case study

What is your thinking as to what some of the nursing problems (nursing diagnoses) here might be before I begin to show you how to pick this apart and show you how to figure out what the priority problem is?

well, aspiration pneumonia and sepsis are medical diagnoses and not nursing diagnoses or nursing problems. risk for sepsis r/t history of aspiration pneumonia m/b increase wbc & temp, tachypnea, and apnea is a potential (as in does not exist yet) problem. risk for sepsis is not an official nanda nursing diagnosis and sepsis is a medical diagnosis. nanda and most nursing programs won't let nurses use a medical diagnosis in a nursing diagnostic statement. in a "risk for" diagnosis, the r/t part of the diagnostic statement lists the risk factors that lead to the problem and there can never be any m/b's which are the signs and symptoms that prove the existence of actual nursing problems because "risk for" diagnoses are not actual nursing problems. if you have signs and symptoms of sepsis, then the patient has sepsis and not a risk for sepsis. if the patient has sepsis, a nurse cannot diagnose it because a nurse does not have a license to do that. do you see the problem you have run into?

to determine this patient's nursing problems you have to apply the nursing process. you can see other examples of how this is done on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

step 1 assessment - assessment consists of:

• a health history (review of systems) - this is a 47-year old hispanic male that was admitted to the er from a skilled nursing facility with suspected aspiration pneumonia and sepsis. he was also found to be dehydrated. he has a severe mental disability and cerebral palsy, seizure disorder, dysphagia, severe chronic contractures and is non-communicative (doesn't speak?). he has a history of aspiration pneumonia.
  
• performing a physical exam - since this is a case scenario the physical assessment data has been provided for you: labored breathing with alternating episodes of tachypnea and apnea, o2 sat 92% on 50% o2 by mask, bilateral rhonchi, tachycardia at times, blood pressure between 80/65 and 138/52, and rectal temp was 104.5f.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - all we really have been told is that he has dysphagia, is non-communicative and has contractures, but a lot of conclusions can be drawn from this.
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you should be looking up aspiration pneumonia, sepsis, dehydration, and cerebral palsy. sepsis, in particular, has specific symptoms, as does pneumonia.
  
  • http://www.merck.com/mmpe/sec05/ch052/ch052f.html - aspiration pneumonitis and pneumonia
    
  • http://www.merck.com/mmpe/sec06/ch068/ch068a.html - sepsis and septic shock
    
  • http://www.merck.com/mmpe/sec19/ch276/ch276b.html - dehydration
    
  • http://www.merck.com/mmpe/sec19/ch283/ch283b.html - cerebral palsy
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - the gastrostomy tube is a medical treatment for his dysphagia. the iv piperacillin and tazobactam is a combination antibiotic probably given for the fever and elevated wbc count (http://www.drugs.com/ppa/piperacillin-sodium-tazobactam-sodium.html). other abnormal labs included sodium 156 (normal is 136-145), chloride 118 (normal is 90-110), urea nitrogen 38 (normal is 10-20), ph 7.56 (normal is 7.35-7.45), and hematocrit 58.5% (normal 42%-52%).

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data.

• labored breathing with alternating episodes of tachypnea and apnea
  
• bilateral rhonchi
  
• tachycardia
  
• blood pressure between 80/65 and 138/52
  
• rectal temp of 104.5f
  
• dysphagia
  
• contractures
  
• non-communicative
  
• gastrostomy tube
  
• sodium 156 (normal is 136-145)
  
• chloride 118 (normal is 90-110)
  
• urea nitrogen 38 (normal is 10-20)
  
• ph 7.56 (normal is 7.35-7.45)
  
• wbc 11,690 (normal is 5,000-10,000)
  
• hematocrit 58.5% (normal 42%-52%)
  
• history of seizures
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. every nursing diagnosis has a set of signs and symptoms just as every medical diagnosis has a set of signs and symptoms. prioritization is done according to maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). the priority nursing diagnosis based on the data is

• ineffective airway clearance r/t infection and neuromuscular dysfunction aeb (m/b) alternating episodes of tachypnea and apnea, bilateral rhonchi and no cough.
  

an equally important problem on the same level is

• ineffective breathing pattern r/t neuromuscular impairment aeb (m/b) labored breathing with alternating episodes of tachypnea and apnea.
  

these are the two top nursing problems. there are others.

would this priority nursing diagnosis work:

fluid volume deficit related to npo status or inadequate fluid intake?

what interventions can i do for this pt. on npo status beside administering iv fluids as ordered, monitoring i&o, weight, b/p, heart rate and respiratory status, and skin turgor, provide daily oral care?

he has a gtube and he is on npo status. please help. thanks much.

fluid volume deficit related to npo status or inadequate fluid intake

the construction of the 3-part diagnostic statement follows this format:

• problem- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.

  
  

• etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  
• symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.