Nursing Diagnosis Help

SN - TKG · Apr 10, 2009

I couldn't find where to edit my post so....

I forget to put in her vitals: BP 122/68, Radial Pulse 84, Apical HR 78, Temp 98.2, RR: 20, deep, unlabored.

Also - with her Peg tube placement it is LUQ - not RUQ...

Thanks again!

Daytonite, BSN, RN · Apr 11, 2009

you need 5 nursing diagnoses: 3 physiological and 2 safety & security. with a trach, needing suctioning, tubing feeding q3h and being incontinent (urine x 6 and bm x 3) these nurses are very busy with this patient. i didn't mention that her medications, while most are liquids, have to be given via the peg tube by a licensed nurse. what you came up with was the following (i tried to keep them sequenced in priority order per maslow's hierarchy of needs) and the problems i found with them:

risk for ineffective airway clearance related to dependence on patent stoma and presence of thick copious secretions.
- this is an anticipated need. i think this is a misdiagnosis. the fact that during your assessment you got coorifice bilateral lung sounds and this patient is consistently being suctioned for thick yellow mucus is because she cannot cough the secretions out herself. people do have trachs and do not require suctioning when they can cough the secretions out themselves. these are symptoms of ineffective airway clearance, the actual problem, and not risk for ineffective airway clearance, the anticipated problem.
- even if this were risk for ineffective airway clearance, the related factor (related to) must be what is causing the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway (the definition of this diagnosis - page 308, nanda international nursing diagnoses: definitions and classifications 2009-2011). it is this thick and excessive mucous and not dependence on patent stoma.
- since i say this is an actual problem, aeb's, or evidence, must support or prove the existence of the problem. it is the coorifice bilateral lung sounds and although you do not have this listed, i'm betting that she does not have an effective cough.
- i believe her diagnosis should be (and it would be sequenced as the first diagnosis): ineffective airway clearance related to thick copious secretions as evidenced by coorifice bilateral lung sounds [and nonproductive cough]. [physiological need for oxygen]
- all the suctioning that is done for her in a nursing intervention that goes with this nursing diagnosis.

[*]risk for imbalance fluid volume 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.

this is really confusing and i was trying to make some kind of sense of what you were trying to say. when a patient is getting diuretics, fluids are intended to be lost. deficient fluid volume is dehydrationand excess fluid volume is overhydration. you can have one or the other but not both at the same time which is what it sounds like you are saying. it sounds schizophrenic. people who cannot eat, have no control over their intake, and are on controlled tube feedings have a risk for dehydration. i didn't see any mention of renal failure in this patient. the renal artery stent is to maintain the patency of the renal artery and i don't see any mention of renal problems. i do see cad and the stent makes me think her cad is the more likely reason for the stenting. bun tends to elevate as people age and since there is no accompanying elevated creatinine that would verify to me that renal disease is not present. bun elevates when some dehydration is present as tends to happen when not enough supplemental water is not given along with tube feedings.
again, based on assessment information, i think this may be another misdiagnosis and deficient fluid volume may indeed be present.
i believe her diagnosis should be (and it would be sequenced as the second diagnosis): deficient fluid volume related to inadequate supplemental water administration as evidenced by cap refill

[*]i also would have diagnosed impaired physical mobility r/t neuromuscular impairment secondary to cva [physiologic need for activity]

this gives you your diagnosis for nursing interventions for turning q2h and rom.

[*]complete self care deficit complete, bathing, grooming, toileting, feeding, as evidenced by complete immobility and inability to care for self.

these are usually broken down into the four individual diagnoses: bathing/hygiene self-care deficit, and dressing/grooming self-care deficit. i don't believe you have feeding and toileting self-care deficits because this patient has a peg tube and gets round-the clock tube feeding. you mentioned nothing about her being sat up for meals or being fed any kind of prepared food. that may be why you do not have any evidence for a diagnosis of risk for aspiration. also, this patient is incontinent (urine x 6 and bm x 3) and if she is not being toileted (taken to the bathroom) or asking to go to the bathroom (you say she is unable to communicate) then there is no evidence to support using a toileting self-care deficit.
you list no related to, or etiology, in your diagnostic statement. the related factor (related to) for her self-care deficits is a neurological impairment which is secondary to the cva that she had.
her diagnoses would be:
- bathing/hygiene self-care deficit related to neuromuscular impairment secondary to cva[physiologic need for comfort]
- dressing/grooming self-care deficit related to neuromuscular impairment secondary to cva[physiologic need for comfort]

[*]impaired skin integrity 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.

