Need some help prioritizing my Dx's

nixonk86 · Dec 5, 2014

Difficult to answer being unsure of what you have been taught in this subject but consider lithium toxicity as this could contribute to many of the patients symptoms and anyone on lithium needs their levels checked. With an elevated creatinine the patient could have acute renal impairment which will increase lithium levels, also lithium can contribute to renal impairment.

Something I would like to know is what benzos did the patient overdose on and what is their half life? Are some of the symptoms due to high levels of benzos still on board? Do they need to be reversed with flumazinil (although the benzos may be preventing further ETOH withdrawal)

Esme12, ASN, BSN, RN · Dec 5, 2014

Is she only at risk for suicide? Why did she take the benzos? Is she actively suicidal? Know the effects of Lithium.....could this have had an effect on the NA level? Lithium: Drug Uses, Dosage and Side Effects - Drugs.com

Care plans are all about the patient assessment. What the patient needs right now. Where they in the hospital? Are they living in long term care? Where did you meet the patient?

If this is an actual patient....what is your assessment? What were the vital signs? What did the patient complain of? Are the ambulatory? How are they at performing their ADL's?

Here is my normal speech.....You have fallen into the trick bag that many nursing students do....picking a diagnosis then trying to fit the patient into that diagnosis.

All care plans are based off of the patient assessment... Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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: ADPIE

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)

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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 is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

A nursing diagnosis statement sounds like this.....from our GrnTea

"I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

Esme12, ASN, BSN, RN · Dec 5, 2014

Care plans are prioritized by Maslows....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.

Maslow's Hierarchy of Needs | Simply Psychology

Esme12, ASN, BSN, RN · Dec 5, 2014

Maslow believed that there are needs are similar to instincts and play a major role in motivating behavior. Physiological, security, social, and esteem needs are deficiency needs (also known as D-needs), meaning that these needs arise due to deprivation. Satisfying these lower-level needs is important in order to avoid unpleasant feelings or consequences.

Maslow termed the highest-level of the pyramid as growth needs. Growth needs do not stem from a lack of something, but rather from a desire to grow as a person.Maslow's Hierarchy of Needs | Simply Psychology

Five Levels of the Hierarchy of Needs
There are five different levels in Maslow’s hierarchy of needs:
Physiological Needs
These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.
Security Needs
These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health care, safe neighborhoods, and shelter from the environment.
Social Needs
These include needs for belonging, love, and affection. Maslow described these needs as less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.
Esteem Needs
After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.
Self-actualizing Needs
This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

Workplace recovery strategies for a changing world

Esme12, ASN, BSN, RN · Dec 5, 2014

Now....if she took the benzos as a suicidal ideation I would think her safety is paramount. If she is on Lithium I would think hypernatremia/electrolyte imbalance would be priority as well. If she is lethargic I would think that she is at risk for airway issues.

here are 6 major electrolytes. Sodium, potassium, calcium, chloride, magnesium and phosphorus. It is primarily potassium, calcium and sodium that will cause problems when they are out of whack.

hypokalemia
hyperkalemia
hypocalcemia
hypercalcemia
hyponatremia
hypernatremia

When there is a sodium imbalance quite often there will be changes in mental status - confusion, delirium, etc. Often seen with traumatic brain injury where diabetes insipidus (pathological voiding of large amounts of dilute urine) and its opposite SIADH (syndrome of inappropriate antidiuretic hormone - minimal urine output but very concentrated) may occur. Sodium imbalances are also seen with dehydration in some patients (elderly, burn victims, many others) and the blood levels will go up. Very rarely, sodium levels in the blood will go down because of consuming large quantities of fluids.

The other main electrolyte imbalance seen is when potassium is out of whack, and its most serious consequence is cardiac problems that can be life-threatening (you will see T wave changes: depression with hypokalemia, elevation with hyperkalemia, among other changes in the EKG like QRS interval changes).

For these 2 main electrolyte imbalances remember: Sodium equals mentation, and Potassium equals cardiac.

Sodium does affect fluid. In fact, they say sodium always follows water. There are a lot of people with edema related hypernatremia; and a lot of dehydration related to sodium and chloride losses. Potassium tends to affect the heart and in the clinical area you will see dramatic instances of people with hypokalemia and hyperkalemia. Calcium affects the muscles and is not as commonly seen clinically because it is detected because of lab testing.

