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Discussion

HELP!!! 2/11/09 - 5 Nursing diagnoses and prioritizing. I am new today.

I have a patient that I need to do nursing diagnoses and a care plan for. He is a w 82YOM admitted to a nursing home. Vitals are bp 110/68, p 72 irregular, RR 27, T 97.9, O2 100% with 2L of O2 via nasal cannula. His past medical history is HTN, dysphagia, bradycardia, glaucoma, arrythemia, degenerative disc disease, cardiomegaly, atrial fibrillation, bilateral knee replacement, bilateral cateract surgery, hernia repair, RLS, speech is dysarthric. Urinary retention with enlarged prostate(BPH), Bleeds easily since his CVA s/p left humoral head resurfacing surgery 11/4/08 acute onset of left hemiplegia, right eye deviation, left facial droop. (Right MCA Ischemic attack), broken back several years ago, No atrophy or fasiculations noted, breath sounds are clear to auscultation, 11/25/08 Mild bibaasilar atelectasis pleural effusion, respiratory difficulty, ABG's show pH 7.49, PCO2 of 40, PO2 of 111, hyperlipidemia, restless legs, and hyperglycemia.

His lab results 1/27 shows:

PT 38.4 H

INR 3.8 H

Creatinine 0.51 L

Glucose 125 H

Total protein 6.1

RBC 4.4 L

HGB 13.2 L

HCT 38.0 L

RDW 15.3 H

Urinalysis shows

2+ urine protein

4+ Blood

+ Nitrates

RBC 20-50

WBC 0-2

A couple of nursing diagnoses I came up with are:

Impaired gas exchange r/t pleural effusion secondary to atelectasis

Decreased Cardiac Output r/t Cardiac Arrythemias ssecondary to Atrial fibrillation

I was thinking of an Ineffective breathing pattern, something to do with with Urinary retention. I was also thinking of doing altered sensory perception r/t central vision loss secondary to glaucoma and bilateral cateracts, and a knowledge deficit about decreased endurance and debility,but not sure about the etiology on how to word it.

Am I going about this the wrong way? :idea: Do I need to have other priorities?

Is there anyone who can help me? I would really appreciate it.

Thanks,

LeAnn

Featured Replies

  • Expert

you gave a lot of the patient's history. did you do a physical assessment of the patient other than doing vital signs? did you work with the patient? how is he at doing any of his adls (bathing, dressing, mobility, eating, toileting, and grooming)? what medications have been ordered for the patient? that information needs to be considered before determining any nursing diagnoses.

  • Author

i did do a physical assessment on him.

december he weighed 204, now he weighs 195.2, he is a&ox4, responds to touch, sound, and replys to asked questions. he can do pretty much anything with the right side of his body, but his left arm cant do anything. he is able to feel when i touch his left arm, just cant move it. he is immobile, that morning i used a hoyer lift to transfer him from the bed to the shower chair and w/c. he is able to see out of both eyes, they are intact and jerky with a right gaze deviation. perrla at 3mm. conjunctiva pink sclera white. he is hoh and wears a hearing aid. his breathing patterns were labored, no aventitious sounds heard. crt 3

how is he at doing any of his adls

bathing - i used a hoyer lift to transfer him to the bathing chair and take him to the shower room then showered him.

dressing - i put his clothes on him and used the hoyer lift to stand him up and pull his pants up

mobility - immobile - use hoyer lift

eating - he is able to feed himself using his right arm. that morning he stayed in bed and ate his breakfast, lunch time he went to the self-feeding dining room. he ate breakfast - 100% food 360/ml fluids and lunch - 100% food and 480 ml fluid. he also has a restriction to only drink honey-thickened liquids and is on a puree diet

toileting - he wears a diaper. when he was getting his shower, he had a bm and he didnt realize that he was doing it. a cna asked him if he was done, he said yes and continued to have the bm

grooming - i did everything for him, combed his hair, applied deoderant, lotion of dry skin. he didn't need to shave

what medications have been ordered for the patient? he is on the following medications:

