Help needed prioritizing NDx. Progressive dementia/hypernatremia

[tarheelsu]

I could really use some help prioritizing nursing diagnoses for my clinical patient from this week. This is my first time putting a post up like this, so please let me know if I leave anything out.

72 year old female history admitting diagnosis of hypernatremia, hypotension, and fever. Other current dx: protein calorie malnutrition (BMI

Other history: seizure disorder, HTN, dyslipidemia, PRES syndrome, probably meningioma, GERD, lower back pain. Hysterectomy.

She was brought to the hospital when her home health nurse couldn't get a BP on her. Then they ran labs on her and found her sodium level to be very high (161). I saw her when she had been in the hospital 3 days.

Assessement:

VS: Temp 99 Ax, Pulse 112, RR 19, BP 116/69 O2 sat 95%

general: Emaciated, frail, disoriented, elderly female laying in bed in fetal position. In no apparent distress when resting.

Neuro: Blind in left eye. Disoriented x 3. Arouses to touch, pain and sound. Obeys commands at times (takes sip from straw, opens mouth for spoon) but at other times does not. Confused. Does not acknowledge son or grandson. Speech understandable at times, but inappropriate. At other times speech slurred and incomprehensible. Grunts frequently. Grips equal and strong.

HEENT: normal except dry mucus membranes

Pulmonary: WNL. On room air. O2 sat 95%.

Cardio: normal except tachycardic. Pedal pulses thready (+1).

GI: WNL except incontinent of stool. BS hypoactive. Last BM the day before, brown and hard.

Renal: WNL except has indwelling cath, inserted on admission. Urine clear yellow, etc.

Musc: normal except very weak and stiff ROM

Skin: normal except skin very rough, flaky and dry. Stage II (just barely) decubitus ulcers on right and left sacrum.

She screams in pain whenever she is moved. She can't use the pain scale. She is completely immobile, can't turn herself in bed, etc.

Orders:

BG Q6H

VS Q8, neuro checks Q2

strict I&O

puree diet with thin liquids. 1:1 feed.

Bed rest

Titrate O2 to keep above 92%

1/2 NS at 125 mL/hr

Foley.

Seizure and aspiration precautions.

Labs:

WBC: 12.H

RBC: 3.07L Hcb: 8.8L Hct: 26.9L

Glucose: ranges from 206-170

Bun and creatine were high on admissin, but normal now

Sodium: 148H

Potassium: 3.1L

Chloride: 117H

TSH: 0.326L

CK/CPK: 220, 344, 342 - run 8 hours, then 6 hours apart

Clean catch urine showed infection with gram neg rods

Urine positive for ketones, high protein, WBCs

Head CT showed no acute pathology.

CXR: showed right lower airspace disease, likely pneumonia.

Meds: cefriaxone 1 gm IVPB Q24, heparin 5000 units SQ Q8H, insulin lispro sliding scale Q8H, Flagyl 500 mg IVPB Q8H, Potassium PO 40 mEq Q24H x 2 doses, oxycodone 2.5 mg PRN Q8H for pain.

So with all of that background, I've come up with tons of diagnoses, I'm just having a hard time prioritizing them.

She doesn't have any airway issues. Breathing, she seems fine, even though she likely has pneumonia. Circulation:

Decreased cardiac output r/t decreased plasma volume and poor cardiac contractility

Deficient fluid volume r/t inadequate fluid intake

Then outside of that:

Imbalanced nutrition: less than body requirements r/t to inability to ingest or digest food

Impaired mucous membrane r/t ind inadequate oral secretions

Chronic confusion r/t neurologic changes secondary to dementia

Hyperthermia r/t an increased metabolic state secondary to infection

Impaired skin integrity r/t malnutrition and immobility secondary to decubitus ulcers

Impaired verbal communication r/t aphasia

Total urinary and bowel incontinence r/t cognitive and self care deficits

Total self-care deficit r/t cognitive deficit

impaired physical mobility r/t neuromuscular impairment

acute pain r/t ???

risk for injury r/t potential for seizures secondary to hypernatremia and history of seizures

Her fluid balance seemed to be pretty much in control while I was there, she took in 1000 mL by IV, approx 500 oral water and juice, urine output: 900 mL total over shift. The main issue I dealt with was trying to get her to eat. I was able to get her to eat about 1/3 of her breakfast and no lunch and then 2 little cups of applesauce in the afternoon. Since she is completely bedridden, I had to turn her frequently and she screamed with pain when I did this and almost seemed to contract up into a ball when moved.

Thanks so much for the help!

[darlink]

I would start with pain as my priority. First thing I would do is get better orders for pain meds so you can pre-medicate prior to every turn.