I need help with my Nursing Diagnosis! ( I need 5 with care plans - 3 physiological and 2 safety & security)
My patients info is:
Female, age 62, in a Nursing home facility.
Medical diagnosis: CVA(Stroke), CAD(Coronary Artery Disease), Small Bowel Obstruction
Past surgeries are listed as: Aortobifemoral Bypass, Subsequent small bowel obstruction, renal artery stent, peg placed, open cholecystectomy, tracheostomy
She has a Peg tube (RUQ) with Intermittent (q3hrs) Bolus feedings of 156ML of High Nitrogen Fibersource Formula,
Also has 100ML free water (q3hrs)
Notable Labs are: hgb: 11.5, Bun 26, CO2: 31, Glucose:156 (she is non-diabetic) (potassium, serum sodium were not noted on chart)
mucus membranes moist, pink, skin tugor immediate, cap refill < 3 seconds
She has a trach tube with the O2 set at 10L/Min with humidity set at 33%, with some thick yellow mucus noted in suctioning tubing, suctioning done as needed.
Peg care is done daily, no signs of swelling, redness, or gastric drainage.
Trach care is done daily, no signs of redness, swelling or excessive secretions.
Lung sounds alternated between clear and equal bilaterally, to coarse bilaterally - when suctioning was needed.
Total dependence for ADL's, cannot care for self.
Turn q2hrs, change adult diapers q2hrs, unable to communicate
6-8 clear yellow voids per day.
3 soft (very soft, but not diarrhea), brown BM's per day
Hydrochlorothiazine 25mg via peg tube am
Robinul 2 mg at 08:00,20:00 via peg tube
Potassium Chloride Liquid susp 30Meq daily am via peg tube
Zestril 10Mg daily am via peg tube
Gervite - Oral Liq susp 15ml daily am via peg tube
Aspirin tablet 325mg daily am via peg tube
Reglan syrup 10mg at 08:00, 12:00, 17:00 via peg tube
Zantac Syrup 15mg/ml, 150mg (10ml) daily in am via peg tube
Dilantin susp 6ml at 08:00, 20:00 via peg tube
The current diagnosis I have come up with are:
1) Airway clearance ineffective, risk for related to dependence on patent stoma and presence of thick copious secretions.
2) Fluid volume imbalance, risk for more/less than requirements related to decreased renal perfusion, increased water and sodium retention, use of diuretics to eliminate excessive water and high glucose feeding solution causing dehydration.
I cannot decide on a 3rd physiological that applies to my patient.
I do not believe that there is enough evidence to support:
Aspiration, risk for or
Nutrition, less than body requirements
I also think that I need the following:But not sure of the correct wording and which two apply most for safety and security....
- Infection, risk for related to broken skin at peg site and at trach site.
- Skin Integrity Impaired related to broken skin at peg site, trach site, and complete immobility increasing the risk of impaired skin perfusion as evidenced by peg site, trach site, and complete immobility.
- Self care deficit complete, bathing, grooming, toileting, feeding, as evidenced by complete immobility and inability to care for self.
Any help in creating appropriate diagnosis and care plans would be GREATLY appreciated!!!
Thanks - Back to school at 38 - 1st year Nursing Student
I think with the Fluid volume imbalance - I was obviously confused myself...but my thinking was that they were giving her meds to reduce fluid/sodium for her heart, which could be a Fluid volume excess problem, but they also needed to make sure that she had enough fluids to avoid dehydration, which would be a Fluid volume deficit....so I thought that I needed to list it as imbalanced. I did not understand the stent, and thought it had to do with the kidneys...its a learning curve.
Thank you very much Daytonite! This is a huge help and blessing!
Have a great Easter.
Last edit by SN - TKG on Apr 10, '09