Care plan helpppp

[NewNurse91D]

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.

[NewNurse91D]

thank you! =] and now im going to look at immobility vs breathing for my other one. Im going to look at both angles and see what I can do with each and which ever one can get me more results, cover more and leave me more room for progress is where im going to go. Im leaning towards the breathing one though because its a result of the immbolitly.

ALSO-he is constipated and has DOE!

Gosh I hope one day I can think like you guys. I didn't even see any of those s/s as connected like you guys did.

[LittleRedOwl, ADN, ASN, BSN, RN]

I started nursing school last august, and graduate in one month. I am not even a seasoned nurse! You'll get there. You're on the right track.

[NewNurse91D]

Awh congrats!! That's so awesome! I am so happy for you. I am so scared that I won't be able to see it and critically think. I'm in second semester.

[LittleRedOwl, ADN, ASN, BSN, RN]

Second semester is rough. It will come to you. Until you learn the disease processes fully it's difficult to think critically. Concept mapping helps. If your program does that you'll start understanding when you get to those.

Look at your patients abnormal findings and ask yourself why it's there. You can always keep asking why and you'll usually find your way to what I helped you see with this patient. Know what's normal first off and recognize and research the why's.

[NewNurse91D]

Yupp! Thats what I've been doing lately-research and why! It helps a lot

[ixchel]

Okay, I'm on my laptop now, where I can think and type bigger.

No, you do not want to focus on medical treatments. But, you do want to focus on what is going on medically, to also recognize what the patient needs from a nursing standpoint. Here is how I think through what you are saying. (And forgive me, because a lot of this will be simplified, not because I think you're an idiot but because it pieces together this way in my brain.)

You indicated the reason for admission is gout and AKI.

Putting together the reason for admission, with the history and current assessment data and labs, I consider what is going on with all of this. First, gout is a condition resulting from accumulated uric acid in the body. Uric acid would normally dissolve within the blood and be excreted via the kidneys.

BUN and creatinine are elevated presently, leading to the conclusion that this person has AKI. AKI can happen for a variety of reasons. Blood pressure can be one, however, this patient's current BP is 136/60, which really isn't that high. With a heart rate of 67, it seems the blood pressure may be pretty well tolerated by this person's body.

I look to the liver for this next. The liver is damaged by cirrhosis and hep C, damaging the ability to properly synthesize proteins, as evidenced by the decreased total protein and serum albumin. Proteins play a role in fluids re-entering the vascular space - they are needed for it. Does the patient have edema? The edema may be a result of this.

Diabetes also damages circulation. What was his AIC? Blood glucose level? I don't think this part is a really big deal right this very second, but in the long run, it makes things more complicated. If the blood is having a hard time circulating, how is it going to get the uric acid out through the kidneys?

Now I turn my brain to the WBCs, temperature, and respirations. It makes me wonder a couple of things, when AKI is in the picture: what is urine output like? Volume? Appearance? If anything is outside what would be expected, I would want to see a urinalysis and culture. WBCs and temp (albeit, only slightly elevated) indicate to me that there is a source of infection somewhere. Is this being investigated? My money is on UTI.

With all of that in consideration, my brain lands squarely on fluid volume being a very important important thing to address right now. This person needs adequate hydration, adequate volume in the vascular space. Without that, there is no way to prevent further elevation of uric acid. There is no way to ensure the kidneys are adequately perfused. If there is a UTI, fluids, fluids, fluids! And to assist the fluid in staying in the vascular space, nutritional needs must be met. Higher total protein and serum albumin are very important to this patient right now.

(I think "Doctor needs to XYZ related to QPR as evidenced by ABC" should be an official nursing diagnosis. I'd be asking the doctor to order a urinalysis if one hasn't been ordered yet.)

Maybe one of our more gifted with nursing diagnoses members can put an official nursing diagnosis to that that is adequately backed up by your information given on the patient. It might be a leap to say "Fluid volume deficit r/t AKI, AEB increased uric acid level, BUN, creatinine; decreased albumin". Usually you have to pick from the pretty list NANDA has made up for "related to". Not going to lie - my facility doesn't use NANDA or careplanning like we did in school, so I'm very rusty there.

Other problems that I think are very important to address with this guy now:

Medication compliance. I know he says he takes everything but his gout meds, but what a weird one to choose not to take. Does he take his bipolar meds? Does he take his hypertension meds? He says he controls his diabetes by diet. Does he? What's his A1C? Is he taking opioids for pain only at the hospital? Or does he take them at home? He's a former addict. If he's actually sober and committed to that sobriety, people committed to their recovery will frequently reject opiates. Is he having seeking behaviors? All of this is important education stuff. Taking medications even when feeling well will prevent further hospitalizations, especially when those meds are for blood pressure, diabetes, and gout.

Something else to realize is that following doctor's orders can be a nursing intervention. We get wrapped up into what nurses can do without orders in nursing school careplanning because we should be creative in our ideas on nursing autonomy and effectiveness, but it is absolutely a valid point to say, "Administer acetaminophen 650 mg PO q6h as ordered for fever above 100.4 oral," or something similar to that. Consider what you help in dropping a fever - all your vitals go down, pain goes down, appetite might go up, less sweating and therefore better hydration, improved mental status. So yes, focus on nursing diagnosis and nursing interventions, but nursing interventions can, and should, consider the medical interventions that we receive orders for as well.

Anyway, I hope that helps.

[ixchel]

Another thing - as a previous poster said, if you can back up what YOU think is the priority, then you're fine. You might disagree with me or anyone else here completely. It doesn't make any of us right or wrong. Real world nursing, you're addressing all of the important things simultaneously. You'll never have a charge nurse walk up to you and say, "you only get to do one thing for this guy tonight, so god speed." Prioritization is an obviously important skill that you will develop over time, but you'll never have to actually pick that ONE AND ONLY THING THAT IS VITAL RIGHT NOW in a stable patient. (Crashing patients are different, of course.) Your instructor knows that, and hopefully they are reasonable enough to understand that your assessment and education have led you to believe the priority you have chosen is the most important on the list, and this (whatever evidence you have to back it up) is why.

[NewNurse91D]

thank you very much! thtats very true.

[NewNurse91D]

The pt. does not have any edema. he has a urine output of 500cc. I know for a fact that he did take in 960cc during my 6-noon shift ALONG with getting a copntinous infusion of NS at 100 and hr. BUT the thing is that I don't know how much was already infused when I got there. he had a 500 ml bag and and when I came in there was like a 1/3 already gone. So I wanted to use his I&O has data BUT I cant accurately calculate an intake right?

[NewNurse91D]

also, I did look for a urine alaysis in his chart and there wasn't one done. could his high wbc count be r/t the gout? and about his meds-he said that he stopped taking them because he thought he didn't need them anymore BUT you are right, that it a random one to stop taking. I didn't really push it further when he said that he did take the rest of his meds. He doesn't take anything for bipolar, and he does take pain meds at home. he does seem to be 'seeking' his pain meds a lot. he is always asking for it and always asking about it. personally, don't think that he is sober from alcochol but I have no way to prove that.

[NewNurse91D]

as far as his DM magaenment-I didn't see his ALC in the labs but I did see that his glucose levels were stable\, a tiny pbit on the high side but that's to be expected because he is under stress, he is sick and he is eating more at the hospital. I learned in lec that being in the hospital actually can make someones blood sugars increase

[NewNurse91D]

Would diuretics be a good thing for this pt? I'm thinking-duiretics to promote the excertion of the Uric acid which would help the gout and help the AKI. I was thinking of including that with some of my pharmacological interventions. Right?