Care plan helpppp

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

Hey guys! I need major help with my care plan!

This is my second care plan; and I'm having trouble figuring out which d/x I should use and im concerned that im not making the right choice or that I'm not seeing something incredibly obvious.

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

He has acute kidney injury (AKI), 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.

SO I feel like the d/x could be: ineffective renal tissue perfusion, decreased CO, impaired mobility, or acute pain.

I was just working on the ineffective renal tissue perfusion BUT then I hit a wall and am now second guessing myself BECAUSE I feel like my pt's AKI is a problem r/t decreased CO. So if I'm going to make something a priority, shouldn't it be decreased CO?

I really would appreciate some guidance or advice because i'm definitely confusing myself right now and don't know where to start! and because this is my second care plan, I really want to make this a good one; not a little dinky one.

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Specializes in critical care.

If you'd like to gather your priorities, first start with CAB (circulation, airway, breathing), and then consider maslow's hierarchy.

This guy has a ton of things wrong with him. Which is most acute right this very second? (Hint: pain doesn't kill people.) He has diagnoses that affect circulation, he has lab values indicative of poor nutrition status (may be due to liver issues), his vitals may only be slightly outside normal limits, but don't disregard them. Back up and look at the big picture. Maybe sit down and make lists of what is affected by each of the conditions you listed. Highlight things in each list that can be life altering, or a severe threat to future health. Circle things you find in common (hint: circulation is a big deal in the picture you painted for us here).

Any when you've gathered a bigger picture of how one thing interacts with another, think to yourself..... What does this guy need to get better right now? Is it possible for that thing to even get better? (Keep going down your list of needed things until the answer is "yes".)

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

What in his labs indicates poor nutrition? I have been sitting down trying to connect the dots between each of his conditions and why his labs are the way they are because of them; but I still feel like I don't see those connections yet.

what's most acute this very second for him? I

feel like even though his pain is what's affecting him the most right now, that's caused from the gout so its 'fixable' with gout and pain meds.

Life altering-the AKI, hypertension and cirrhosis & hepatitis. He doesn't want treatment for the hep. The hypertension may be causing this AKI. He has the GOUT which has been a very serious chronic issue for him for many years (his doc came in while I was talking to him and told him that he had the worse case of gout that she has ever seen, he has those tophi masses on his joints too). SO that being said, his circulation problem is the bottom line problem, right?. But the thing is, can that be fixed or can I do something to improve him? Is that even what I should be focusing on?

I'm almost between "decreased cardiac output" and "impaired renal tissue perfusion" as my first d/x (I need two).

His impaired renal perfusion r/t his htn (decreased CO) and GOUT (uric acid levels). BUT the decreased CO is a cause for AKI so shouldn't that be my priority?

Ugh...

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So what I am thinking is that renal circulation doesn't seem like the priority to me. That sounds more like it's medical based and less nursing based. I'd want to pick a legitimate problem I can fix. How are YOU going to care for and fix his renal perfusion. If you can answer that, maybe it is your priority.

But to me that sounds like it's a medical problem. My focus would be pain OR immobility. If he's in SO much pain he can't move he runs the risk of bed sores (risk impaired tissue integrity), and the risk of atelectasis especially since his lung sounds are diminished (Ineffective breathing pattern)! That would be your A/B in ABC priorities, airway and breathing (which do trump circulation contrary to the previous poster, at least in every textbook I have).

My nursing dx would be Ineffective breathing pattern r/t immobility/pain (or whatever is causing it) AEB diminished lung sounds. And his vitals were not unremarkable, resp rate of 24 is tachypnea (normal is 12-20) so he's showing increased WOB too by that measure (did he have use of accessory muscles?)!

I would encourage incentive spirometry, turn/cough/deep breath, maintain pain at comfortable level to ensure he is comfortable enough to take deep breaths, monitor lung sounds and WOB, pt teaching on importance of deep breaths/spirometry.

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I'm thinking the poor nutrition in his lab values are from his hep C and cirrhosis. The liver is very important for utilization of vitamins and nutrients.

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Specializes in critical care.

Nutrition - protein and albumin values

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

VERY good points. I cant fix his poor renal perfusion but I can help fix what is causing it though, right?

I can treat his GOUT, treat his HTN- then the renal perfusion might be better?

I definitlty like the ineffective breathing pattern d/x. because of the pain, which is causing him to be immobile=ineffective breathing pattern. the thing is though is that beside the resp rate, I don't have much evidence to go on for it. He wasn't using accessory muscles.

I can have a d/x of impaired mobility? and then have onbe of my interventions be directed at preventing resp complications.

He did stop taking his GOUT meds a couple months prior to his gout flare up, so he is having compliance issues with the medication regimin.

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

"imbalanced nutrition, less than body requirements" d/x possibly?

even though he isnt underweight?

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The thing is though, nursing care plans don't to aim to cure illnesses, they aim to fix the side effects from illnesses. Your ideas sound like they aim to fix diseases. The doctor should be the one planning how to fix his gout and htn. All you can do to fix those is give meds and that isn't really critically thinking to help your patient. I just don't see what your interventions could be should you choose to go the htn or gout route.

Your patient has diminished breath sounds though in his bases, this is a very very big red flag that he has impaired breathing. So you don't "just" have the rate to go off of as a clue. Diminished=air isn't getting where it should be. This is a real legitimate nursing issue that you can take upon yourself to work on as his nurse. Accessory muscle use would be a dire sign that his respiratory status is tanking. So it's not like you should see that now. But we want to prevent him from getting there. His lungs may just be diminished in the bases, but you could come back in a couple hours, and the level at which they're diminished could change, or he could have crackles. Especially to me since he is so immobilized from pain he is not helping his diminished lungs as is and he really needs help with that.

Impaired immobility is a legitimate issue and you could care plan that.

Nutrition is also legitimate. His labs show impaired nutrition and impaired nutrition impairs healing abilities and puts him at risk for infection.

With this patient being noncompliant another very important diagnoses would be knowledge deficit and he needs teaching tailored to his needs. Assess why he doesnt take his meds... are the side effects causing him to dislike them in which case he needs you to advocate and pass this on to his doctor. Does he not understand the importance... if so teach him. Does he need a referral to support groups in the community? Is he forgetful and does he need pill containers to keep him on track. LOTS of teaching there.

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Specializes in ICU.

His resp are high and his BP is a little wonky. He is in pain which is affecting his ability to move and everything else. Since pain is a vital sign I would get that taken care of. You need to look at the whole picture and what your patient needs now.

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Specializes in critical care.

Is he only skipping his gout meds? What meds is he compliant on?

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Specializes in Geriatrics, In-Home Care, Community Based Nursing.

You are 100% right! Im over here wanting to cure him and his conditions. But my role is to treat his s/s and whats happening as a result of those condtions. Nutrition is a big one for him, because of the wound healing, infection and because he is already compromised from the DM, GOUT inflammation, and the cirrhosis and decreased cardiac output.

I can incorporate the medication compliance teaching in with my ineffective breathing pattern d/x as an intervention, right? like have one of my interventions be directed towards pt teaching of future compliance with medication regimin to prevent another gout attack-therefore preventing the pain and immobility (at least in relation to the gout side of the ineffective breathing). and then incorporate teaching into my nutrition d/x too?

OR should I have one d/x as a knowledge deficit because teaching and figuring out whats going on with his gout meds and then making sure he understands why he needs to eat proplery is almost critical to him beging able to go home and not come back with sepsis or pneumonia or something like that because he isn't eating right or taking his meds.

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