Help Revising Diagnoses Please!

[MJ_14]

So, my patient was admitted for TDRF following a subarachnoid hemorrhage. He was found unconscious in his home after a fall. He has a medical history of schizophrenia, bipolar disorder, chronic kidney disease, seizure, diabetes insipidus, subdural hematoma.

Although he was admitted for TDRF, he is now on a ventilator with full support. He obviously still has a trach collar. He has a sacral wound and wounds on both heels, 1+ pitting edema in both feet, zero movement in both legs and right arm; left arm is the only one that moves, although it's very limited due to its contraction. He doesn't communicate, but can sometimes track you with his gaze. He was incontinent of bowel and had a condom cath. He also had a temp of 94.5 degrees. Hopefully, I didn't forget anything.

We are to come up with 6 diagnoses, one being deficient knowledge r/t ----. Here'es what I've come up with so far:

Ineffective airway clearance r/t presence of secretions AEB diminished breath sounds, inability to cough, dysphagia, purulent secretions on and around trach collar.

Risk for aspiration r/t impaired swallowing, depressed cough, decreased LOC, weakened muscles.

Impaired verbal communication r/t decreased cognitive function AEB disorientation to person, place, time, inability to follow verbal commands, dysphagia, muscle weakness, schizophrenia, bipolar disorder.

Impaired skin integrity r/t prolonged bed rest AEB sacral wound, heel wounds, Z-Flo boots, Dolphin bed, Z-Flo positioner.

I need one more diagnosis + the deficient knowledge (which I will figure out after reviewing my notes from the day). Here are my potentials:

Ineffective Thermoregulation r/t decreased amount of subcutaneous fat OR decreased hypothalamic function secondary to brain injury?? AEB low temp of 94.5.

Impaired physical mobility r/t decreased LOC AEB brain trauma, passive ROM, inability to bear weight.

What do you guys think thus far and what would you suggest? Any help is appreciated!

[nurseprnRN, BSN, RN]

i think your faculty is doing an awesome job. excellent work.

i'd be worried about the temp problem because it's got other implications but the immobility thing is clearly an issue if he already has skin breakdown.

what kind of knowledge deficit is this man ever going to be able to remediate? is there family whose knowledge deficit can be helped?

[Esme12, ASN, BSN, RN]

Was that temp rectal? If it was that is a real big issue for his thermoregulation and he is already suffering from hypothermia. I have to admit.....what is TDRF?

[nurseprnRN, BSN, RN]

yeah, i meant to ask that too. what is tdrf?

[MJ_14]

Hey guys! His family was noncontributory, so I, too, was a little baffled with the patient teaching/knowledge deficit. It's hard to say what exactly he can and cannot understand since he cannot communicate with me, you know?

His temp was taken in his ear and TDRF stands for tracheostomy-dependent respiratory failure, which was due to the subarachnoid hemorrhage from his fall. He is now back on a ventilator with full support.

Since I couldn't exactly figure out why he would have a low temp, I went ahead with the impaired physical mobility as my last diagnosis.

Any other questions or suggestions for me?

[Esme12, ASN, BSN, RN]

Well it would depend on where the bleed was, how much swelling there was, if there was a shift of the brain from the bleed and where residual damage remains. If it affected the thermoregulatory parts of the brain it would affect the ability to maintain normothermia. Some patients develop malignant hyperthermia other lose the ability to maintain their temp and will drift downwards to ambient temperature of the room. These patients of course have poor outcome. But the temp must be a core temp.