Hi, we have our second care plan due this Thursday. My lady is an 87 year old woman with end stage alzheimers disease who cannot communicate and is completely immobile due to contractures of her arms and legs. She is incontinent of bowel and bladder. She has a PICC line for TPN. She is NPO. she has had several fevers and the nurse gave her Tylenol rectally. she had a CBC done and came back with slightly elevated WBC and neutrophils. I looked all through her chart and could not find any mention of infection. She also has mild CHF and slight wheezing upon inhalation. Her HR is 112 and her respirations are 32. We have to have two physiological and one psychosocial nursing diagnosis.
I came up with
Powerlessness related to irreversible progressive degenerative neurological dysfunction secondary to end stage alzheimers disease aeb inability to communicate, complete immobility due to contractures of arms and legs.
risk for infection related to picc line
risk for impaired skin integrity related to complete immobility
Hyperthermia related to infection of unknown origin manifested by temperature of 102.4 F.
I'm not sure of my nursing goals for the powerlessness because she won't make any improvements. Is there a better psychosocial nursing diagnosis I should be using? and which risk for is more important? Im so confused! Any help would be GREATLY appreciated! thank you :)
from everyone's help Im going to use these diagnosis
hyperthermia r/t infection of unknown origin aeb oral temperature of 102.4
risk for compromised human dignity r/t degenerative progressive neurological dysfunction secondary to end stage Alzheimer's disease.
I would like to use impaired gas exchange, but her o2 sat is 95% ( with oxygen). and wouldn't I have to have her abg?
if I did use that Im thinking
Impaired gas exchange r/t tachypnea and wheezing upon inhalation secondary to mild chf aeb respirations of 32 breaths per minute and shallow labored breathing.
she has mild chf, I forgot to mention that. she's only my second patient! I appreciate all of the help, our teachers way of teaching is kind of just do it and ill tell you everything you did wrong! and btw grn tea I am getting my book tomorrow, im sure it will help A LOT thanks
I would like to use impaired gas exchange, but her o2 sat is 95% ( with oxygen). and wouldn't I have to have her abg?
if I did use that Im thinking
Its almost impossible to formulate your statement without either a care plan book, or textbook with specific Nursing diagnosis criteria, etc....
Impaired gas exchange r/t ...what is happening inside the body causing a disturbance in gas exchange at the cellular/tissue level? ...secondary to...what disease process is causing such a problem...AEB....data
If the patient needs oxygen, then there is something going on that is impeding the exchange of oxygen into the blood and possibly CO2 from exiting. Altered ABGs is not the only indicator for this diagnosis.
Remember, a medical diagnosis cannot be used as a r/t factor.
I would like to use impaired gas exchange, but her o2 sat is 95% ( with oxygen). and wouldn't I have to have her abg?
No. See defining characteristics, below.
Impaired gas exchange r/t tachypnea and wheezing upon inhalation secondary to mild chf aeb respirations of 32 breaths per minute and shallow labored breathing.
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Once again, "related to" has a very specific meaning: caused by. This lady does not have impaired gas exchange caused by tachypnea and wheezing. Why is her gas exchange compromised? What is gas exchange, anyway? Where does it happen, and why?
There are two, and only two, related factors approved for this nursing diagnosis, and they are
1) alveolar-capillary membrane changes or 2) ventilation/perfusion imbalance. Do you know why congestive heart failure causes tachypnea and wheezing? Are either or both of these involved? What did you learn in your pathophysiology course about that?
There are many defining characteristics for this diagnosis, of which abnormal ABGs are one, but it is not the only one and it is not required to make the diagnosis. You have, by my count, 18 other choices. Those are your "as evidenced by" choices. Dyspnea is one of them, as is "abnormal breathing, e.g. (which means "for example") rate, rhythm, or depth. It seems to me that is what you are assessing.
Waitaminnit... you are in LVN school? You can't make nursing diagnoses as an LVN anyway, according to the ANA Scope and Standards of Practice that is an RN function. I am glad they're at least exposing you to it, but ... that's one reason it's so hard for you.
also...a slight increase in WBC usually indicates inflammation. A large increase in WBC usually indicates infection.
Not always, she may be on an immunosuppressant or steroid medication. If she is on predisone and has a slight increase in WBCs, such as 7 to 9, that is a concern.
and btw grn tea I am getting my book tomorrow, im sure it will help A LOT thanks
samanthaAnn2014
6 Posts
from everyone's help Im going to use these diagnosis
hyperthermia r/t infection of unknown origin aeb oral temperature of 102.4
risk for compromised human dignity r/t degenerative progressive neurological dysfunction secondary to end stage Alzheimer's disease.
I would like to use impaired gas exchange, but her o2 sat is 95% ( with oxygen). and wouldn't I have to have her abg?
if I did use that Im thinking
Impaired gas exchange r/t tachypnea and wheezing upon inhalation secondary to mild chf aeb respirations of 32 breaths per minute and shallow labored breathing.
ps. she does not have a foley cath