RN DX prioritization...HELP!!!!

  1. All right I have gone into total and complete brain fry! I have written this awesome case study on a patient and have all of the RN diagnoses but just can't seem to figure out the BEST order. Could ya help??? I know Maslows and I know ABC's...Just can't seem to figure this out because they are all physiological.

    History: This guy is 65 years old, End stage COPD, 152kg. Came into ER in respiratory failure and intubated. Found to be in SVT and electrocardioverted. He had pleural effusion and the CT scan showed a suspicious mass in his chest. Thoracotomy performed and 1 liter of adipose tissue was removed from his pleura. That was back in mid-July. He is still in the ICU with hyperthermia, still intubated and switched to a trach at the end of August
    Can you help me put these in the right order?


    1.) Impaired gas exchange related to ventilation/perfusion mismatching or pulmonary shunting as evidenced by low PO2 & high CO2 in ABG and adventitious breath sounds on auscultation. (Respiratory)

    2.) Risk for aspiration related to dysfunction of normal protective mechanism (cough reflex) due to high levels of sedation. (Respiratory)

    3.) Ineffective breathing pattern related to musculoskeletal fatigue as evidenced by unsuccessful weaning of mechanical ventilation. (Respiratory)

    4.) Decreased cardiac output related to alterations in preload as evidenced by impaired tissue perfusion (edema, decreased urinary output) (Cardiac)

    5.) Excessive fluid volume related to renal dysfunction as evidenced by third spacing in the extremities and crackles auscultated in the lungs. (Cardiac)

    6.) Decreased cardiac output related to changes in afterload as evidenced by labile blood pressures. (Cardiac)

    7.) Activity intolerance related to imbalance between nutritional supple and illness demand as evidenced by increased blood sugars. (Endocrine)

    8.) Imbalanced Nutrition: Less than body requirements related to increase in metabolic demands evidenced by low albumin. (Endocrine)

    9.) Risk for infection due to circulatory changes and delayed healing of decubitus ulcers and post chest tube site. (Endocrine)
    Last edit by 2007_RN on Sep 16, '06 : Reason: Spelling error
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    About 2007_RN

    Joined: Jun '05; Posts: 27
    too many!!!

    13 Comments

  3. by   Altra
    1, 4 & 6, 5, 2, 8, 3, 9, 7

    Just my take on it ...

    ** I would consider combining 4 & 6 as they are both the same problem: decreased cardiac output.

    ** I put risk of aspiration ahead of some others. There are instructors who will tell you that a "risk for" problem NEVER comes ahead of an actual problem and in theory I agree with that logic; however, in my mind the probable outcome of that risk of aspiration takes greater precedence than, say, activity intolerance. You know your instructor -- you'll know how he/she wants you to address this.

    ** Is elevated blood glucose evidence of activity intolerance? In my mind, activity for this pt. is currently limited to maintaining VS, turning and passive ROM. What is happening to this pt.'s VS when he is repositioned or passive ROMs are done?
  4. by   2007_RN
    HI thanks for your input. My idea of activity intolerance eas because his respiration rate goes up into the 30's above the vent settings of 14! HIs pulse rate goes into the 90's (not too alarming but he usually sits around the low 70's..due to his meds) He usually has hypotension 80's/50's and with "activity' these all change. It takes a bit and he is back at baseline. NOt a strong diagnosis I know but my instructor went over these with me and she changed this one to deal with endocrine as the three systems I am dealing with are respiratory, endocrine, and cardiac. It is really hard to find good dx's for endocrine acording to Nanda guidelines. Any suggestions in dealing with the change in his vital signs and would it still sit low on the priority list as it is only transient. (please excuse any spelling errors I am typing as fast as I can! I am still writing up the care plans for each of these puppies)
  5. by   Altra
    The change in vital signs is indeed evidence of activity intolerance, but when compared to the other problems it still sits pretty low on the list. (Someone needs to change the vent settings or implement other interventions to correct that poor man's ABGs -- NOW -- or he will be what other nurses on this board have referred to as a "well-ventilated corpse.")

    You're right - endocrine issues can be harder to pin down than the more obvious ABC issues. But don't get sucked into the trap of "creating" an endocrine issue where there isn't one just to be able to say you included it in the care plan. My point was, are elevated blood sugars evidence of activity intolerance?

    Good luck with this assignment ... I've been out of school a year so the memory of 30-page care plans is still kinda fresh, although it seems like a world away now!
  6. by   2007_RN
    You are right about the increased BS not being a sign of activity intolerance. It really has not much to do with it at this moment. Grrr....

