What is this clients major presenting health problems?

  1. 0 Hi nurses

    My case study is as follows: I have an 85 year old patient, he has been admitted with abdominal pain (liver region) that has been constant for the past week, be has been vomiting and has not had any food or fluids in 2 days. He has a temp of 39.3C, BP 90/50, HR 110 bpm, RR 28/min SaO2 98% on air - he is anxious, feverish and refusing treatment. His english is poor and he lives with family who state he has become confused and forgetful. He has lost a lot of weight over the last year and weighs 53kg.

    Would I be right in stating that his 2 major presenting health problems are deficient fluid intake and hyperthermia and 1 potential major health problem is inbalanced nutrition?

    I also need 4 goals/outcomes for the first prioritized diagnosis (deficient fluid intake) which i'm a bit unsure about although I came up with
    1. Increase fluid intake - at least 2000mL/day (is this an outcome though?)
    2. Maintain urine output >30mL/hr
    3. Demonstrate elastic skin turgor & moist pink membranes
    4. Retain urine specific gravity within normal limits (???)

    I also need 2 nursing interventions for each goal

    Am I on the right track here or have I got the priorities wrong?
    Any advice would be much appreciated
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  3. Visit  marsy82} profile page

    About marsy82

    Joined Aug '12; Posts: 30; Likes: 6.

    11 Comments so far...

  4. Visit  blackvans1234} profile page
    0
    Which will kill him first?

    That's what I'd choose.

    I think you're on target with the deficient fluid intake, seems like cholecystitis...but then again we just learned about that so everyone is getting that DX from me!
  5. Visit  marsy82} profile page
    0
    Thanks blackvans, I suppose what makes this difficult is that there is no medical diagnoses, although I thought maybe cirrhosis?? Anyway, I just wanted to make sure that I had prioritized right
  6. Visit  Esme12} profile page
    0
    85 year old patient, he has been admitted with abdominal pain (liver region) that has been constant for the past week, be has been vomiting and has not had any food or fluids in 2 days. He has a temp of 39.3C, BP 90/50, HR 110 bpm, RR 28/min SaO2 98% on air - he is anxious, feverish and refusing treatment. His English is poor and he lives with family who state he has become confused and forgetful. He has lost a lot of weight over the last year and weighs 53kg.
    What care plan book do you have? Do you have a care plan book that contains the NANDA I taxonomy (definitions) or NANDA I itself? I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition.

    Looking at this information......as a nurse what would alarm you when you went in first thing in the morning that you would come out of the room and say....I need to call the MD? What would kill them first (Maslows Hierarchy of needs)

    What would alarm you first.....

    BP 90/50, HR 110 bpm, RR 28/min
    vomiting and has not had any food or fluids in 2 days.
    abdominal pain
    feverish 39.3C,
    confused and forgetful
    refusing treatment
    English is poor
    weighs 53kg

    Is it a decreased intake.....is that NANDA diagnosis? Or do you mean.....Deficient Fluid volume R/T decreased fluid intake AEB ......what?

    What evidence do you have that proves that this patient has deficient volume. How does your patient fit into this definition of deficient fluid volume.

    NANDA-I Definition: Deficient fluid volume
    Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level
    Defining Characteristics
    Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness
    Related Factors (r/t)
    Active fluid volume loss; failure of regulatory mechanisms

    What else do you see on the list that needs to be addressed....
    BP 90/50, HR 110 bpm, RR 28/min
    vomiting and has not had any food or fluids in 2 days.
    abdominal pain
    feverish 39.3C,
    confused and forgetful
    refusing treatment
    English is poor
    weighs 53kg

    Are there any other nursing diagnosis that applies to your patient?. Things like......Acute Pain, Risk for Shock, imbalanced Nutrition: less than body requirements, Acute Confusion.....if this was you grandfather/father, and as a nurse, what would you want addressed first?

    Do you see where this is going?