asprin 325mg for stroke prevention

avodart 0.5mg for bph

cozaar 50mg for stroke

colace 100mg for stool softener

nexium 40mg for gerd

sertraline 50mg for depression

warfarin 5mg for atrial fibrillation

mirapex 0.125mg for rls

prn nitroquick 0.4mg for chest pain

ambien 5mg for sleep

flowmax 0.4mg for bph

glycopyrrolate 1mg for decrease gi and rr secretions

lipitor 80mg for stroke

prn albuterol 0.83mg/ml for acute bronchospasm

genebs 325mg for mild pain

prn hydrocodone 7.5mg for severe pain

prn ipratropium nebulizer

mucinex 5mg for mucous/coughing

  • Expert

to choose any diagnosis you must have the evidence to support using it. i went through the data you listed. i will get to the self-care deficits information momentarily. but the other data listed out to this (in order of importance):

  • labored breathing
  • incontinent
  • can't move his left arm
  • has a right gaze deviation
  • hoh

these are symptoms (evidence) of nursing problems. "labored breathing" is vague. when does his breathing get labored? what makes it better or worse?

  • total urinary incontinence r/t neuromuscular impairment aeb unawareness of incontinence
  • bowel incontinence r/t decline in muscle tone and impaired cognition aeb had a bm while being showered, he didn't realize that he was doing it and when asked if he was done he said yes and continued to have the bm.
  • impaired physical mobility r/t neuromuscular impairment and compromised cardiovascular endurance aeb inability to move left arm
  • disturbed sensory perception, visual and auditory r/t neuromuscular impairment and altered sensory reception aeb a right gaze deviation and hoh.
  • bathing/hygiene self-care deficit r/t neuromuscular impairment aeb unable to get to shower room and unable to wash or dry self
  • dressing/grooming self-care deficit r/t neuromuscular impairment aeb unable to put clothing on or take off, unable to put on shoes or socks and unable to take clothes out of closet

i want to address the nursing diagnoses you came up with and point some things out:

impaired gas exchange r/t pleural effusion secondary to atelectasis

there is no evidence of
impaired gas exchange
. and, if there was,
pleural effusion
is not a suitable related factor for this diagnosis. it is, in fact, a medical diagnosis. because this is a physiological nursing diagnosis the related factor has to be connected with the underlying pathophysiology going on. there are only two things it can be for this diagnosis: the alveoli are so damaged by disease that the o2/co2 interchange is compromised (alveolar-capillary membrane changes), or the alveoli are so clogged up with exudates and secretions that the o2/co2 interchange is compromised (ventilation perfusion imbalance).

decreased cardiac output r/t cardiac arrhythmias secondary to atrial fibrillation

again, no evidence of this. no symptoms of the atrial fibrillation.

i was thinking of an ineffective breathing pattern, something to do with urinary retention. i was also thinking of doing altered sensory perception r/t central vision loss secondary to glaucoma and bilateral cataracts, and a knowledge deficit about decreased endurance and debility, but not sure about the etiology on how to word it.

you need more respiratory data. i can't see using urinary retention because how can you determine the symptoms? i did the disturbed sensory perception above. his eye deviation is probably because of his cva. there is no way of knowing what his visual impairment is as a result of his glaucoma unless he is able to tell you. it is still, ultimately, a neuro impairment because the ocular pressure caused by glaucoma damages the optic nerve. and the cataracts are altering the sensory reception. is this man capable of learning? i worked in ltc. the first thing we would try to do with him is get his bowel movements regulated and try to get him continent of stool (bowel training).

i'm sure i have overlooked a few things since this man has many medical conditions. my goal was to put together a few diagnoses to show you how the data that you collected correlated with the nursing diagnoses. every nursing diagnosis has a list of signs and symptoms that belong with it and your patient must match with at least one or two of them.

  • Author

I really appreciate your help. It gave me a lot of understanding about his situation and gave me important things to think about when doing this. I hope one day, this will come as easy for me as it does for you

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