    FYI..Respiratory is in there all day changing his settings. His lungs are just so full of crap. He is septic now so thirs spacing is becoming a major problem. Just adds to his lung issues. THe nurses say he is just circling the drain

    I have a love/hate thing with these care plans. I love how it makes things just stick and get you deep into critical thinking but I am SO TIRED of sitting in front of my computer. It is a beautiful day outside and I want to be doing anything other than sitting here!

    Alright I really appreciate you help and time looking into this.
  7. by   UM Review RN
    Quote from 2007_rn
    you are right about the increased bs not being a sign of activity intolerance. it really has not much to do with it at this moment. grrr....
    Quote from 2007_rn

    fyi..respiratory is in there all day changing his settings. his lungs are just so full of crap. he is septic now so thirs spacing is becoming a major problem. just adds to his lung issues. the nurses say he is just circling the drain

    i have a love/hate thing with these care plans. i love how it makes things just stick and get you deep into critical thinking but i am so tired of sitting in front of my computer. it is a beautiful day outside and i want to be doing anything other than sitting here!

    alright i really appreciate you help and time looking into this.
    ok, if the patient is septic, you might want to consider the sepsis alone as causing changes in blood glucose.

    9.) risk for infection due to circulatory changes and delayed healing of decubitus ulcers and post chest tube site. (endocrine)

    also, if the patient is septic, that eliminates the "risk for" dx because he has a systemic infection.

    here's a great website on sepsis to help you out with tying together all these symptoms that you're seeing.

    www.sepsis.com has an incredible video (it's very short) that can literally show you some of the processes that are occurring with this patient:

    http://www.sepsis.com/overview/micro...p?reqnavid=1.9


    you were wondering about endocrine diagnoses. in sepsis, glycemic control is very important:

    related measures
    glycemic control goal

    background:
    following initial stabilization of patients with severe sepsis, blood glucose should be maintained < 150 mg/dl (8.3 mmol/l). studies supporting the role of glycemic control have used continuous infusion of insulin and glucose. with this protocol, glucose should be monitored frequently after initiation of the protocol (every 30–60 minutes) and on a regular basis (every 4 hours) once the blood glucose concentration has stabilized.

    hyperglycemia, caused by insulin resistance in the liver and muscle, is a common finding in intensive care unit (icu) patients. it can be considered an adaptive response, providing glucose for the brain, red cells, and wound healing, and is generally only treated when blood glucose increases to > 215 mg/dl (>12 mmol/l). conventional wisdom in the icu has been that hyperglycemia is beneficial and that hypoglycemia is dangerous and should be avoided. this concept has been challenged recently, and controlling blood glucose levels by intensive insulin therapy decreased mortality and morbidity in surgical critically ill patients.

    from: http://www.ihi.org/ihi/topics/criticalcare/sepsis


    you said that the nurses say that this patient is circling the drain, and that's very sad, because although the mortality rate is very high from sepsis, the outcomes have been proven to be better for those patients who have a nurse that recognizes the symptoms early and gets very aggressive with the fastest interventions possible.

    so you're learning something very important and very valuable as you care for this patient.
    Last edit by UM Review RN on Sep 16, '06
  8. by   2007_RN
    Wow! Valuable help! Thank you so much (Both of you!) What treaures you are to students!

    Cher
  9. by   Daytonite
    i hate to throw another monkey wrench in the works here, but. . .i have a few thoughts for you.

    any diagnoses beginning with the words "risk of" are anticipatory problems and should be placed at the bottom of your nursing diagnosis listings. that is in the nanda guidelines.

    agree with mlos. you can combine #4 and #6 into one nursing diagnostic statement.

    switch #7 with #8. nutrition takes priority over movement on maslow's pyramid in the physiological tier. no food results in a dead patient who isn't going to be moving anywhere. bad way to explain this, i know, but food is more important than movement when it comes to basic needs to sustain life. however, i don't know that your nursing diagnosis #8 is a good diagnosis for you to use, and i will tell you why. the nanda definition of imbalanced nutrition: less than body requirements is "intake of nutrients insufficient to meet metabolic needs" (nursing diagnoses: definitions & classification 2005-2006, nanda, page 126). the cause, or etiology, of this, per nanda, same page on the above referenced source, is the "inability to ingest or digest food or absorb nutrients due to biological, psychological, or economic factors". that doesn't sound like the case with your patient unless you have assessment data to support that.

