Nursing diagnosis help...please!

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I have a patient who has a long history of illness.. but he is in the hospital for a UTI, he has MR, parkinson's disease, renal failure, cannot talk, can barely move and is on bedrest. he is also developing a pressure ulcer stage one on his sacrum. he was doing alot of belly breathing. he has elevated wbc count of 23.

during the end of my clinical day the pt's bp was 166/77 hr was 128 and was not responding to me. the ekg showed no abnormalities, neither did the chest xray. temp was 103.

i wondered if someone could tell me what the most important diagnosis would be. i have a ton, but i'm really paranoid about my teacher and i wanna try and get it right. so far i have:

Impaired skin integrity r/t rigidity, decreased range of motion, bradykenesia, inability to turn self in bed,increased shearing forces and increased pressure on sacrum secondary to necessity of keeping client in semi fowler position to avoid aspiration aeb possible stage one pressure ulcer on sacrum.

impaired physical mobility r/t effects of muscle rigidity, tremors and slowness of movements on activity of daily living in parkinsons disease aeb inability to ambulate and perform adl

impaired verbal communication r/t dysarthria seconday to ataxia of muscles in speech in parkinsons disease aeb no verbal communication.

can someone help me? Thanks

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Specializes in L & D, Med-Surge, Dialysis.

I will help you out not only with answer but with the whole information. Pm me your email i will send you NSG DX FILE you can use through out your program.

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i havent posted 15 posts yet so i cant do private messages... can u send me a private message w/your email address than i'll send you an email?

Thanks

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Specializes in Cardiac, Derm, OB.

Hi, does that nsg diag file contain pedi? Just asking definitely need ideas for that area.

As for the patient while all those other issues are good. It seems his main problem is the UTI and possibly sepsis.

I think:

1st: Hyperthermia r/t infectious process aeb elevated core temp of 103 and elevated wbc count of 23.

2nd: Impaired skin integrity r/t immobility aeb stage I pressure ulcer on sacrum

3rd: tossup between pain r/t UTI aeb increased BP, HR.....did you assess?? risk for infection (2ndary) r/t stage I pressure ulcer

Hope these help, just some ideas.

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Specializes in L & D, Med-Surge, Dialysis.
i havent posted 15 posts yet so i cant do private messages... Can u send me a private message w/your email address than i'll send you an email?

Thanks

i do try to send you the file, each time i copy the file from my desktop shows cover page. Maybe bcoz the file is in a cd format. I'll try if i get one across to you.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you need to see this allnurses thread on construction of care plans: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

a care plan is a collection of the patient's nursing problems and strategies you are going to employ to do something about them. we use the nursing process (a tool) to help us do care planning. using the nursing process helps keep you focused and organized in your thinking.

step 1 - assessment of the patient involves all of the following:

  • a health history (review of systems) - has a long history of illness (mr, parkinson's disease, renal failure, developing a stage i pressure ulcer on his sacrum). admitted for a uti.
  • performing a physical exam - all you have posted is
    • temp 103

    • b/p 166/77

    • hr 128

    • does a lot of belly breathing

    • was not responding to me

    • cannot talk (on bedrest)

    • can barely move

    • elevated wbc count of 23

    • in your nursing diagnostic statements you mention: inability to ambulate and perform adls

    [*]assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - ???. probably a lot of them since he is on bedrest.

    [*]reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the very first thing you should be doing is looking up the signs and symptoms of mr, parkinson's disease, renal failure, and pressure ulcers.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none listed.

step 2 - determining the nursing problems (nursing diagnoses) - from all the assessment data that you collect about the patient only the abnormal data is what is crucial to and form the evidence that proves the existence of nursing problems, so you need to list them out. i already did that with the information you supplied, but i suspect there is a lot that you either missed or may not have believed was important. but working with the abnormal data you posted his list of abnormal data is:

  • temp 103
  • elevated wbc count of 23
  • b/p 166/77
  • hr 128
  • does a lot of belly breathing
  • was not responding to me
  • can barely move (on bedrest)
  • inability to ambulate
  • inability to perform adls
  • cannot talk

the problems: i moved and grouped the data a bit so some things could be noted. (1) an elevated wbc, fever, and tachycardia are systems of an infection. you should add that to the list of diseases you need to be reviewing signs, symptoms and complications of. (2) people with long term or chronic illness often become lethargic and unresponsive when their infections become septic (enter the blood stream). look up sepsis. its signs and symptoms include: fever, tachycardia, and tachypnea; bp remains normal. other signs of the causative infection are generally present. as severe sepsis or septic shock develops, the first sign may be confusion or decreased alertness. (3) being barely able to move which is manifested by an inability to ambulate suggests a mobility problem that probably has the parkinson's and the mental retardation at its etiology. it is also contributing to the complication of the pressure ulcer because he is on bedrest. (4) the inability to perform daily adls needs to be specified. what is it that he can't do? what do the nurses have to do for him? none of your nursing diagnoses addressed this. adls are our specialty. you missed identifying this as a problem. (5) not being able to talk and communicate his needs is a safety problem. it means we need to find a way to communicate with him, if possible, and help determine what is bothering him. otherwise, he is totally dependent on our assessment skills to determine his problems.

so, what is all that in the wording of nursing diagnoses (and in priority per maslow's hierarchy of need)?