this is written incorrectly. the diagnostic name, impaired skin integrity, is correct.
the related factor must be the etiology, or cause, of the skin breakdown at the peg and trach sites. being immobile does not cause the skin around the peg and trach tubes to break down. immobility causes pressure sores, but not skin breakdown around these kinds of tubes. it is the moisture of the secretions combined with the process of maceration that is causing the skin to break down. maceration is a term that means "the dissolution of skin". the moisture weakens the skin so that friction or sheering forces against it, supplied by movement of these tubes, causes the skin to be excoriated or torn away. it is when these areas become open that bacteria or yeast can then invade. so, it is related to moisture, sheering forces and friction.
the aeb information is always the evidence (as evidenced by) that supports or proves the problem (impaired skin integrity) exists. peg site, trach site, and complete immobility are not evidence of impaired skin integrity. that process of maceration that gives us the skin breakdown around these tubes is the evidence of this skin breakdown. describe it. what does that skin look like? is it red? how much (mm's, cm's) of the skin around these stomas is involved? is there any drainage? what color is it? if you need help assessing and describing skin/wounds, see these websites:
- http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx - pressure ulcer training tutorial (includes photos)
- http://www.hill-rom.com/usa/pdf/ctg285.pdf - guidelines for staging of pressure ulcers
[*]her diagnosis would be: impaired skin integrity related to moisture, sheering forces and friction as evidenced by [describe what the skin looks like around the peg and trach tubes and the perineal area since this patient is incontinent] [safety need].

[*]i also would have diagnosed impaired verbal communication related to presence of tracheostomy and neuromuscular impairment as evidence by inability to speak [or communicate needs] [safety need]

how does any communication occur with this patient at all? how will the patient communicate if they are having pain or in distress? communication is a safety issue and that would be a second safety diagnosis you could use.

[*]risk for infection related to broken skin at peg site and at trach site.

the related factor for this is what allows the infection to invade (the broken skin) and is really covered in the diagnosis of impaired skin integrity with the interventions that will be performed.
the more serious infection you are looking to prevent is sepsis because this patient cannot communicate, so you must always assess. sepsis is difficult to assess and monitor for. skin infections are easy to see. with "risk for" diagnoses your interventions can only be:
- strategies to prevent the problem from happening in the first place (you are already doing these in the interventions of other diagnoses)
- monitoring for the specific signs and symptoms of this problem (sepsis)
  - temperature > 38° c or
  - heart rate > 90 beats/min
  - respiratory rate > 20 breaths/min or paco2
  - wbc count > 12,000 cells/μl or 10% immature form
  [*]reporting any symptoms that do occur to the doctor or other concerned professional

Daytonite, BSN, RN · Apr 11, 2009

the software does not want to format the diagnoses correctly. they should be:

ineffective airway clearance related to thick copious secretions as evidenced by coorifice bilateral lung sounds [and nonproductive cough]. [physiological need for oxygen]
deficient fluid volume related to inadequate supplemental water administration as evidenced by cap refill
impaired physical mobility r/t neuromuscular impairment secondary to cva [physiologic need for activity]
bathing/hygiene self-care deficit related to neuromuscular impairment secondary to cva[physiologic need for comfort]
dressing/grooming self-care deficit related to neuromuscular impairment secondary to cva[physiologic need for comfort]
impaired skin integrity related to moisture, sheering forces and friction as evidenced by [describe what the skin looks like around the peg and trach tubes and the perineal area since this patient is incontinent] [safety need].
impaired verbal communication related to presence of tracheostomy and neuromuscular impairment as evidence by inability to speak [or communicate needs] [safety need]
risk for infection related to broken skin at peg site and at trach site. [anticipated safety need]

SN - TKG · Apr 11, 2009

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.

scholarshipboy · Mar 11, 2010

i like u daytonite every where i go i read a post of yours just had to say hi

MattiesMama · Mar 12, 2010

Go with your ABC’s for the physiological. Innefective Airway Clearance should be the priority dx. There’s your airway!

Her CO2 is 31-that’s low. You didn’t list any other ABG’s so I’m assuming they were within the normal range. It’s possible she’s in respiratory alkalosis, so a possible NANDA would be Impaired gas exchange r/t hyperinflation of the alveoli. Is she on a vent or is she breathing spontaneously? She isn’t tachypnic yet but a resp. rate of 20 is right on the borderline. That would cover breathing.

Given that she has CAD and a hx of CVA, you could finish that off with ineffective tissue perfusion for your third…but you need more supporting evidence. What did her heart sound like? Was her pulse regular? Any abnormal sounds? How were her peripheral pulses? Does she have orthostatic hypotension?

For safety and security-I definitely think the impaired communication is crucial. She’s definitely at risk for infection-not just on the skin but respiratory as well. What is her mental status like? Would she be able to alert someone if she needed help?