    in addition, i don't agree with you about low albumin being a symptom of imbalanced nutrition. there would be other indicators of the imbalanced nutrition such as weight loss, mechanical difficulties with swallowing, not wanting to eat, or lack of interest in food to list a few. low albumin ties in to the endocrine system when it comes to the transport and circulation of lipid-soluble hormones, estrogen being the primary one that depends on albumin. i don't see that as a particular need for this patient. the bigger question i see, however, is why, or how, is this patient losing his plasma proteins? low albumin levels are more likely to be related to cardiac or renal dysfunction. low albumin (albuminemia) can be used as one of the defining characteristics (an aeb) of your excessive fluid volume diagnosis since his edema is undoubtedly, in part, due to his low albumin levels. does this patient have anasarca? you mention he has edema. is this edema throughout his body?

    if the patient is already septic, then i can see a better way to take care of any problems with the decubitus ulcer by combining it with the sepsis. i would use ineffective tissue perfusion: cardiopulmonary and peripheral r/t decreased systemic vascular resistance for the sepsis and the decubitus. the supporting symptoms would be blood culture results (i assume that's how the sepsis was confirmed), the hyperthermia and delayed healing in the decubitus ulcer because of the presence of edema.

    this is the way i would sequence the nursing diagnoses:
    1. impaired gas exchange
    2. ineffective breathing pattern
    3. decreased cardiac output (#4 and 6 combined)
    4. ineffective tissue perfusion
    5. excessive fluid volume
    6. activity intolerance
    7. risk for aspiration
    i was wondering if there was some reason why you didn't post your thread on one of the nursing student forums? the only reason i happened to find your post was because i did a search for any recent posts for the keyword "nanda". i do this periodically looking for students who need help with care plans or nursing diagnoses.
  10. by   rn/writer
    Quote from 2007_RN
    All right I have gone into total and complete brain fry! I have written this awesome case study on a patient and have all of the RN diagnoses but just can't seem to figure out the BEST order. Could ya help??? I know Maslows and I know ABC's...Just can't seem to figure this out because they are all physiological.

    History: This guy is 65 years old, End stage COPD, 152kg. Came into ER in respiratory failure and intubated. Found to be in SVT and electrocardioverted. He had pleural effusion and the CT scan showed a suspicious mass in his chest. Thoracotomy performed and 1 liter of adipose tissue was removed from his pleura. That was back in mid-July. He is still in the ICU with hyperthermia, still intubated and switched to a trach at the end of August
    Can you help me put these in the right order?


    1.) Impaired gas exchange related to ventilation/perfusion mismatching or pulmonary shunting as evidenced by low PO2 & high CO2 in ABG and adventitious breath sounds on auscultation. (Respiratory)

    2.) Risk for aspiration related to dysfunction of normal protective mechanism (cough reflex) due to high levels of sedation. (Respiratory)

    3.) Ineffective breathing pattern related to musculoskeletal fatigue as evidenced by unsuccessful weaning of mechanical ventilation. (Respiratory)

    4.) Decreased cardiac output related to alterations in preload as evidenced by impaired tissue perfusion (edema, decreased urinary output) (Cardiac)

    5.) Excessive fluid volume related to renal dysfunction as evidenced by third spacing in the extremities and crackles auscultated in the lungs. (Cardiac)

    6.) Decreased cardiac output related to changes in afterload as evidenced by labile blood pressures. (Cardiac)

    7.) Activity intolerance related to imbalance between nutritional supple and illness demand as evidenced by increased blood sugars. (Endocrine)

    8.) Imbalanced Nutrition: Less than body requirements related to increase in metabolic demands evidenced by low albumin. (Endocrine)

    9.) Risk for infection due to circulatory changes and delayed healing of decubitus ulcers and post chest tube site. (Endocrine)
    I've been out of school for a while, but we were taught that any nursing diagnosis we came up with had to be something that we as nurses could do something about. If nurses couldn't provide any action that would address the diagnosis, then it was viewed as a medical diagnosis.

    Even though these look like pretty accurate assessments of this poor man's condition, some of these diagnoses seem more medical in nature than nursing-related.
  11. by   augigi
    Agree the endocrine issue is hyperglycaemic control related to sepsis.

    Sounds like the guy needs some decent respiratory care, and someone needs to find a source of infection - the hemodynamic lability would definitely make me highly suspicious that he has an infectious process going on..

