Another Priority Nursing Diagnosis

ampela · Apr 12, 2014

Since the patient has a history of chronic anemia, then the priority would be making sure that there is adequate perfusion. So therefore Ineffective tissue perfusion should be prioritized? I am torn between GI and Cardiovascular systems but this case study is focusing on cardiovascular.... :cry: Btw the vitals are WNL and SpO2 is 98% on room air. No SOB at rest, and grade 1/6 murmurs.

Esme12, ASN, BSN, RN · Apr 12, 2014

I am not all that awake yet. What care plan resource do you have? What semester are you? What is PPM and what is F/C. I assume that F/C is foley cath but I an racking my brain for PPM. HLD must be Hyperlipidemia?

ampela · Apr 12, 2014

I apologize for the abbreviations- PPM is permanent pacemaker, F/C is foley catheter, and HLD is hyperlipidemia. CAD is coronary artery disease and CKD is chronic kidney disease. I am in my intermediate-advanced med/surg class and I am using Carpenito's Nursing Diagnosis and Doenges's Nursing Pocket Guide in addition to Brunner and Suddarth's Textbook of Med/Surg Nursing. Thank you for replying!

Esme12, ASN, BSN, RN · Apr 12, 2014

That is the problem with abbreviations that are not approved. The are regional or facility familiar....and I am nursing a cup of coffee.

Care plans are all about the assessment of the patient. Your patient has heart failure and anemia

There was little bleeding when she was admitted but she stated that it has lasted for last 2 weeks, and she had pantoprazole drip, Lasix IVP, and blood transfusion. CAre plans are the recipe card for caring for the patient. What do you need to think about as you go about your day that are important to this patient.
She is A/O x 4, standby assist, has dependent edema 1+ in BLE, weak peripheral pulses in BLE, and has a F/C. Her labs are WNL except for low H/H levels, low RBCs, high BNP, and high BUN/Cr. Her lipid panel shows slightly high LDL and low HDL but otherwise normal. Troponins are negative. Chest X-ray shows moderate pulmonary congestion. The bleeding has stopped when I assessed her 4 days later and it seems to me that controlling her fluid retention seems number one because she complained of shortness of breath and weakness upon exertion x 2 weeks and she had a weight gain of 20 lbs but has since lost 6 lbs. The main plan of care is to continue diuresis. My focus is on the cardiovascular system.

You prioritize to what can kill them first. Your patient has heart failure that is still an issue because her BNP remains elevated and her CXR still shows moderate failure. She still has dyspnea on exertion, edema, weight gain. How did her lungs sound? Was she on 02? How does her chronic kidney disease affect her? Will this affect her diuresis? What were the BUN CR.? What was the H/H? What are her electrolytes? You say she has readiness diagnosis....what has she verbalized to you?

Your patient has heart failure which is still an issue for her. SO.... she has a Decreased Cardiac Output. She has excess fluid volume from the pump failure as well as kidney disease. But she also has deficient fluid volume due to the GI bleeding. Because of the pump failure and anemia she is at risk for decreased cardiac tissue perfusion. She has ineffective peripheral tissue perfusion related to pump failure. She is at risk for infection due to her foley. The lasix drip and renal disease put her at risk for electrolyte imbalance.

Esme12, ASN, BSN, RN · Apr 12, 2014

Each NANDA I has it's own definition and characteristics that are applicable to the diagnosis. Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. Many students do the exact opposite and grab a diagnosis and try to retro fit the patient into that diagnosis.

What your patient shows you....what they say...what they NEED. What you should be looking for on this patient should come first. Then you decide which diagnosis fits.

Then you decide you statement...

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Esme12, ASN, BSN, RN · Apr 12, 2014

So now looking at these diagnosis. What should come first for you patient

I have ordered the nursing diagnoses in the following order (there are more but at least one physiological, one psychosocial, and one educational):
1. Excess fluid volume R/T compromised circulatory mechanism secondary to chronic diastolic heart failure AEB orthopnea, shortness of breath, dependent edema in bilateral lower extremities, decreased peripheral pulses in lower extremities, weight gain, pulmonary congestion, and decreased H/H levels
2. Ineffective tissue perfusion R/T compromised circulatory system and decreased hemoglobin concentration in the blood secondary to anemia, gastrointestinal bleeding and chronic heart failure AEB dyspnea, dependent edema on bilateral lower extremities, weak peripheral pulses at lower extremities, rough and hard skin in lower extremities.
3. Ineffective breathing pattern R/T compromised circulatory system secondary to pulmonary congestion AEB shortness of breath, orthopnea, pulmonary congestion, dyspnea upon exertion.
4. Decreased cardiac output R/T altered preload, afterload, and contractility of the heart secondary to chronic heart failure AEB shortness of breath, orthopnea, fatigue, weight gain, dependent edema in bilateral lower extremities, decreased peripheral pulses in the lower extremities, and diminished breath sounds in the bases of the lungs
5. Readiness for enhanced coping
6. Readiness for enhanced knowledge

Malorymug · Apr 12, 2014

I'm following this thread closely because I need more practice with priorities too. I think I would like to see Decreased cardiac output first and Excess fluid volume 4th for the sake of ABCs.

