Need a little help with this nursing dx....

Daytonite, BSN, RN · Dec 10, 2008

using the nursing process. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

bronchopneumonia
copd (emphysema type) exacerbation
sleep apnea
chronic insomnia
abnormal cholesterol
benign prostatic hypertrophy
neuropathy
326.5 lbs (obese)
71 yr old w m
medical treatment
- oxygen at 2l/min via nc

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of all the abnormal assessment data

o2 sat 92-94% - these are normal sats
sob
resp of 22-24
wheezing
sputum is thick, greenish-white in color
dizziness while standing/walking
weak pulse
skin pallor
+1 edema in ankles & feet bilateral
turgor 3+ - what scale of measurement are you using. i do not recognize this. i searched through 2 medical examination books and found nothing this descriptive of skin turgor. there is a grading scale for pulses and edema that uses 0 through 4+. is this what you are describing? i, honestly, do not know if this is an abnormal finding or not.
abdomen is distended
abdominal tenderness upon palpation
pain rated at 1/10

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

ineffective tissue perfusion, cardiopulmonary, peripheral and gastrointestinal r/t impaired oxygen transport aeb dizziness while standing/walking, weak pulse [need to specify where], skin pallor, bilateral +1 edema in ankles & feet and distended abdomen
ineffective airway clearance r/t chronic obstructive airway disease aeb sob, respirations of 22-24, wheezing and production of thick, greenish-white sputum
acute pain r/t peritoneal fluid retention aeb abdominal tenderness upon palpation with pain rated at 1/10

risk for impaired skin integrity r/t obesity.

i don't follow your thinking here. the risk factors (causes) of impaired skin (skin breakdown) are things such as pressure, moisture, immobilization and shearing. you can see what the others are because they are listed on this web page:

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=48

with obesity, the complications include respiratory problems, hypertension, heart disease, diabetes, sleep apnea (patient already has this), renal disease, and gallbladder disease. obese people have sedentary lifestyles and eat more than they should.

you might want to look closer at his diet and try to diagnose

imbalanced nutrition: more than body requirements

. this patient has already has cholesterol problems which puts him at risk for gallbladder and heart problems.

why does he have the peripheral edema? is he on any blood pressure meds or diuretics? the problem of sleep apnea is that the person's heart can stop beating and they can die in their sleep from the hypoxia. does he receive cpap at night?

LiliyaRN · Dec 10, 2008

your first two dx are great

but you dont seem to have enough evidence to prove or show why you think that obesity will show risk for integrity of his skin...unless there was breakage or excoriation between the folds?

Daytonite, BSN, RN · Dec 10, 2008

impaired gas exchange r/t alveolar-capillary membrane changes aeb sob, dizziness while standing/walking, o2 sat 92-94%, increased respirations, and skin pallor.

this diagnosis is specifically referring to what happens because of oxygen and carbon dioxide not being able to be effectively exchanged in the alveoli. review the definition and defining characteristics of this diagnosis here:

"short of breath" is only one symptom, but it is the symptom of other respiratory problems as well. "dizziness while standing/walking" has to do with

perfusion

of blood and oxygen to the brain. your "o2 sat 92-94%" are within normal limits and not abnormal at all so they cannot serve as a defining characteristic (symptom). the "increased respirations" is

not

a symptom of this diagnosis; respirations are increased

all the time

when there is hypoxia. the "skin pallor" is a result of the blood not carrying enough oxygen to the tissues and is another

perfusion

problem, not a respiratory problem.

activity intolerance r/t insufficient oxygenation aeb dizziness while walking, and sob.

i'm sorry for not addressing this more specifically in my post. i looked carefully at the all the information you had posted. i would have liked to used

activity intolerance

too, but you just didn't have enough supporting evidence. this man has good o2 sats for one thing. you don't have any actual vital signs that show how his heart, respiratory or blood pressure change with activity which are among the defining characteristics of that diagnosis. people who are activity intolerant can't take more than a few steps or walk a few feet before they start having heaving respirations (sometimes wheezing) heart rates and blood pressures that elevate if the nurses bother to take them before and after, becoming diaphoretic and they tell you they have to sit down because they are not going to be able to make it any further (fatigue). if they are on telemetry they can have ekg changes. you really don't have the evidence to prove that this problem exists. when you see someone like this you won't forget it.

RNnTrainin' · Dec 11, 2008

I should have given you more of the information that I had. When I was thinking of the activity intolerance, when he removed his NC, and was on RA, his sats dropped to 87% or so. He would remove it to walk to the bathroom,etc. As soon as he would get to the br, he would have to rest before taking more action. Then, he would go back to the bed, and have to rest before lifting his feet onto the bed. This fatigue was accompanied with very labored breaths. I did do his vitals before going to the br, and his bp went from 98/64 to 102/68, and respirations went from 22 bpm to 26 bpm O2 dropped from 94 to 87 this particular time. After getting him back in bed and situated and he took the time he needed to calm down, (15-20 mins), bp-R-O2 returned to "his" normal.

As for the Risk for impaired skin integrity r/t obesity....I was in the mind frame that he was pretty much bed bound, he was too large to change positions as he should have, and I was thinking of the stress on the pressure points along with the continually dampened sheets (from some mild sweating). This information I left out as well.

With the Impaired gas exchange, I understand your comments, and now realize I was off on this one completely!! I am struggling so much with these careplans....this pt had so much I could have chosen from, and I drew a blank on all of my options.....thank you so much for your replies. Talking it out helps more than you can imagine!!! I ended up going over these with my instructor this morning, and she helped me out, but I felt very unprepared for clinical, and I don't like not being prepared. I am sure this rookie will get the hang of this in time.....thanks again!!

Daytonite, BSN, RN · Dec 11, 2008

Talking it out helps more than you can imagine!!! I ended up going over these with my instructor this morning and she helped me out, but I felt very unprepared for clinical, and I don't like not being prepared. I am sure this rookie will get the hang of this in time.....thanks again!![/quote']
Yes, it comes with time and experience. Seeing what patients experience also helps. Putting what you see together with what you learn from textbooks also helps. Good luck!