Boggled with a case scenario

[littley]

okay, i've tried to avoid using this to help figure out a case scenario but i'm on my last hair here. our professor gave us a packet of scenarios to practice with. right now, its our first clinical semester. we're not focusing on prioritizing yet because we haven't done med-surg. the main focus is to gather data and formulate a dx and careplan. saying that, i am going to give you the case and then tell you what i'm having the issue with. the case is as follows:

mrs. d is a 73 y/o recently widowed female with a hx of cad and mi 5 years ago. niddm for 7 years. is in fairly good health. mrs. d was brought into the er by her daugther who wasn't able to reach her by phone, went to her apartment, and found her on the floor lethargic, with no recollection of how she ended up on the floor. the pt was admitted with a dx of syncope. vitals signs: bp 148/94, p 93 and irregular, r 24, blood sugar 317. physical assessment shows no signs of injury or bruises, able to move all extremities on command with no pain. at present, mrs d is quiet, answers questions with short replies appropriately. she is withdrawn, states she wants to be left alone, and has been seen crying. appetite is poor, color is pale, and she cannot remember the last time she had a "decent meal" and "could care less".

now, the easiest thing that jumps out at me with clustering info is hopelessness. one dx i came up with is hopelessnes r/t deteriorating physical condition aeb subjective: "could care less" and obj: decreased verbalization ,poor appetite, withdrawn, and lack of involvement in care as demonstrated by unstable glucose level. however, even though they don't want us to prioritize, i can't just overlook her unstable vital signs. my issue is that i think her hyperglycemia ties into all that however, i cannot find a nursing dx that allows me to establish that. for example, i though of ineffective cardiopulmonary tissue perfusion because of the tachypnea and arrythmia, etc. but i cannot find a r/t factor. i know that high blood sugar levels can cause hypovolemia (which is a r/t factor) however, the only symptom of hypovolemia that i have info to compare on is the bp, that its high. hypovolemia cause a decrease in bp. there were a few other dx's that it was the same thing...i could not find r/t factor that matched he situation.

i can use the hopelessness and it won't be wrong but i want to learn in the process how tie signs, symptoms, diseases, and medical dx's altogether. i'm sure once i do med surg it'll be easier for me but in the meantime, i have pulled a dozen books and can't figure it out for this case. just want a little insight to start training my brain to think like a nurse.

[Daytonite, BSN, RN]

use the nursing process. it is a problem solving tool we have to help us.

step 1 assessment - assessment consists of:

• a health history (review of systems) - this has been done for you since this is a case scenario
  
• performing a physical exam - this has been done for you since this is a case scenario
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - can't really do this here because it is a case scenario
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the scenario told you she was admitted with syncope, has niddm, has a history of cad (this never gets better and always gets progressively worse) and had an mi 5 years ago.
  
• reviewing the signs, symptoms and side effects of the medications they are taking - none mentioned
  

the mention that she was admitted for syncope is important as is that she has a history of cad. the fact that she was found on the floor lethargic may be related to the syncope or it could be related to the hint that she states she hasn't eaten a decent meal for a while. i would look up the reasons for people having syncope (fainting). she may be dehydrated. she may have a cardiac problem. these scenarios set these situations up deliberately to leave things open to several possibilities. syncope due to a heart problem will lead to signs and symptoms of the nursing diagnosis of

decreased cardiac output.

syncope due to dehydration will lead to signs and symptoms of the nursing diagnosis of either

deficient fluid volume

or

imbalanced nutrition: less than body requirements

. she may have some depression. depression is a medical diagnosis. to find a nursing diagnosis you need to look at the symptoms she is displaying.

here is the list of abnormal data, grouped, that i pulled out. this is what becomes the defining characteristics (signs and symptoms) of any nursing diagnoses i decide to use:

• b/p 148/94
  
  
• pulse 93 and irregular
  
  
• color is pale
  
  
• appetite is poor
  
  
• blood sugar 317
  
  
• answers questions with short replies
  
  
• withdrawn
  
  
• states she wants to be left alone
  
  
• has been seen crying
  
  
• cannot remember the last time she had a "decent meal" and "could care less"
  
  

step #2 determination of the patient's problem(s)/nursing diagnosis - i must have evidence before i can tack a diagnosis on someone. i don't like her hypertension and irregular heart rate. it certainly suggests something to do with her cad. the pale coloring could be poor perfusion--maybe. diabetics can still have high blood sugars even if they haven't eaten. and, what are the symptoms of hyperglycemia anyway? here is where you look at the abnormal data and start to make some decisions. keep maslow's hierarchy of needs in mind because physiological needs get addressed first and remember that this lady was found on the floor by her daughter because she wasn't answering her phone. i will leave you to your thoughts. good luck!

[littley]

Thanks so much for your help! And thanks for not giving me a direct answer...I still wanted to figure it out on my own. Decreased cardiac output was one of my main choices. With her irregular heart rate, CAD, MI, and hypertension it made sense. Thanks again for your help.

[Daytonite, BSN, RN]

Go get 'em! :redbeathe