. 0
    Respiratory diagnoses are tricky... I have really tried this semester to get these straight. My clinical instructor says that when you pick the right one, she can tell that you really know your pathophysiology.

    How about Impaired Spontaneous Ventilation? Maybe daytonite has a r/t that would fit... how about r/t inefficient metabolic regulatory mechanisms secondary to diabetes? I didn't get that from NANDA- I just made it up- just so that's clear. (Our teacher made us do these ourselves for awhile and then check NANDA and use the actual phrases they use.)

    I can't wait to get to ICU!!! I'm just a 3rd semester- (med/ peds unit. )
  8. 0
    To daytonite:
    great post but pertinent negatives are also always needed and good especially when dealing with DKA. It is info that is needed on change of shift or when there is a change in pt condition. If you call the MD with all this info but you can't tell them the change because you don't know the baseline/previous data he is gonna say figure out what changed before you call me, because he won't do anything if there is no change or it isn't one to worry about based on previous assessments.
  9. 0
    Quote from lcarey1
    To daytonite:
    great post but pertinent negatives are also always needed and good especially when dealing with DKA. It is info that is needed on change of shift or when there is a change in pt condition. If you call the MD with all this info but you can't tell them the change because you don't know the baseline/previous data he is gonna say figure out what changed before you call me, because he won't do anything if there is no change or it isn't one to worry about based on previous assessments.
    Welcome to AN! The largest online nursing community!

    This is just a FYI....this post is over 3 years old and our beloved Daytonite passed away in 2010.


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