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.
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
when I asked him, he said he stopped taking them because he thought he "didn't need them anymore". since he hadn't had a gout attack in so long, I guess he assumed that he didn't have to take them (knowledge deficit). but as far as any other meds that he hasn't been taking, he said that at home he is taking his other meds. evidently he stopped taking his gout meds a few months back.
You could group med compliance in with nutrition. I am suspicious his poor lab values relate to all his medical conditions, and if he's not caring for those by taking his meds, nutrition is going to be an issue. If you want to group it in with something and not have it stand alone.
You sound like you're clicking and on the right track now.
Bed bound= risks bed sores, lung issues, etc.
Poor nutrition= poor healing, risk for bed sores/skin breakdown, risk of infection.
Noncompliant= knowlege deficit and teaching r/t meds. Also on his diseases too, does he even understand them all?
Vitals/abnormal lung findings= breathing impaired/ risk of getting worse.
You're really seeing the bigger picture now. It's up to you what is most important and how you'll plan care. He is your patient. Think what will help him the most and what risks the worst long term effects. Just be ready to defend to your teachers why you prioritized what you did. It's all subjective, you just need to understand the why's and what's to care for him and be ready to defend your choices :)
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
he has the impaired mobility and ineffective breathing pattern r/t the pain and gout. so by fixing the pain-I can help make his breathing and mobility better. which is priority.
then my second d/x I guess would be focused on nutritional and medication education.
I don't know why, but I feel like that's not enough for him. Its like im telling myself that "ineffective breathing pattern and knowledge deficit" couldn't possibly make my pt. better. and I don't know why I think that -_- I think im over thinking it or something and want to make it more complicated
You can really group teaching anywhere you want by the way. You can have it in each diagnoses and spread it out. That shows good critical thinking having it incorporated everywhere.
What's going to "fix your patient" is teaching him the proper care! He seems to think that if he gets better he can stop taking meds. It's very important that he understands "These are life long illnesses, they aren't going away, and you should never discontinue meds without consulting your doctor". Teaching this will "fix" him long term preventing him from letting himself get this bad to be hospitalized.
And if you're worried breathing as a dx isnt fixing everything. Go for pain or immobility as your nursing diagnoses. One of the BEST things you can do to fix a patient is mobilize them. When they're immobile their lungs start getting stagnant and they have breathing problems, they get constipated, they risk skin breakdown, etc. If you can improve your patients pain (which is a fine nursing dx) he will breath better and deeper not being in pain, he will move and get up which will help soso much in his body, it will help his cholesterol, his BP, and his diagnoses by getting up and moving (and teaching the long term importance of being active as well if he isnt).
These little things we do as nurses don't cure a person, but without them your patient would sit in bed let their lungs turn to mush so to speak, get sores all over the place and get septic, and they will not get better. Your patient needs good nutrition, less pain so he can move, and he needs to make an effort to breath and keep up his strength.
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
yeah, putting it into each d/x will be me another d/x to work with. instead of using one whole on to teaching-incorporate it in with each one. the one thing I do like about having one d/x for knowledge deficit, is that I can bring in allllll of his conditions into one arena and just educate on everythinggg from his nutirition to medication to gout prevention to cardiac health to infection and skin. if I did two d/x with teaching incorporated into them, I might not be able to hit on all of the teachings he needs.
Specializes in Geriatrics, In-Home Care, Community Based Nursing.
very true! I think im trying to 'do too much'. in the midst of focusing on everything else-I over looked those very significant areas. and without management of those areas he wont get any better regardless of what I do for everything else.
Then it sounds like you've chosen! Go with knowledge deficit. Really nutrition is mostly teaching/knowlege anyways you can teach him to increase protein intake (as long as there isn't a medical reason that makes that bad) which would be the only nonteaching thing I'd do as a nurse for nutrition. I'd eliminate nutrition and incorporate that into knowledge deficit. It's a wise choice.
NewNurse91D
109 Posts
what do you see with his BP?