Cholecystectomy with Delirium Case Study

[SeattleJess]

Okay, I am really stuck on writing a paper. We need to use the nursing process to develop and create care plans for one "psychological" nursing diagnosis and two "medical" nursing diagnoses.

Patient is a 74 year-old obese female admitted for an open cholecystectomy. Patient was alert, oriented x 4 and compliant with requests during day shift. She also received 30 mg of oxycodone PRN in the 8 hours before shift change; her max PRN dosage is 20 mg/8 hours (5-10 mg/4hrs).

Patient tries to get out of bed 2 hours after shift change, hallucinating snakes under the bed. She has tremors in her hands when they are extended and is oriented to person only. You give her 2 mg of lorazepam for anxiety and 40 minutes later, she hits you in the face when you try to check her dressing. Her wound is held together with steri-strips and covered by gauze.

I can think of many diagnoses but I'm not sure how to prioritize them. The best "psych" diagnosis would seem to be "Risk for Other- or Self-Directed Violence." Chronic confusion is given in our psych text, but there is nothing to indicate that this is chronic and not acute. Technically, "acute confusion" is a medical diagnosis as it comes from Carpenito... or is it psych because it obviously deals with mental state.

There is nothing about pain...

Davis Drugs says the max dose of lorazepam for geriatric patients is 0.5mg and that it potentiates the respiratory depression of opioid analgesics. Upper GI surgeries commonly cause shallow breathing. But there is nothing in the scenario about respirations or info on effects of lorazepam or oxy, for that matter. Is it making things up to be concerned about Risk for Impaired Breathing Pattern, given these facts?

When I sort through everything, trying not to bring in anything not in the scenario, I think of Risk for Trauma, Risk for Falls, Risk for Infection are important. Too many risks, right? Self-Care deficit... but that's assuming facts not given explicitly.

I don't know how to think about this. Our instructors have said they won't answer these sort of questions. (Citation I know. It's how to decide among the gazillions of NDs that I need to know... and that is not taught much in class.)

So... I'm going to take a break and go for a brisk walk in the rain. Can anyone help me figure out how to think about this assignment? What knowledge can I bring into my assessment? How do I pick the priority diagnoses? I want to pick acute confusion because if THAT is successfully treated, the self-care deficits, risk for violence, etc. are probably solved. But is that a psych diagnosis if it's not listed in Townsend? Preventing violence doesn't solve the problems that would give rise to the other diagnoses.

I'm really discouraged. My brain is just not working well on this, I'm getting anxious, and I'm getting WAY black-and-white in my thinking as in "I'll fail out of nursing school" and "I don't have what it takes to be a nurse.

I hope someone can help me to focus and make reasoned judgments. I'm not being lazy, just stupid, I fear.

[SeattleJess]

I will post to myself. I am going with acute delirium for my psych diagnosis even though it isn't listed in our required psych text book as a psych diagnosis. Dare to use common sense!

Now on to the next diagnosis. Still would be great to have comments.