    What else would cause a significant weight loss over a year that would affect an elderly patient other than GB or cirrhosis....could it be cancer?
    Last edit by Esme12 on Feb 25, '13
  7. Visit  GrnTea} profile page
    0
    A nurse doesn't need a medical diagnosis to make nursing diagnoses, so that's no excuse for having a hard time on this one.

    As a matter of fact, some of our patients are admitted with unknown medical diagnoses, so then what would happen then if you had to wait on physicians to take the lead on all care? Answer to that one: The patient would be screwed.

    A couple of thoughts here:

    Esme has given you the way to start to think about this scenario. One thing that might help you is if this is not some anonymous old man, but someone you know well and can visualize in that bed. What would be your first priority then, given the assessment data you have? Would Comfort be right up there? What would help with that?

    Think about the physiology here. He is elderly, he hasn't had any po intake for days, his BP is low, and he is tachycardic, febrile and has altered mental status. What are those defining characteristics, all of a piece, saying to you? (Hint: Esme has just become page 186 in the NANDA-I 2012-2014 book-- shazaam!) YOU don't need to know why this has happened to make a nursing diagnosis.

    The fever is part of the deficient fluid volume, not a separate entity (probably), although Fever is an approved nsg diagnosis (look it up).

    Why the ?? about the specific gravity? Do you know what SG is yet and what it tells you?
  8. Visit  marsy82} profile page
    0
    Thanks for all the help Esme & Grntea

    I don't have a careplan book, we have not been advised to buy one either I believe we are to use our prescribed texts and academic journal articles as a means of research and evidence. The info provided about the patient is all that I know so I can't determine if he is experiencing other symptoms without doing further tests (which is impossible seeming this is an imaginary scenario, I can't tell if he has dry mucous membranes or decreased skin turgor etc).

    The first thing that alerted me was the fact he has not had fluids in 2 days, although this is subjective data do you think it is still worth prioritizing first? To me, his vitals are all concerning yet can they all be related to the fact he has not had fluids in 2 days? So assuming I take care of his fluids - would this also take care of his vitals? - What about the vomiting? Could that be due to the pain he is in or could he could in fact have some sort of infection that is related to his fever/HR etc (another possibility, but how do I prove that this is what it could be?) Am I on the right track by taking care of fluids first and vomiting second? Is there even an intervention for vomiting or would I be better to address his pain, hmm critical thinking lol
    Last edit by marsy82 on Feb 23, '13
  9. Visit  Esme12} profile page
    0
    They don't want you to buy a care plan book???? What the heck??? What do you use to get your NANDA I diagnosis? Even if you have not been "Advised" to get one it would behoove you to purchase one.....your life will become manageable!!! It will help make sense of everything. without a book I have no idea how you are finding your NANDA I nursing diagnosis.

    Look up dehydration.....what does it do? What can it cause? Will a human die without water? What are they signs that someone doesn't have enough water on board? What happens to the B/P pulse and respirations?

    Will having a fever cause more rapid fluid loss? Does vomiting also cause a fluid loss? Will vomiting worsen dehydration?

    The elderly....like the very young are more susceptible to volume loss and fever. Fever and dehydration can cause confusion, hallucinations and death.

    If you replace the lacking volume causing his vitals to be abnormal....the logical thing is to assume that his vital will return to baseline as well.....if they do not then you are going to have to start over and try to figure out what is wrong.

    It is very possible that if you hydrate a patient they will stop vomiting.....but why else is this patient vomiting? If their intestine is blocked and nothing is moving through the bowel to exit out as excrement...where will it go? Out the mouth...right?

    If you have just had half of your bowel removed and have a abdominal incision and now you are throwing up.....would you be in pain? If your bowels suddenly stopped working to the point that your abdominal contents are finding another exit (your mouth) would you abdomen hurt?