  1. hyperthermia
  2. impaired physical (or bed) mobility
  3. self care deficit(s) - need to be specified (toileting, eating, bathing, hygiene)
  4. impaired skin integrity
  5. impaired verbal communication
  6. delayed growth and development
  7. risk for infection - talking about sepsis here. the elevated wbc and fever tell us he already has an infection. he's on an antibiotic?

- - - - - - - - - - - - - - -

with regard to the diagnoses you posted:

impaired skin integrity r/t rigidity, decreased range of motion, bradykenesia, inability to turn self in bed,increased shearing forces and increased pressure on sacrum secondary to necessity of keeping client in semi fowler position to avoid aspiration aeb possible stage one pressure ulcer on sacrum.

p (problem)
-
impaired skin integrity

  • definition:
    altered epidermis and/or dermis
    .

e (etiology, or cause of the problem)
- rigidity, decreased range of motion, bradykenesia, inability to turn self in bed,increased shearing forces and increased pressure on sacrum secondary to necessity of keeping client in semi fowler position to avoid aspiration

  • you already stated that this is a
    pressure ulcer
    .
    pressure
    is the cause. saying the pressure is "increased" is unnecessary

  • "rigidity" is not a cause of skin breakdown

  • "decreased range of motion" should be reworded as "physical immobility"

  • "bradykenesia" (slowness of movement) is not a cause of pressure ulcers

  • "inability to turn self in bed" is a
    symptom
    of
    impaired bed mobility

  • you do not need to say "increased" shearing forces. simply saying ''shearing forces", which is a cause of skin breakdown will do.

  • "secondary to" is only used to include a medical disease or condition. "necessity of keeping client in semi fowler position to avoid aspiration" is a
    treatment
    and has no reason to be in the etiology section of this diagnostic statement. treatments are part of the planning to do something about a problem. you are still in the problem identification phase. it sounds like you are saying one of the treatments is a problem--then change the plan of care. he can be turned while in fowler's position, but don't blame being in fowler's position or the nurses for not keeping him turned because of it--it looks unprofessional.

s (symptoms, or evidence, of the problem)
- possible stage one pressure ulcer on sacrum

impaired physical mobility r/t effects of muscle rigidity, tremors and slowness of movements on activity of daily living in parkinsons disease aeb inability to ambulate and perform adl

p (problem)
- impaired physical mobility

  • definition:
    limitation in independent movement, purposeful physical movement of the body or one or more extremities.

e (etiology, or cause, of the problem)
- effects of muscle rigidity, tremors and slowness of movements on activity of daily living in parkinsons disease

  • "effects of" is unnecessary to list with muscle rigidity

  • "tremors and slowness of movements" are
    symptoms
    of the
    impaired physical mobility
    and do not belong with the etiology.

  • if the muscle rigidity is because of the parkinson's then state it as
    secondary to parkinson's disease.

  • do cognitive impairment, contractures, decreased muscle control, mass or strength, disuse, neurovascular impairment or pain have anything to do with the etiology of his
    impaired physical mobility
    ? all are etiological factors for this diagnosis.

s (symptoms, or evidence of the problem)
- inability to ambulate and perform adl

  • "inability to perform adls" is not appropriate as a symptom for this diagnosis. if the patient has problems performing adls, diagnose one or more of the
    self-care deficits
    and be specific as to what those deficits are.

impaired verbal communication r/t dysarthria seconday to ataxia of muscles in speech in parkinsons disease aeb no verbal communication.

p (problem)
- impaired verbal communication

  • definition:
    decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols
    .

e (etiology, or cause, of the problem)
- dysarthria seconday to ataxia of muscles in speech in parkinsons disease

  • dysarthria
    is a medical diagnostic term i would not use. i would check to see if your instructor would allow you to use it.

  • if there is "ataxia" causing defective muscular movement when voluntary muscular movements are attempted, then that would be the etiology, but you stated that he cannot talk. did that mean he doesn't attempt to talk or that he tries to talk and is not understood. you need to clarify this.

  • if the physical cause is because of the parkinson's then state it as
    secondary to parkinson's disease.

s (symptoms, or evidence of the problem)
- no verbal communication

  • what does "no verbal communication" mean and what are the symptoms the patient displays? does he have problems with reception, processing, or transmission of messages? you need to make this clear by describing his symptoms and include the correct related factors (etiologies) in the proper section of the diagnostic statement.

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