I'm in a bit of a dilemma trying to write up a care plan. Two things are holding me back. 1.) actual problem vs risk for. This age old debate has been brought up several times here and I've read through them, but still a bit uncertain. 2.) I can't come up with a nursing diagnosis for this situation:
90 yrs old male, admitted for back pain ( compression fracture ). Pain is under control. Alerted to person but not time/place. History of hypertension and dementia. Urine appears slightly concentrated w/ 500 mL output in last 20 hours (intake roughly the same). BUN elevated to double normal level, creatinine elevated slightly. Hemoglobin and Hemtocrit decreased also. Electrolytes all in balance except calcium, which is low. Pt. is not dehydrated, no signs of edema.
Because of the dark urine, elevated BUN and creatinine I'm sure the renal system is compromised in some way. But what can I use as a diagnosis? A urinary analysis and kidney scan results are not available.
I have an actual diagnosis- pain r/t the compression fracture. But the renal system is of more importance because of it's role in homeostasis, so would an at risk for trump an actual diagnosis here? The renal failure has not been officially diagnosed medically yet, it's a new occurrence.
Thank you! Seems I made a mistake, the output for the last 20 hours was 500 mL, intake for the 8 hours I was there was approximately 500. Lungs sounds were not dry, mucous membranes and skin turgor are good. No stool was passed during my time there.
See, these are all the nursing assessments you should be making as a matter of course. You are in nursing school, and that's what we do. You presented us with medical diagnoses, but not much in the way of nursing assessment.
And even for 8 hours, an intake of only 500cc is poor. What was his intake for the rest of those 20 hours? You're going to need to look at balance in time as well as amounts, and BUN and hematocrit will tell you about dehydration. Lung sounds "not dry"? In what way? Dependent crackles, like in early CHF, or rattly rhonchi, as in pneumonia?
I stand by my opinion that "risk for ineffective renal perfusion" is met by several risk factors as you describe them. And of course this is a very real risk to his health, such as it is already.
Well, I must confess that I'm not too familiar by what you mean by "dry" lung sounds. I listened to the lungs for over a minute, did not hear any wheezing, rales, rhonci or any other adventitious lung sounds.
OK, those are dry lungs. Wet lungs make all sorts of funny sounds. Rales, which should have a little ^ over the "a" but I can't seem to make that happen on this posting medium, sound like when you take a bunch of hair between finger and thumb and rub it between them next to your ear. They are caused by moisture in the alveoli and are indications of, most often, pulmonary edema from heart failure (which is, after all, a sign of fluid overload, at last more than that heart can handle). "Dependent rales" are the ones that are closest to the floor, due to the influence of gravity on chest blood flow-- could be the base of the lungs in someone upright, or the back in someone who's supine, or the lower lung in someone turned on his side. So when someone says, "Does he sound wet?" that's what they mean. Really dry lungs mean there's no fluid overload...and this guy certainly sounds dry. Just one more data point.
I read all of this with great fascination. Esme and Grntea have been valuable resources for helping me think like a nurse and how a nurse should respond. I am taking all of this knowledge and tucking it away for when I start the program in the fall. Thank you guys for your invaluable input.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I read all of this with great fascination. Esme and Grntea have been valuable resources for helping me think like a nurse and how a nurse should respond. I am taking all of this knowledge and tucking it away for when I start the program in the fall. Thank you guys for your invaluable input.
We are happy to help...show me an inch I'll take you a mile....((HUGS))
Oh my goddess, she wants to learn to think like a nurse...be still, my heart! It's all we ever wanted for our students. You have made my day, thank you so much.
First you have to determine the cause of the fracture, is this new? Or old, thereby could be a refferred pain secondary to renal failure. As it is also stated, both renal profile are deranged( BUN/creat) which could also be a tool for a differential diagnosis for an underlying renal failure, i would assume when you said that the patient is not dehydrated meaning in appearance? Otherwise both the Blood tests results does not say this. You can always formulate your own nursing diagnosis based on both your subjective and objective signs and symptoms, apart from pain, alteration in fluid and electrolytes, as well as dehydration is a good start.
Compression fracture with well controlled pain? What is the pain controlled with? What medication might an older person take in larger quantities that can cause renal injury and anemia?
Compression fracture is recent. The patient is in pain sporadically, but subsides with medication. Doing a diagnosis on pain is fairly simple, and because it is "controlled" I was directed to go with another diagnosis. Risk for ineffective renal perfusion seems to be my best bet so far, possibly dehydration. Thank you guys so much. I believe I have learned more about critical nurse thinking in this thread than I have in the past 8 months in school.
tnstudent21
15 Posts
Thank you! Seems I made a mistake, the output for the last 20 hours was 500 mL, intake for the 8 hours I was there was approximately 500. Lungs sounds were not dry, mucous membranes and skin turgor are good. No stool was passed during my time there.