care plan help needed!!!!

[NewNurse91D]

Hey guys!

I am doing my second care plan; and my pt. was a bit more complicated than I originally thought. SO now I am sitting here with a million and one conditions and complications and s/s and have NO idea what to have my two d/x as.

I am THINKING of having Acute Pain and Impaired Tissue Perfusion. But I used Acute pain as one of my d/x for my last care plan and really don't want to use acute again as a priority d/x.

I have a 60yo man. admitted for GOUT attack and uncontrolled pain.

He has acute kidney failure, bipolar depression, hypertension. very severe GOUT, hyperlipidemia, cirrhosis of the liver r/t alcoholism (pt. stated he is now sober though and has been sober for a few years), he also has hepatitis C, and type 2 DM.

That being said, his DM is well managed without the use of insulin or oral antidiabetics (he manages it through diet evidently). The pain he was in was almost unbearable for him, he literally did not get out of bed all day. He is ordered pain meds BUT they only seem to help him IF he keeps still (pain level at a 3/10); but once he moves, his pain levels increase to like a 6/10 while medicated. He can barley move at all because of the GOUT (its affect mainly his L arm but it seems to have spread down the whole R leg, so even changing positions in bed seems to be a battle for him).

His vitals were all unremarkable, BP 136/60, P 64, T99.7, R24 and O2 was at 97 RA. lung sounds clear but diminished in bases. His H&H and RBC were low, all his specific WBC values were increased, BUN/creat were increased, uric acid was high, total protein and albumin were both low.

If I am looking at this properly, it seems to me like he has like 3 separate problems here- inflammation/infection maybe r/t the GOUT (from all his specific wbc counts being elevated? right?); I see that he is have liver issues (low albumin and total protein and high uric acid & along with his h/x.); AND a tissue perfusion problem (both renal and peripheral) r/t his acute kidney failure, DM, and HTN.

Any thoughts? I am so scrambled with all of this info and I'm not even sure if I'm looking at this in the right way. I don't know what my priority should be because all of his problems seem to be of equal importance =/

[RN403, BSN, RN]

Your nursing diagnoses do not come from lab values, but, rather the assessment of the patient. Your nursing diagnoses come from your findings as the nurse when you assess your patient.

Pain would be one as you stated. Now what do you think the others could be when looking at the assessment information?

When attempting to prioritize your diagnoses remember ABCS, maslows, and acute vs chronic. Also, remember that you can identify risks for your patient based on your assessment findings. Ex: risk for injury r/t unsteady gait AEB ...and say what you see.

[NewNurse91D]

My professor doesn't want us to use "risk for" diagnoses. But as far as aassessment data; I saw him in pain, in ability to move, sever swelling, low urine output, diminished lung sounds in bases, no PERRLA. Honesty, his assessment didn't really give me a whole lot besides send of the gout.

[NewNurse91D]

Abcs: his airway and breathing at okay but his heart is not. It is said that AKI can be caused by hypertension (bc htn decreases cardiac output) and DM so I feel like decreased cardiac output would be a good d/x.