Esme12, ASN, BSN, RN · Apr 12, 2014

But the decreased cardiac output causes fluid overload....compounded by chronic kidney disease...which in turn causes ineffective breathing and tissue perfusion. Right?

The ND statements here need to be tweeked a bit but I want to get the basic order they be to be first.

ampela · Apr 12, 2014

Thanks for replies. Decreased Cardiac Output is the patient's underlying issue that will in turn cause Ineffective Peripheral Tissue Perfusion, Ineffective Breathing Pattern, and Excess Fluid Volume. The patient has Deficient Fluid Volume due to her anemia.. I hesitate to put Decreased Cardiac Output or Excess Fluid Volume as my priorities because one instructor focuses on what will become life-threatening first, while the other focuses on what will impact the patient most. In one class simulation what we all thought in class was Excess Fluid Volume the instructor said it was Ineffective Breathing Pattern because it was life-threatening.

The patient's lungs sounded clear on auscultation but a bit diminished at the bases. No crackles, wheezing, stridor was heard. The patient was on room air and she has no dyspnea at rest. The BUN and CR was 41 and 1.6, and the Hgb was 9.9 and Hct was 30.4. Electrolytes: sodium was 136, potassium was 4.1, chloride was 97, calcium was 8.9, and magnesium was 2.2. PT/INR was 13.9/1.1, and PTT was 31. The diuretic treatment seems to be working well as she has had 6 lbs weight loss since admission. As far as I can tell, there hasn't been any aggressive treatment for her chronic kidney disease other than encouraging fluids and controlling her diet.

Readiness diagnoses:

Readiness for Enhanced Coping R/T inadequate caregiver to patient ratio at residence (1:2) AEB one caregiver present to take care of patient and spouse, acknowledgement of need for social support from family, friends, and community, acknowledgement of individual power in disease management, and need for community resources.

Readiness for Enhanced Knowledge R/T recent episode of exacerbation of chronic heart failure AEB expressed interest in learning, inquisition on disease process, verbalized understanding of disease process, initiative in ambulation, and monitoring of own daily weight.

I agree that my diagnoses still need to a lot of editing- thanks for reading!

ampela · Apr 12, 2014

*Edited from above--

Readiness for Enhanced Coping R/T acknowledgement of inadequate assistance at residence AEB one caregiver present to take care of patient and spouse, recognition of individual limitations and need for external resources, and acceptance of social support from family and community.

Re-prioritization: I am thinking along the lines of ABC- 1. Ineffective Breathing Pattern 2. Ineffective Tissue Perfusion 3. Excess Fluid Volume 4. Decreased Cardiac Output 5. Readiness for Enhanced Coping 6. Readiness for Enhanced Knowledge

Esme12, ASN, BSN, RN · Apr 12, 2014

Thanks for replies. Decreased Cardiac Output is the patient's underlying issue that will in turn cause Ineffective Peripheral Tissue Perfusion, Ineffective Breathing Pattern, and Excess Fluid Volume. The patient has Deficient Fluid Volume due to her anemia.. I hesitate to put Decreased Cardiac Output or Excess Fluid Volume as my priorities because one instructor focuses on what will become life-threatening first, while the other focuses on what will impact the patient most. In one class simulation what we all thought in class was Excess Fluid Volume the instructor said it was Ineffective Breathing Pattern because it was life-threatening.
The patient's lungs sounded clear on auscultation but a bit diminished at the bases. No crackles, wheezing, stridor was heard. The patient was on room air and she has no dyspnea at rest. The BUN and CR was 41 and 1.6, and the Hgb was 9.9 and Hct was 30.4. Electrolytes: sodium was 136, potassium was 4.1, chloride was 97, calcium was 8.9, and magnesium was 2.2. PT/INR was 13.9/1.1, and PTT was 31. The diuretic treatment seems to be working well as she has had 6 lbs weight loss since admission. As far as I can tell, there hasn't been any aggressive treatment for her chronic kidney disease other than encouraging fluids and controlling her diet.
Readiness diagnoses:
Readiness for Enhanced Coping R/T inadequate caregiver to patient ratio at residence (1:2) AEB one caregiver present to take care of patient and spouse, acknowledgement of need for social support from family, friends, and community, acknowledgement of individual power in disease management, and need for community resources.
Readiness for Enhanced Knowledge R/T recent episode of exacerbation of chronic heart failure AEB expressed interest in learning, inquisition on disease process, verbalized understanding of disease process, initiative in ambulation, and monitoring of own daily weight.
I agree that my diagnoses still need to a lot of editing- thanks for reading!

Better.

The point is though the heart failure and lung congestion will kill her first because it causes ineffective breathing pattern. But I guess if you are looking at acuity fo rright now her breathing is affected and is her priority problem.

Out of curiosity what was her BNP? I also question the ineffective tissue perfusion s second for it isn't life threatening. Bad pulses won't kill her.

I think maybe....ineffective breathing pattern, excess fluid, infective tissue, decreased cardiac output.