    Sorry that didn't help with your care plan though
  12. by   UM Review RN
    Quote from rn/writer
    I've been out of school for a while, but we were taught that any nursing diagnosis we came up with had to be something that we as nurses could do something about. If nurses couldn't provide any action that would address the diagnosis, then it was viewed as a medical diagnosis.

    Even though these look like pretty accurate assessments of this poor man's condition, some of these diagnoses seem more medical in nature than nursing-related.

    True, Miranda, I did give medical information because the sepsis problem wasn't mentioned until later. It's the medical dx that makes everything else going on with this patient make sense, so I thought it best to provide a little info on the subject.

    Sepsis is a very challenging situation but a great learning experience. We've all seen that a sepsis dx is not usually the primary dx when a patient is admitted and how crucial it is to put all those symptoms together and get prompt interventions going.


    I always found it a bit easier to decide which nursing dx's to use when I had the patho down.
  13. by   leslie :-D
    Quote from Angie O'Plasty, RN

    Sepsis is a very challenging situation but a great learning experience. We've all seen that a sepsis dx is not usually the primary dx when a patient is admitted and how crucial it is to put all those symptoms together and get prompt interventions going.
    i apologize but please allow me to get ot for a bit. maybe it will tie in w/the ops' care plan anyway.

    what does a ncp look like for one w/sepsis?
    icu nurses, care to educate?
    i ask, because when my mother was transferred to the icu for sepsis- yes, she was vented, had 3 or 4 different pressors going, a few abx, tpn, albumin, blood....the nurses worked non-stop on her for 2 wks.
    so while they are doctors' orders- it's the nurses who maintain these patients.
    they are continually titrating gtts and putting out fires.
    i was w/her for days, went home for a few and was called back because she had deteriorated even more.
    her vasculature had collapsed, had gross ascites...i just can't imagine not having a careplan in place.
    the responsiblities of the icu nurse are immeasurable.
    the implications of sepsis would make a remarkable, remarkable care plan.
    but i suppose when one doesn't have personal experience, it would be challenging to write.

    so....any input would be appreciated.
    i for one, would love to be educated.

    leslie
  14. by   UM Review RN
    Quote from earle58
    i apologize but please allow me to get ot for a bit. maybe it will tie in w/the ops' care plan anyway.

    what does a ncp look like for one w/sepsis?
    icu nurses, care to educate?
    i ask, because when my mother was transferred to the icu for sepsis- yes, she was vented, had 3 or 4 different pressors going, a few abx, tpn, albumin, blood....the nurses worked non-stop on her for 2 wks.
    so while they are doctors' orders- it's the nurses who maintain these patients.
    they are continually titrating gtts and putting out fires.
    i was w/her for days, went home for a few and was called back because she had deteriorated even more.
    her vasculature had collapsed, had gross ascites...i just can't imagine not having a careplan in place.
    the responsiblities of the icu nurse are immeasurable.
    the implications of sepsis would make a remarkable, remarkable care plan.
    but i suppose when one doesn't have personal experience, it would be challenging to write.

    so....any input would be appreciated.
    i for one, would love to be educated.

    leslie
    i learned to look for sepsis whenever a patient's bp was low and they simply didn't seem to be improving. the s/s are very vague at times, and this is difficult to diagnose. therefore, why it is so important for us nurses to be aware of the constellation of symptoms, because early intervention is so crucial.

    i also had an opportunity to identify a relative who was septic--his wife and i were talking on the phone. i could hear him in the background saying nonsensical things, when normally he was a/o x3. she thought maybe he'd had a stroke or was getting more forgetful. i had her take his temp--it was 103. had her call 911 and get him to er. he was uroseptic. i was quite surprised that he survived as he has end-stage ms.

    anyhow, that prompted me to learn more about it, and there are some excellent resources available now that there is a campaign to identify and treat sepsis victims.

    here are the websites i found. some of this stuff was over my head to a certain degree, but still i think i picked up on enough to get the gist of it.

    http://www.sepsis.com/index.jsp

    http://www.ihi.org/ihi/topics/criticalcare/sepsis/

    if i find any more of these, leslie, i'll just pm them to you.

    to the op: as i mentioned earlier, you might feel that some of these articles are a little too medical in nature or a little over your head right now, but try reading them, even if you have to struggle a little, or better yet, i'd print out a couple and ask your instructor to go over them with you all, because this is a very important problem among our patient population and you will be seeing a lot of this in your career.

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