help with daignosis

[caroline ames]

Can anyone please help me out? I am racking my brain to come up with a nursing diagnosis for my patient. Her admitting diagnosis was acute renal failure. She was on tele in a sinus rhythm with a rate of 98. She had no edema an output of about 50 ml /hr lungs clear afebrile, no edema. basically she had none of the things you would expect to find in a renal patient. Her morning labs came back with a critical ca++ level of 5.7 we contacted the Dr. who ordered calcium gluconate stat. She became shaky , disoriented and had a seizure before we could get the calcium hung luckily I was keeping a close eye and was able to call a rapid response immediately. The only cardiac change was during her seizure she was sinus tachy at 102-110. Please help!!!!! Thanks

[NurseInTheD]

Some ideas...

Risk for injury (r/t seizure activity)

Risk for cardiac dysrhythmia (r/t myocardial irritability secondary to hypocalcemia)

[Daytonite, BSN, RN]

there is a sticky thread with information and examples of how to develop nursing diagnoses on allnurses here:

https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

a care plan is a determination of the patient's nursing problems and is based on their responses to their medical disease. we use the nursing process as a tool in helping us determine what those problems are and follow the steps in the order that they occur.

step 1 assessment - assessment consists of:

• a health history (review of systems) - none provided
  
• performing a physical exam - the only physical assessment data you have provided is that the patient was shaky, disoriented, had a seizure, had sinus tachycardia of 102-110 and bad urine output of output of about 50 ml /hr which is not abnormal.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) none provided
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition since this patient was admitted with acute renal failure and also has hypocalcemia both conditions should be researched, their pathophysiologies looked and signs and symptoms checked. the pathophysiologies are needed to be known for the construction of nursing diagnostic statements. you also want to confirm that you did not miss noticing any symptoms in the patient. i have seen hypocalcemic patients before. did this patient have muscular spasms? they are very painful.
  
  • http://www.merck.com/mmpe/sec17/ch233/ch233b.html - acute renal failure
    
  • http://www.merck.com/mmpe/sec12/ch156/ch156g.html - hypocalcemia
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - ????

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data -

• tachycardia of 98 (admission)
  
• sinus tachycardia at 102-110
  
• critical ca++ level of 5.7
  
• shaky
  
• disoriented
  
• seizure
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses

• decreased cardiac output
  
• activity intolerance
  
• imbalanced nutrition: less than body requirements
  
• acute confusion
  
• risk for injury
  

[caroline ames]

Thank you so much this has been very helpful. We are not allowed to use "risk for" diagnosis ,activity intolerance etc. as our instructor views them as too common.

[Daytonite, BSN, RN]

I don't see "Risk for" diagnoses as "common". They tell me that the nurse isn't thinking. "Risk for" diagnoses mean the nurse isn't finding any nursing problems in the patient. Why then is the patient in the hospital if they need no nursing care? I would tell people that if you have to back into a care plan, at least think about what nursing problems go with the nursing care that is being done for the patient. It's kind of illogical, but it gets you there. If you then go back and look at how to do it using the nursing process it will help you learn the more logical way of thinking these problems through. It is why I am always doing Step #1, Step #2, Step #3 to help get people thinking about the nursing process.

Keep working at this. It gets easier. Best wishes to you.

[caroline ames]

I agree that in practice we must consider at risk for diagnosis to optimize patient care.to be a good nurse our job is to prevent complications. we are just not allowed to use them for the assignment. Thanks so much!!!