Gallstone pancreatitis care plan...help

[schantzy143]

i have a care plan due soon and since my instructor is not emailing me back and answering my questions, i could really use some help. my patient is 78 years old and diagnosed with gallstone pancreatitis. he is in a lot of pain, has inspiriatory and expiratory wheezes throughout his lungs, sob, his bun (42) and creatinine (4.25) levels are also really high which to me indicates acute renal failure. the patient is on 3lnc, xopenex aerosol treatments, dilaudid q4hrs, lasix, potassium chloride, zosyn, has elevated bilirubin, wbc, alt, ast, amylase, and lipase.he is on a clear liquid diet, is hr ranges from 99-110, occasional sinus tachy on telemetry, +1 edema lower extremities, productive cough with thick yellow sputum, firm &distended/obese abdomen, voided 450ml during 7 hours of clinical day, took in a little over 1000ml during that time, and had warm/dry skin. potassium, iron, albumin, sodium, calcium, hct, hgb, and rbc are all low. there is obviously a lot going on with this patient so i am having a hard time coming up with 5 diagnoses, 3 of which i have to work out. so far i have

• ineffective airway clearance related to increased mucous production as evidenced by sob, inspiratory and expiratory wheezes throughout lungs, pox 93% on 3lnc, productive cough with thick yellow sputum and xopenex aerosol treatments three times a day.
  
• acute pain related to obstruction and inflammation of the common bile duct, inflammation, edema, distention of the pancreas, and peritoneal irritation as evidenced by patient reporting a pain of 8 on a 1 to 10 scale, the need for dilaudid every 4 hours, pain and tenderness in ruq and back, and pain when coughing.
  
  

i'm not sure if the second one sounds right because i tried describing what causes the pain, and in this case it's the gallstones (obstructing the common bile duct) and the pancreatitis. i also wasn't sure if i should include the diagnsostic studies (ultrasound:small stones and sludge within the gallbladder. gallbladder wall approx. 4mm, and ct scan: gallstones, dilated cbd and peri-pancreatic inflammation)

i was also thinking of using ineffective breathing pattern due to the pain and inflammation and maybe also due to the use of dilaudid which causes respiratory depression, and maybe the secretions could be a cause too???

i think that the acute kidney failure also needs to be addressed so i was thinking excessive fluid volume related to renal insufficiency as evidenced by intake greater than output, shortness of breath, +1 edema bilaterally in lower extremities, need for lasix 120mg iv, and (i would like to put the labs here but i'm not sure which ones, i'm thinking the decrease sodium, hct, hgb, and rbc????) i'm really confused, i kept going back and forth between fluid excess and fluid deficit..am i right with excessive fluid volume?? the patient is on lasix which would make me think of deficient fluid volume...but that's the only past of the assessment that would make me think fluid deficet, unless i mixed the labs up.

and for the last one i was going to do imbalanced nutrition: less than body requirement related to reduced food intake (clear liquid diet), and increased metabolic needs...

i would really appreciate any feedback, it's really nice to bounce my ideas off other people.

[lvloverRN]

i think your 1st nursing dx is only a risk - not an actual (risk for ineffective airway clearance) . you can add, fluid volumme imbalance (he/she could be excess in one compartment and have a deficit on the other) r/t impaired regulatory mechanism (kidney) , definitely ineffective breathing pattern r/t pain, impaired gas exchange related to secretions in the lungs. if your pt is very sick, you can have more than 5 dx. hope this helps. our school does not require us to do "as evidenced by" so im not used to it =)

[Sheryl18]

I would definately put something in on the cardiac issue. Decreased cardiac output? Ineffective tissue perfusion too.

[jnick31]

re: fluid deficit v. excessive. He has edema, wet lung sounds, SOB, is tachy (may be the pain or r/t fluid) and is retaining fluid... that tells me excessive. If you wanted to use deficit, I think it would be a risk for r/t lasix admin. But you might get a mouthful back from your instructor. :) depends on the instructor I guess.

My school doesn't make us use labs and such on our Dx... we just have to include it in a "labs" section of the care plan and explaine what they mean/why they are off.

You could maybe use Nutrition: less than body requirements (clr diet), I agree that something cardiac should be adressed, as well as risk or actual electrolyte imbalances.

As for your second Dx, You have inflammation listed x2, and I might change "distention of the pancreas" to "abd distention" (unless you got to actually feel his pancreas :) Only other changes I would make are just rewording things... but they would say the same thing you did.

[jnick31]

just reread the bottom half. :) Spot on with the nutrition.