Nursing Diagnoses Help!

[b_howard]

I have a dying patient, and I have to come up with 2 priority nursing diagnoses, 5 goals (for each diagnosis) and 5 interventions for each goal. The main medical diagnosis is renal insufficiency, this patient isn't expected to live many more hours. This patient has also been diagnosed with hyperkalemia and CHF. Assessment wise, this patient is listless, and lethargic, the pulse is strong and regular the heart sounds are irregular, there is edema in both arms, respirations are shallow and irregular there are expiratory wheezes in both lungs and at 10 breaths per minute.

I'm not very good with nursing diagnoses, especially for a dying patient. I've thought about something along the lines of comfort measures or knowledge deficit (for the family). If there is anyone out there that could help, it would really be appreciated.

Thank you!

[KAYBDT6, BSN, RN]

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=22

[Daytonite, BSN, RN]

nursing diagnoses, which are merely names for the nursing problems the patient has, are always based upon the signs and symptoms of these nursing problems that the patient has. therefore, they are dependent on the nurse having done a thorough assessment of the patient.

i usually approach care planning from a nursing process viewpoint, but with a dying patient, in particular, the nurses overall goal is to support the deterioration of the patient's condition. that doesn't always sit well with some people, but there it is. nanda doesn't really have a nursing diagnosis for this, but there has been one that has been used unofficially for a long time. i don't know if your instructors will allow it, but i will provide it for you for your consideration and you can run it by the instructors and see if they will let you use it.

• impaired comfort r/t physical deterioration aeb listlessness and lethargy - and any other observations you remember that the patient seemed in discomfort, uncomfortable or restless
  

otherwise, you use the symptoms you observed:

• irregular heart rate
  
• respirations are 10, shallow and irregular
  
• expiratory wheezes in both lungs
  
• edema in both arms
  

along with knowledge of the pathophysiologies of her medical diseases (chf, hyperkalemia and the renal insufficiency) to diagnose these 2 nursing problems in this order of priority (heart then lungs):

• decreased cardiac output r/t altered heart rate and rhythm and elevated potassium levels secondary to chf and hyperkalemia aeb irregular heart rate and peripheral edema in arms
  
• ineffective airway clearance r/t retained secretions aeb respirations of 10 that are shallow and irregular with expiratory wheezes in both lungs
  

her heart will probably stop first because her potassium level is elevating so high. high potassium levels cause heart block so that the heart will stop beating. i am not really sure about that edema in her arms being of cardiovascular origin. it's puzzling that she doesn't also have edema in her legs. did she have mastectomies?

as far as doing knowledge deficit (for the family) i wouldn't advise that with the physical evidence that you do have on the patient. the focus of a care plan is always about the patient--not the family. when you start turning to the family you still need to make the patient the focus. and as i started out, although it is uncomfortable, there are a lot of things we can do to support the deterioration of someone who is dying. i worked in long-term care and took care of many dying patients. they shouldn't get swept under the rug because they are at the end of their days. see these weblinks for ideas for care of dying patients:

• http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_index.html
  
• http://www.stvincent.org/ourservices/hospice/preparing/default.htm
  

good luck with the remainder of your care plan.

[b_howard]

Thank you so much, that will help out a lot! I really appreciate it!

[Daytonite, BSN, RN]

You are very welcome.

[WeirdNurseKelly, BSN, RN]

Another tip which might be helpful, you can use this for this patient and other patients. I like to look up ther clinical diagnosis in my nursing diagnosis book and then go from there. The nursing diagnosis book will give some nursing diagnoses for that particular clinical diagnosis. I find that I can tweak what the book says so it follows along with what my patients symptoms are. It helps me out a lot.

Good luck.

[awalker1015]

KellT1203~

Which nursing diagnosis book do you have? Mine isn't organized like that and yours sounds much more helpful...

Thanks!

Amanda

[b_howard]

Yeah, my book actually sucks too. The interventions for each nursing diagnoses are so generic, I need to look into getting a really detailed nursing diagnosis book.

[Daytonite, BSN, RN]

you are talking about a medical disease/condition to nursing diagnosis cross reference. they can be found in

• nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig
  
• the appendix of newer editions of taber's cyclopedic medical dictionary