Care Planning

[ala2ch]

Hi Guys,

I want to develop a nursing care plan for my patient but I can't really tell which two nursing diagnosis to develop as a priority.

A case of a 59 year old male known to have End stage renal disease, hypertension, diabetes type II, parkinsonism (on Madopar), vascular dementia,history of cerebrovascular accidents, who was presented to the ER with decreased level of consciousness, respiratory distress, and decreased PO intake.

The patient inserted a tracheostomy on my clinical day, he is semi-comatosed, has diarrhea, acintobacter and lactose-fermenting bacilli as hospital-acquired infections.

Chest X-ray showed congestion with a ? evidence of underlying pneumonia.

He was admitted with uremic encephalopathy and dyspnea. Creatinine 20 , BUN 225.

He has sacral stage II and bilateral hells stage II pressure ulcers.

Activity: CBR , Diet: Fresubin Fiber 87 ml/hr

has right internal jugular ash split for hemodialysis, foley catheter.

His current medications are:

Flagyl5600 mg per OG Q 8 hrs

Caltrate 600 mg per OG Q hrs

Madopar 250 per OG TID

Colistin inhaled 80 mg by nebulizer Q 12 hrs

Eprex 10000 units subcutaneously once per week

Nexium 40 mg IVD Q 12 hrs

Atrovent 6 puffs + Ventoline 4 puffs by aerochamber Q 8 hrs

Colistin 80 mg IVD daily to be given after dialysis

Please anyone can help respond as soon as possible :) Thank You !

[Esme12, ASN, BSN, RN]

You are in your third semester right? Based on your assessment....... What about this patient should concern you right away as you begin to care for him? Is this a real patient?

A case of a 59 year old male known to have End stage renal disease, hypertension, diabetes type II, parkinsons (on Madopar), vascular dementia, history of cerebrovascular accidents, who was presented to the ER with decreased level of consciousness, respiratory distress, and decreased PO intake.

The patient inserted a tracheostomy on my clinical day, he is semi-comatose, has diarrhea, acintobacter and lactose-fermenting bacilli as hospital-acquired infections.

Chest X-ray showed congestion with a ? evidence of underlying pneumonia.

He was admitted with uremic encephalopathy and dyspnea. Creatinine 20 , BUN 225.

He has sacral stage II and bilateral heels stage II pressure ulcers.

Activity: CBR , Diet: Fresubin Fiber 87 ml/hr

has right internal jugular ash split for hemodialysis, foley catheter.

His current medications are:

Flagyl5600 mg per OG Q 8 hrs

Caltrate 600 mg per OG Q hrs

Madopar 250 per OG TID

Colistin inhaled 80 mg by nebulizer Q 12 hrs

Eprex 10000 units subcutaneously once per week

Nexium 40 mg IVD Q 12 hrs

Atrovent 6 puffs + Ventolin 4 puffs by aerochamber Q 8 hrs

Colistin 80 mg IVD daily to be given after dialysis

It sounds like you copied this off the H&P.......What is your assessment of this patient? What are the vital signs? what do their lungs sound like?

Tell me about your patient....What do they NEED?

[ala2ch]

This is a real patient ! I really cant tell what is his priority ND ! I really appreciate your response after 274 people viewed my post only u responded please help me !

He has petechiae on his upper extremeties, his IV site and ashsplit is dry and clean, his lungs are clear, he responds only to painful stimuli.

Thank YOu !

[ala2ch]

I listed all the findings i got from the patient's chart and cardix that's why u feel its a fake patient

[MendedHeart]

New trach? Airway?

Encephalopathy? ^ICP?

[ala2ch]

he was intbated on mechanical ventilator the a new trach was planned for him

no ICP was present

[ala2ch]

426 people viewed my post and still no response ???????? please anyone help meeeeee the deadline of my online careplan is midnight and now it's 8:15 p.m please anyone

[MendedHeart]

End stage renal= impaired tissue perfusion:renal r/t damaged vessels in kidneys 2° esrd aeb bun, creat.uop?? Hd

[ala2ch]

cr 4.3 and BUN 59

[MendedHeart]

Ok..you can use all that data for that ND

[MendedHeart]

Also a higher priority is airway...Impaired gas exchange...this is def a must..your pt is on mech vent right...so it has to b impaired or he wouldnt b

[ala2ch]

Does this diagnosis looks ok ? About the yissue perfusion i really cant tell if the patient have the same signs and symptoms of renal tissue perfusion ??[TABLE]

[TR]

[TD]

Impaired Gas Exchange related to altered alveolar-capillary membrane changes (collapse of the alveoli due to pneumonia) and altered LOC manifested by hypoxia, inability to move secretions, and semi-comatosed state, CPOT is zero.

[/TD]

[/TR]

[/TABLE]

[TABLE]

[TR]

[TD]

Impaired Gas Exchange related to altered alveolar-capillary membrane changes (collapse of the alveoli due to pneumonia) and altered LOC manifested by hypoxia, inability to move secretions, and semi-comatosed state, CPOT is zero.

[/TD]

[/TR]

[/TABLE]