I need help with prioritization.

Liebchen · Mar 1, 2012

Ok, I am thinking, because his admitting DX was cellulitis and this is giving pain, this must be addressed first.

So, I have come up with: Ineffective tissue perfusion r/t edema aeb redness, blisters and pitting edema.

I am thinking that he has a knowledge deficit or non-compliance r/t his diabetes. Am I on the right track at all?

Blue Cat · Mar 1, 2012

I think you should focus on the fluid volume excess. I had a patient with cellulitis in clinical last semester and made pain my priority dx and my instructor wanted me to focus on the FVE. Look up cellulitis in your care plan book and it should list some potential nsg dx's for that. Hope this helps....

Blue

Liebchen · Mar 1, 2012

Thank you Blue...looking it up now.

MattNurse, MSN, RN · Mar 1, 2012

"So do I concentrate on the cellulitis part of his problems? Do I address his diet? Hypertension? lack of activity? They are all so closely related, I don't know where to start? They all seem so very important."

Ask yourself, why is he in the hospital? What is the most acute issue that needs to be resolved? To me from reading your list he has a lot of problems as his baseline.

Cellulitis is going to provide you with several nursing diagnosis:

Infection (you need to be concerned w/ his kidney function w/ certain antibiotics commonly used to treat cellulitis as well)

acute pain related to inflammatory process

ineffective tissue perfusion related to severe edema

impaired skin integrity

-My concerns when I have someone with severe cellulitis is that they will become septic, SIRs, MODS, shock (among other things)

His BMI provides you with imbalanced nutrition: more then body requirements. Sounds like you could do Ineffective health maintenance. His obstructive sleep apnea can be gas exchange issues (airway).

I didn't assess patient, but do you think he is becoming septic? YOu wrote in past medical history that he has "Chronic Kidney disease stage lV" then wrote "He says, he is not having trouble with his kidneys and never has, and that the Dr. has never addressed this issue with him." Is he not coping with his disease state? like denial?

What was his albumin, his H&H, WBC's? Is he afebrile? Are all of his vital signs stable?

If his blood pressure is stable on antihypertensives then I would say don't address that issue. You probably cannot address his obesity in the long term during an acute hospital stay, except for maintaining a heart healthy, low calorie diabetic diet. Lack of activity is not going to be addressed until you resolve the priority of cellulitis (pain, infection, tissue perfusion).

Blue Cat · Mar 1, 2012

I just re-read your OP and I think you should disregard my input! I just saw that your pt doesn't have any renal issues and mine did, so that may be why my instructor wanted me to address the FVE. Sorry for any confusion.

MattNurse, MSN, RN · Mar 1, 2012

I don't think fluid volume excess is a bad idea.... patient is close to dialysis with that potassium and GFR. Also with heart disease and all the edema.

How did his lungs sound? Does he have effective gas exchange on room air?

Guy sounds like a mess and if it were me I would prioritize pain highly as cellulitis is very painful, but pain usually doesn't kill someone.

Liebchen · Mar 1, 2012

Thank you very much. This is really making me think. Blue, he does have serious renal issues, but as MattNurse stated, he is apparently in denial as it has been addressed in his chart over and over and throughout the years. He is in a VA facility and has been there for almost two months. After a team meeting, it was decided that no discharge would happen until his cellulitis was under control. He was invited to the team meeting, but would not come. All of his functional assessments, mini-mental and depression scale showed slight depression. He won't socialize with the other patients either. He sits in his room all day and watches tv. His vitals are fairly decent. BP running just a little high 135/85 sometimes lower. Temp is good. His legs are getting better. GFR keeps getting lower and that was one of my biggest concerns. When I started caring for him 8 weeks ago, his GFR was in the 40's, and now, it is 29. BUN and Creatinine is also steadily increasing. He is beginning to get nauseated several times per day.

You gave me a lot to think about, and I really appreciate it.

Editing to let you know, that his lungs are clear A&P. Heart sounds S1 and S2 present, no extra sounds noted. no murmurs. No oxygen.

MattNurse, MSN, RN · Mar 1, 2012

Just remember you are still a student and this is a very difficult care plan and a very complicated patient. If you prioritize ineffective tissue perfusion over fluid volume excess or vice versa and your clinical instructor doesn't agree ask him/her to explain their reasoning and you will learn a lot from this patient.

The labs seem classic for someone on the road to dialysis. If the patient is in denial you may be looking at some end of life/palliative care issues beyond the initial diagnosis of cellulitis.

Liebchen · Mar 1, 2012

Thank you so very much, for your input. It really helps me to start my thinking process, when I have things thrown out there. We needed 3-5 nursing dx. Now, I have come up with several more.. this will be a very good thinking process for me.

Thank you for all your help.

Liebchen · Mar 1, 2012

Ok, I have taken what you said, and I have written four DX. I think I have them prioritized correctly. Can you critique? I know you said that I should address the patients pain so I am thinking that should be top on the list, after infection. I was a bit confused, though, should I address the fluid volume, which would then take care of some edema which may reduce pain and infection? Oh my goodness.... This is why I stink at this. But then, an at risk diagnosis would not be priority, would it?

1.) Risk for infection r/t or impaired tissue integrity r/t alterations in fluid volume aeb severe peripheral edema.

2.) Acute pain r/t inflammatory process aeb patients refusal to walk and statements that he is in pain.

3.) Fluid volume excess secondary to renal failure aeb peripheral edema, elevated BUN and Creatinine and decreased GFR.

4.) Imbalanced nutrition: more than body requirements aeb BMI of 52.4

Esme12, ASN, BSN, RN · Mar 1, 2012

ok, i have taken what you said, and i have written four dx. i think i have them prioritized correctly. can you critique? i know you said that i should address the patients pain so i am thinking that should be top on the list, after infection. i was a bit confused, though, should i address the fluid volume, which would then take care of some edema which may reduce pain and infection? oh my goodness.... this is why i stink at this. but then, an at risk diagnosis would not be priority, would it?
1.) risk for infection r/t or impaired tissue integrity r/t alterations in fluid volume aeb severe peripheral edema.
2.) acute pain r/t inflammatory process aeb patients refusal to walk and statements that he is in pain.
3.) fluid volume excess secondary to renal failure aeb peripheral edema, elevated bun and creatinine and decreased gfr.
4.) imbalanced nutrition: more than body requirements aeb bmi of 52.4

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

so your patient is obese (imbalanced nutrition > than needs, knowlege deficit, body image) , has an infection in his le, (impaired mobility) he complains of pain(acute pain/chronic) he has lower extremity edema and abnormal renal function....whether he admits it or not(knowlege deficit. he lacks insight to his disease and disease process

http://www.pterrywave.com/nursing/care plans/13.aspx

http://www.pterrywave.com/nursing/care plans/15.aspx

http://www.pterrywave.com/nursing/care plans/33.aspx

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality: what you are calling a nursing diagnosis (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).

ok....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans. i have supplied links of examples at the bottom for care plans.

then think...... maslows hierachy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

self-actualization – e.g. morality, creativity, problem solving.
esteem – e.g. confidence, self-esteem, achievement, respect.
belongingness – e.g. love, friendship, intimacy, family.
safety – e.g. security of environment, employment, resources, health, property.
physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.

assumptions

maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
growth needs are the highest level, which is self-actualization, or the self-fulfillment.
maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
self actualized people were reality and problem centered.
they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
they tended to be spontaneous and simple.

application in nursing

maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

i hope this helped:)