Sodium - body water balance
Potassium - contraction of skeletal and smooth muscle and nerve impulse conduction
Calcium - formation and structure of bones and teeth, cell structure and function, cell membrane permeability and impulse transmission, the contraction of all muscle types and is necessary in the blood clotting process
Chloride - important in the digestive acids; closely linked to sodium
Magnesium - affects nerve and muscle action by affecting calcium usage, activates enzymes involved in carbohydrate and protein metabolism, helps in the transport of sodium and potassium across cell membranes, and influences the levels of sodium, potassium, calcium and some body hormones (parathyroid hormone)
Phosphorus - formation and structure of bones and teeth, this electrolyte is needed in the following activities: utilization of B vitamins, acid base homeostasis, bone formation, nerve and muscle activity, cell division, the transmission of hereditary traits, metabolism of carbohydrates, proteins and fats
http://www.elmhurst.edu/~chm/vchembook/253fluidkidneys.html

Esme12, ASN, BSN, RN · Dec 5, 2014

Here is my assessment and my Dx's
53 y/o female, ETOH withdrawal and benzodiazepene overdose. Hx: Bipolar 1 disorder, known to hospital psych unit, previous suicide attempt
Vitals: 147/100 (baseline for her), RR 20 breathing is deep and even, temp 98.5, SpO2 99%, PR 80
Meds: Lorazepam PRN for SAS >5, Lithium, Levothyroxine, D5W 1/2 NS
Labs indicated Hypernatremia (I don't remember the exact values, sodium and creatinine elevated)
Admitted overnight for benzo overdose, was on O2 but the order was discontinued in the AM. Modified consistency diet. Oriented to person and time only. She had a 1:1 sitter. Slow to respond to verbal stimuli, responded quickly to touch. Weak and sluggish movements. Hand grasps equal but weak. Could not ambulate on her own, used the bedside commode and needed total care for bathing/tooth care etc. Fall Risk Level 3. Her skin was very dry. Lung sounds were clear. She had a telemetry monitor but no events, normal sinus rhythm.
Nursing Dx's (in no particular order):
1. Risk for Electrolyte Imbalance r/t Hypernatremia aeb serum electrolyte abnormality (sodium)
Interventions: Administering parenteral fluids as ordered and monitoring their effects, monitoring lab values as ordered
2. Risk for Suicide r/t previous suicide attempt aeb an attempt to harm oneself, utilizing mood altering substances
Interventions: Developing a positive therapeutic relationship with the patient, placing patient in the least restrictive, safe, and monitored environment
3. Risk for Injury r/t Sensory Dysfunction, Sedative Drugs aeb difficulty with ambulation, shuffling gait, confusion
Interventions: Helping the patient sit in a stable chair with armrests, maintaining the bed in a low position, ensuring call light within reach, assisting patient to the bedside commode
4. Ineffective Coping r/t Alcohol Dependence aeb abuse of chemical agents, destructive behavior toward self, use of forms of coping that impede adaptive behavior
Interventions: Monitoring the patient's risk of harming self orothers , Providing the patient and his or her familywith needed information regarding conditionand treatment , Referring the patient for additional or moreintensive therapies as needed ,Watching for factors that contribute toineffective coping
5. Acute Confusion r/t alcohol withdrawal delirium, drug abuse aeb Fluctuation in cognition, Increased agitation, Decreased Level of consciousness
Interventions: Assessing and monitoring for acutechanges in cognition and behavior, Keeping the patient's sleep-wake cycleas normal as possible, Treating the underlying cause of deliriumin collaboration with the healthcare team, Involve family members in care
I am leaning toward Ineffective Coping and Acute Confusion as the two to include, but I hate to leave out anything involving safety/risk for injury.
Another part of this project is identifying any diagnostic procedures/surgeries she might need and also "interprofessional care". I know that her blood serum values will continued to be monitored and she will also have a psych eval. As far as identifying other members of the healthcare team being involved, I can only think of psych. Anything else I might be missing?
Any thoughts you guys can share would be greatly appreciated :)

If she is actively suicidal safety is key. If her NA is elevated she is no longer at risk for this. If her husband not supportive there are family dynamics at work here.

What do you think?