    Google....dehydration of the elderly.
    Google....Small bowel obstruction.
    Google....fever.
  10. Visit  marsy82} profile page
    0
    Thanks for your input Esme. Nope, no care plan book, I might borrow one from the library or download one from the database though.
  11. Visit  GrnTea} profile page
    1
    Quote from marsy82
    Thanks for your input Esme. Nope, no care plan book, I might borrow one from the library or download one from the database though.
    Run your little fingertips to your favorite online bookseller and get the NANDA-I 2012-2014 stat. You will never be sorry, you will use it all through school, and you will have the final word on nursing plans of care at your fingertips. It will teach you to think like a nurse. Free 2-day shipping for students on Amazon.
    Esme12 likes this.
  12. Visit  marsy82} profile page
    0
    Ok, after a bit of research i'm going to attack this a little differently. So I think the first priority should be the hyperthermia - once taken care of can eliminate his temp, fever, HP, RR and possibly his vomiting (by regulating temp, managing fluid intake and treating fever). This leaves his low BP and pain to take care of - as a result of his low BP he is at risk of falls, it can also be contributing to his confusion/nausea. The pain is a tricky one as I don't know what his actual level of pain is, all I know is that it is constant, would I be better taking care of risk of falls first and pain after - is this sounding a bit better, I have found a care plan book to help with diagnosis
  13. Visit  Esme12} profile page
    1
    No.......think about what you need to think about, which is more important? Which one of these pieces of information.....could kill him first? It won't matter that your patient has a fever if they don't have a B/P. Take a deep breath and read very carefully what I have written. I have given you ALL the information you need to solve this question

    Don't over think this......you don't need a medical diagnosis to make your nursing mind work.

    I gave you the order in which to think about first......
    Looking at this information......as a nurse what would alarm you when you went in first thing in the morning that you would come out of the room and say....I need to call the MD? What would kill them first (Maslows Hierarchy of needs)
    What would alarm you first.....

    BP 90/50, HR 110 bpm, RR 28/min
    vomiting and has not had any food or fluids in 2 days.
    39.3C,
    abdominal pain
    feverish
    confused and forgetful
    refusing treatment
    English is poor
    weighs 53kg
    Have you studied Maslow's yet? If you do not replace the patients volume......their blood pressure will continue to drop and if they do not have a blood pressure they will die...Although they have a fever....if you correct the volume you may correct (partially) the fever.

    It can be a toss up which you fix first...the temp is 102.7. However in this patient because of the SBO, vomiting and inability to take fluids for days prior to admission....... this becomes the most important in this patient. I know it's hard when the patient isn't in front of you too look at and see what alarms you the most.
    This leaves his low BP and pain to take care of - it can also be contributing to his confusion/nausea.
    You are almost there.....you even see that after treating the fever you are still left with hypotension/shock with confusion.....which continues to threaten this patients life.

    While fever can cause a patient to become confused (common in the elderly)......dehydration can also cause confusion.....hypotension/shock and death. Even if this patient is septic.....the hypotension would need to be addressed for septic patient require high volumes of fluid.

    In the real world .....you would further assess fluid status like the mucous membranes, skin turgor, and urine output. As well as a variety of blood work at your disposal to help your thought process. You would be doing these interventions essentially simultaneously.

    This patient has a bowel obstruction.....they are vomiting any gastric/intestinal contents. They are unable to take any fluid because it comes right back out. (like a plugged toilet.....if you try to put anything in....it comes right back up). They are in pain from this obstruction and they have become confused, restless, anxious, agitated. He has also developed a fever.

    As the nurse...you see this sweet little old man with an anxious family....you can barely hear his blood pressure because it is so low, he is dehydrated, in pain...with a fever. Which would make you the most concerned.

    Don't over think this......you don't need a medical diagnosis to make your nursing mind work.
    Last edit by Esme12 on Feb 25, '13
    marsy82 likes this.
  14. Visit  GrnTea} profile page
    1
    Dehydration will cause fever. Why is that? What are the ways your body regulates its temperature? Merely giving some antipyretic (which is part of a medical plan of care, not a nursing plan of care) will not fix that. Keep thinking.
    Esme12 likes this.


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