Fast help needed with Renal disease and hypocalcemia

[dixiemama]

Patient was 29 yr old with End Stage Renal Disease. She did her own peritoneal dialysis at home for past 2 years and did it for herself in hospital. She was in hospital for a total parathyroidectomy due to hyperparathyroidism. Her calcium levels remained low (considered critical levels by lab standards). No symptoms of the hypocalcemia were present. I have several diagnosis but can't seem to put them in order of priority.

1. impaired tissue integrity - due to the large, slight swollen incision on neck from surgery

2. risk for ineffective airway clearance r/t edema (of surgical site)

3. risk for injury r/t effects of hypocalcemia

4. risk of fluid volume excess r/t renal impairment OR retention of dialysalate OR compromised regulatory mechanism

5. risk for infection r/t surgical procedure

6. risk for infection: peritoneal r/t presence of catheter

I understand that airway is always first but this is just a "risk" as opposed to other things that are actually happening. The low calcium seems like a really big deal to me but when I look in my care plan books at Nanda wording and interventions - there just doesn't seem to be many true interventions other than administering the prescribed meds, teaching, and monitoring for complications. So, would you use the hypocalcemia (how would you word your diagnosis), or the surgical site tissue integrity, or the airway risk (since airway is always a priority - pt had slight swelling, a small amount of swallowing difficulty but lung sounds were normal, even, clear, etc. .... Please help me --- Due 8:00 in the morning!!!

[yoginurse2b]

Yeah I do agree with you that the low Ca level is a concern because it will lead to seizures and tetany. I would definitely consider risk for injury r/t hypocalcemia or risk for ineffective airway as priority as compared to impair skin integrity since surgeries usually cause damage to the skin anyway.

[PsychNurseWannaBe, BSN, RN]

well…sometimes nanda and i don’t get along. j i think it is a great guide but sometimes i find it a little uncomforting to do something just because it’s stated. i personally believe that there are times when a risk for has a greater risk of going wrong with greater implications and will therefore put it above an actual. i know i will probably get my hand slapped for saying that. j

i did reword some things and i still am not completely sold on how i worded it.

1. risk for ineffective airway clearance r/t swollen surgical incision on neck.

2. impaired tissue integrity r/t surgical procedure aeb large slightly swollen incision on the neck.

3. risk for injury r/t low serum calcium levels

4. risk for fluid volume excess r/t renal impairment; secondary to compromised regulatory mechanism and complications of dialysis

5. risk for infection r/t invasive surgical procedure

6. risk for infection r/t presence of peritoneal catheter

i don’t know if i would really use all 6. i think maybe some could be combined. for example interventions for impaired tissue integrity would include monitoring for s/s of infection, so i don’t know if i would restate it.

[Esther2007]

1. Risk for ineffective airway clearance related to swollen surgical incision on neck.

2. Risk for infection r/t surgical procedure

3. Risk for infection: peritoneal r/t presence of catheter

4. Impaired tissue? that is a questionable diagnosis (damaged or destroyed tissue e.g cornea, mucous membrane, integumentary or subcutaneous), I usually use impaired tissue integrity for stage 3 and 4 pressure ulcer patients. Check with your instructor on that one.

5. Risk for injury r/t to hypocalcemia

6. Risk of fluid volume excess r/t renal impairment OR retention of dialysalate OR compromised regulatory mechanism

[Daytonite, BSN, RN]

.anticipatory problems are always sequenced last and in the same order of priority, i.e., physiological needs first, followed by safety, then love and belonging, self-esteem and finally self-actualization. so. . .

1. impaired tissue integrity - due to the large, slight swollen incision on neck from surgery
   
2. risk for ineffective airway clearance r/t edema (of surgical site)
   
3. risk of fluid volume excess r/t renal impairment or retention of dialysalate or compromised regulatory mechanism
   
4. risk for infection r/t surgical procedure
   
5. risk for infection: peritoneal r/t presence of catheter
   
6. risk for injury r/t effects of hypocalcemia

there are problems with the construction of your diagnostic statements, however.

impaired tissue integrity - due to the large, slight swollen incision on neck from surgery

the related factor must be the underlying cause of the impaired tissue integrity. in this case it is "surgical intervention". "large, slight swollen incision on neck" is actually a defining characteristic (symptom) of the diagnosis. your diagnostic statement should read something like this:

impaired tissue integrity related to surgical intervention as evidenced by a large, swollen incision on the neck

risk for ineffective airway clearance r/t edema (of surgical site)

the risk factor here has to be something that will cause an obstruction of the respiratory tract or airway. the edema should be stated as causing such so it should read:

risk for ineffective airway clearance related to edema of the airway.

risk of fluid volume excess r/t renal impairment or retention of dialysalate or compromised regulatory mechanism

you can state one or all three as risk factors, but do not use "or" between them.

risk for infection r/t surgical procedure

risk for infection: peritoneal r/t presence of catheter

just state:

risk for infection.

i assume with the first statement you are aiming at a potential wound infection and for the second a potential catheter infection. both can be addressed under one nursing diagnostic statement. just make it clear in your nursing interventions and goals which is which. with "risk for" diagnoses your nursing interventions are going to be to monitor for the specific signs and symptoms of the two types of infection as well as measures to prevent them from occurring. that's the best you can do with these kinds of diagnoses.