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.
Those look pretty good, but you're not telling us what YOUR assessment was. You sound as if you're still trying to cram medical facts into a nursing diagnosis that sounds plausible to you, but you're not using your nursing assessment to derive it and giving little or no nursing assessment findings to justify it.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
Colistin 80 mg IVD daily to be given after dialysis
Please anyone can help respond as soon as possible :) Thank You !
Your assessment....what is YOUR assessment. You go into the patient room you see them. What is their color, skin temp/color, lungs sounds, is there edema.
listed all the findings i got from the patient's chart and cardix
is NOT the assessment. THIS is where you are missing vital information! This is why you struggle. YOU look at the patient what do you see???? NOT what is written and see on the chart. >400 people looked at your thread and couldn't help you for the information to help you just isn't there.
From what I gather...you, have a patient that was admitted in severe uremia....
Creatinine 20 , BUN 225
those labs are now..,
cr 4.3 and BUN 59
They are
semi-comatosed
with a new trach with invasive lines in place.
What do this patients lungs sound like? You say they respond to painful stimuli.....do they locallize noxious stimuli, withdrawl from noxious stimuli? or do they have abnormal extension or abnormal flexation to noxious stimuli?
How are they being fed?
Fresubin Fiber 87 ml/hr
Through the IV or NGT? How is their skin? What are the bowels sounds? How is the patients buttox/peri-area with the diarrhea? Will that affect nutritional/hydration status of the patient?
Wheer are this patients "hospital acquired infections" located? Lungs? Blood? Are the febrile? Are the hypoxic? What is their O2 sat?
He has sacral stage II and bilateral hells stage II pressure ulcers.
how is his skin integrity being care for? What do these woulds need? how are they being cared for? Is the infection here? Are they on antibiotics?
Colistin 80 mg
Care plans are aALL about the ASSESSMENT...of the patient...NOT the patients chart.
When you look at the patient an touch the patient what do you see, feel, hear, What do they NEED? If this were your loved one....what would you want done for them?
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
Those look pretty good, but you're not telling us what YOUR assessment was. You sound as if you're still trying to cram medical facts into a nursing diagnosis that sounds plausible to you, but you're not using your nursing assessment to derive it and giving little or no nursing assessment findings to justify it.