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Discussion

Care Plan Question...Please Help!

My patient is an 80yo M with a history of HTN, DM, cirrhosis secondary to Hepatitis C, blindness, and dementia. He is hypokalemic (3.3) and thrombocytopenic (26,000). BUN is 84, creatinine is 3.5. Low eGFR, low INR, high PT. Vitals are normal except for high RR of 22 and high BP which he takes Norvasc for. Blood sugar was below 150 (so no coverage) both mornings I cared for him. He is Islamic and speaks no English. His son translates for him but is not always around. No history of tobacco, alcohol, or drug use. He is on bedrest; has a peritoneal drain and a condom catheter; is incontinent of stool; has skin tears on his forearms, tops of thighs, and buttocks. He is very skinny but eats all of his food (Kosher). He is DNR. Discharge planning included hospice care but the staff was fairly certain his family would not agree to that and would want to take him home so plans were made to send him home with the peritoneal drain and possibly the condom catheter as well. So far my nursing diagnoses are:

1. Risk for bleeding r/t thrombocytopenia (platelet count of 26,000)

2. Bowel incontinence r/t dementia aeb inability to recognize the urge to defecate.

3. Urinary incontinence r/t dementia aeb uninhibited urination at unpredictable times.

4. Impaired dentition r/t self-care deficit aeb excessive plaque and missing teeth.

5. Electrolyte imbalance r/t ascites and peritoneal drain aeb hypokalemia.

6. Ineffective breathing pattern r/t pressure of ascites fluid on diaphragm aeb tachypnea.

7. Fluid volume excess r/t cirrhosis of the liver aeb ascites and pitting edema +1 in the lower extremities.

8. Impaired skin integrity r/t physical immobility and bowel incontinence aeb skin tears on the forearms, tops of thighs, and buttocks.

Am I missing any important diagnoses?

I can't seem to narrow in on what my top 3 would be (I'm thinking it would be #s 6,7,8 although I think #1 is very important but not sure if I can include a "risk for" in my top 3).

Do I need to elaborate on any of the diagnoses I have listed?

I would really appreciate any and all advice I can get. This is my "big assignment" for my main Med-Surg course (3rd semester) and it's due on Tuesday.

Thank you all in advance for your help!

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    Nice Job! You probably have enough ND's but if you wanted to, you could aslo include altered thought process r/t dementia or included renal failure to the electrolyte imbalance ND. I would think electrolyte imbalance of ineffective breathing pattern be in one of the top spots. Good Luck!

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    • Experts

    I think you got them..well done! I would include renal failure as well as there is clear evidence of this in the labs. To prioritize think about what can hurt them first....I have to make dinner....but I''l be back. Is this to be based on all the diagnosis that you can find for this patient?

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    • Author

    Thank you so much for your responses! Esme12...do you mean I should include risk for ineffective renal perfusion? What other NANDA diagnoses could be used for renal failure (besides the excess fluid volume that I already used)? Or should I just add renal failure to my electrolyte imbalance diagnosis like hodgieRN suggested? For example, I could put: "Electrolyte imbalance r/t ascites, continuous peritoneal drain, and renal failure aeb hypokalemia and elevated BUN and creatinine levels."

    We have to list as many diagnoses as we could come up with for our patient and then pick the top 3 priorities to develop a care plan for. Thanks again for the help! I really appreciate it :)

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    • Author
    I think you got them..well done! I would include renal failure as well as there is clear evidence of this in the labs. To prioritize think about what can hurt them first....I have to make dinner....but I''l be back. Is this to be based on all the diagnosis that you can find for this patient?

    How about this for prioritizing?:

    1. Ineffective breathing pattern...

    2. Electrolyte imbalance...

    3. Excess fluid volume...

    I really wanna put impaired skin integrity in there but I guess that would come in at a close #4? Please tell me if you think these should be rearranged in any way. Thanks again!! :)

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    • Author

    Actually, now I'm second guessing myself. "Electrolyte imbalance" isn't a REAL NANDA diagnosis...it's actually listed as "Risk for electrolyte imbalance". So I'm not sure if I should use electrolyte imbalance as a diagnosis. Maybe I can use it as part of my fluid volume excess diagnosis? I feel like I should mention it because it's an out-of-range potassium level which can have extreme consequences on the heart but I don't want to just "make up" a diagnosis that's not NANDA-approved. And this way, I can still include impaired skin integrity like I originally wanted to! Thoughts?

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    • Experts
    patient is an 80yo M with a history of HTN, DM, cirrhosis secondary to Hepatitis C, blindness, and dementia. He is hypokalemic (3.3) and thrombocytopenic (26,000). BUN is 84, creatinine is 3.5. Low eGFR, low INR, high PT. Vitals are normal except for high RR of 22 and high BP which he takes Norvasc for. Blood sugar was below 150 (so no coverage) both mornings I cared for him. He is Islamic and speaks no English. His son translates for him but is not always around. No history of tobacco, alcohol, or drug use. He is on bedrest; has a peritoneal drain and a condom catheter; is incontinent of stool; has skin tears on his forearms, tops of thighs, and buttocks. He is very skinny but eats all of his food (Kosher). He is DNR. Discharge planning included hospice care but the staff was fairly certain his family would not agree to that and would want to take him home so plans were made to send him home with the peritoneal drain and possibly the condom catheter as well. So far my nursing

    What is his assessment? Does he have edema? Does he make urine? He has a peritoneal catheter...what care does this have? You mention that he will be sent home with these....what teaching will be needed for the family/care givers? Depending on your instructor......You can use electrolyte imbalance but what can be caused by hypokalemia like muscle spasms, or cardiac arrhythmia. You mention that this patient is skinny....what about failure to thrive?

    When you use the nursing diagnosis you need to have the supporting evidence in patient problems/symptoms to support using that particular diagnosis. Here is a list of what I think apply....you have done a great job!

    Activity intolerance: he is on bedrest

    Risk for Bleeding: cirrhosis, thrombocytopenia, elevated PT

    Bowel incontinence: incontinent

    Caregiver role strain: hows the family doing?

    Chronic Confusion: dementia

    Risk for compromised Human Dignity: he is a DNR but you indicated the family not prepared for hospice

    Adult Failure to thrive: self explanatory

    Risk for Falls: from his confusion

    Risk for unstable blood Glucose level: he has diabetes

    Excess Fluid volume: ascities

    Risk for Infection: peritoneal catheter

    Impaired physical Mobility: bedrest

    Risk for impaired Liver function: hep C and cirrhosis

    Impaired physical Mobility: emaciated

    Imbalanced Nutrition: less than body requirements: he may be eating but continues to waste away.

    Ineffective peripheral tissue Perfusion: ascites, edema?

    Bathing Self-Care deficit: self explanatory

    Impaired Skin integrity: skin tears.

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