Need help to identify 2 potential actual problems - page 2

Hey im doing a assignment on this following case study and I need to identify 2 actual or potential nursing problems/diagnosis, I have already picked one, which is patient is at risks for fall due... Read More

  1. by   Mavrick
    Why does he need so much oxygen?

    Is 100ml/hr of fluid enough for the next 24 hours?

    How much urine has he had recently?
  2. by   Walrus93
    So like at risks of fluid volume deficit? urine output 500mls since admission and he is nbm atm
  3. by   marienm, RN, CCRN
    I think you should prioritize your nursing diagnoses the same way you would prioritize an acute assessment--start with your ABCs! Airway & Breathing: Why are his oxygen requirements so high? Some MEDICAL reasons could be pain, undiagnosed chest trauma [incidentally, why didn't he get a CT when he arrived?!], fluid overload [why would that happen? how would you know it was happening?], anxiety, drug use. What nursing diagnoses go with these? Circulation: You already discussed the risks for compartment syndrome. What assessments would you use? What signs & symptoms are concerning? [Don't be lulled by the pedal pulse--pulses are one of the last things to go in compartment syndrome.] Also Circulation: How does rhabdomyolysis affect circulation? What organs does it affect? If these organs stop working, what will happen? Will this affect any other organ system?

    I agree with another poster--I think you can find a more important nursing diagnosis than "risk for falls." ACTUAL problems--of which this guy has several--outweigh potential problems. (Now, if he was intoxicated or had a head injury and was very impulsive despite his broken leg, I'd move "risk for falls" up the list. But with the information presented, try starting with the ABCs and see where you get.)
  4. by   marienm, RN, CCRN
    Quote from Walrus93
    So like at risks of fluid volume deficit? urine output 500mls since admission and he is nbm atm
    Combine this with his borderline-low BP and tachycardia and it's certainly a possibility. The case study says he was in the vehicle for several hours and now he's been in the hospital for at least 6 hours (2000 to 0200, right?)...if there's only 500mL urine total, some of that was probably in his bladder pre-accident (I mean, unless he had just used the restroom right before the accident!). So, let's guess he's made 250 mL urine in the last 6 hours...that's about 40mL/hour, which is right around 0.5mL/kg. Under "normal" circumstances that might be an appropriate amount, but if he is in rhabdomyolysis he will need more fluid to flush it out. On the other hand, flooding him with fluid won't do his lungs any favors!

    I have long ago put my nursing diagnosis text book away, but is there a NDX for "fluid instability?"
  5. by   Walrus93
    But i mean the patient is NBM so my nursing problem cant be "patient is dehydrated because i cant give him fluid and needs Dr to write a fluid order"
  6. by   ThePsychWhisperer
    Quote from Walrus93
    But i mean the patient is NBM so my nursing problem cant be "patient is dehydrated because i cant give him fluid and needs Dr to write a fluid order"
    Even if the patient is NPO, there are other ways to introduce fluid (i.e. - a fluid bolus via IV). But I agree with the others that falls should probably be at the bottom of your list. I commend you for knowing fat emboli are a potential complication of long bone fractures. While dehydration may or may not currently be a problem, I highly suggest that you look up what happens when you crush skeletal muscle, and what condition can result. Others have suggested reviewing compartment syndrome and the symptoms and risks associated; neurovascular compromise? His respirations were 24, and he is on a breathing mask; how about impaired oxygenation/impaired gas exchange? In the same vein, what happens to some patients when they are bedridden for extended periods and unable to get up and move around? A risk for pneumonia, maybe? Muscle wasting/weakness? How about actual pain? Just go head to toe. There are so many more important diagnoses here.

    As for how to write the diagnosis for dehydration, if you don't have a diagnosis handbook, try nurselabs.com under care plans. This may help you with devising your care plan.
  7. by   Walrus93
    I know you guys are saying risks for fall shouldnt be important, but the patient already has his morphine, he is on oxygen, so pain and respiratory wise, there isnt much of nursing intervention i could talk about
  8. by   MilliePieRN
    Quote from Walrus93
    I know you guys are saying risks for fall shouldnt be important, but the patient already has his morphine, he is on oxygen, so pain and respiratory wise, there isnt much of nursing intervention i could talk about
    Do Dr orders such as these really negate nursing critical thinking and care planning? Seems like it would give obvious clues to what's important in a pt with this much going on. But by all means, choose risk for falls... he's probably at risk for low self esteem too, maybe you should move that to #2. Could come up with a lot of easy things to say about that.

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