Nursing Diagnosis help

[mark3274]

Hey Everyone I am writing a Process paper and can not seem to find a High priority nursing diagnosis to fit.

Here is the case male 79 year old admitted for CVA X2

Copd 60 year smoker.

K+ 3.3 NA 149 PH 7.28

on lasix 40 mg per J tube

Lanoxin 250 mcg

Albuterol Atrovent

colace senna

robitussin

I already used Ineffective airway clearance for number 1

but MY instuctor wants me to focus on the electrolyte problem I am sure

do you know of any nursing diagnosis that would fit?

I was thinking fluid volume excess.... but does that deal with the fact his electrolytes are all messed up

and yes he is headed to renal failure.. he needs to be striaght cathed to get any urine out of him

no gag reflex TF jevity 1.2 @ 65 cc per hour is only nutrition

The only real water intake he is getting is 250 ml sterile flushes every 4 hours and yet his potassium is always low had to give him a extra 40 mg K+ because his values were so low.

[Jen1228]

I think it might be fluid volume deficit instead of excess. Does he have any edema, crackles, JVD? Just going by the info you've provided, I agree with the Ineffective airway clearance, or you could also do impaired gas exchange. Focusing on the electrolytes, here's what my diagnosis would be:

Hypertonic fluid volume deficit related to inadequate free water supplementation (since he only gets the 1000ml), high-osmolarity enteral feeding formula, and renal insufficiency as evidenced by decreased UOP and altered Na 149.

I would focus more on the fact that the pH is 7.28 rather than the Na and K. Impaired Gas Exchange would be good to address the pH.

Impaired gas exchange related to alveolar-capillary membrane changes (COPD and CVAs) as evidenced by pH of 7.28.

If you have the ABGs that could be an "as evidenced by" too.

I hope this helps. I might be way off, but it's hard to do a nursing diagnosis with little info. If you have the CBC, UA, ABGs, etc. that would definitely help. Good luck!

[NotReady4PrimeTime, RN]

This man has several reasons for his low K+... like the Lasix, albuterol and senna he's getting. Renal failure causes potassium levels to rise, not fall and digoxin is also ssociated with hyperkalemia. Needing to be straight cathed points more to a problem with passage of urine than to none being made. With the limited information you gave, it's impossible to determine that his acidosis is caused purely by respiratory factors. I'd say he's getting enough fluid (1,560 from his tube feeds and 1500 from his q4H free water = 3,060 mL per day) but inadequate potassium and a high protein load from his tube feeds. This would be contraindicated in renal failure. We need more information.

[Virgo_RN, BSN, RN]

Lasix causes potassium loss, so this, in addition to inadequate dietary intake is probably the reason for his hypokalemia. Also, remember that being hypokalemic puts him at risk for digoxin toxicity. He should be on a potassium supplement.

Elevated sodium is probably related to fluid loss as well as inadequate H2O intake. 1500mL of free water is inadequate for someone who is not eating, and tube feedings are hypertonic and can cause hypertonic syndrome.

He is in a state of uncompensated acidosis, and I'm guessing it's respiratory since he has COPD.

I would say your respiratory nursing diagnosis should be Impaired Gas Exchange related to obstructed airway or destruction of alveolar walls, depending on which form of COPD he has.

Imbalanced fluid and electrolytes would fit, I think. We don't know if he has deficient fluid volume, but we do know that he is hypertonic and hypokalemic.

Since he is on Lasix and digoxin, this tells me he is a heart failure patient, and they might want to keep him on the dry side, so I'd be a bit more concerned about the low potassium levels, unless his blood pressure is in the toilet. Then I'd be concerned about him being too dry.

[mark3274]

His HCT is 31 and HB is 9.7

I was thinking of fluid volume excess related to regulatory systems failure because with the HCT and HB being so low and his electrolytes not in balance its a definite sign of fluid imbalance..

he is getting a K+ supplement of 40 mg sometimes more than once per shift.

[Virgo_RN, BSN, RN]

If he had an excess fluid volume, his sodium would be low, not high.

His decreased H&H could be due to a decrease in erythropoietin, which is produced in the kidneys, not to mention impaired nutritional intake and advanced age.

What are his BUN and creatinine?

[mark3274]

his bun is 70 and cratine is 0.7

[mark3274]

he is being givin lasix 40 mg every day they have no dx of heart failure in his charts just prior CAD.

we also suspected that his na level could be do to his jevity formula being the incorrect formula for him but he had rhonchi and crackles in his lungs so he is getting excess fluid from somewhere or why would he be on lasix every day?

also if you look at the defining characteristics he meets just abhout all of them for fluid excess r/t reg system failure including the low hct and hb

[Virgo_RN, BSN, RN]

If he does not have heart failure, then why is he getting digoxin? Also, people with heart failure are commonly on Lasix every day.

In addition, increased BUN with normal creatinine is indicative of dehydration, not excess fluid volume.

Type B COPD is chronic bronchitis, in which the person has excess mucus in the large airways. I would expect to hear ronchi, especially if he is not getting enough fluids to thin his secretions so he can cough them up. Judging by the fact that he is on tube feedings, he is probably unable to cough up his secretions anyway. This guy is seriously at risk for pneumonia.

[Virgo_RN, BSN, RN]

Come to think of it, maybe he does have pneumonia and that's where all the crackles and ronchi are coming from. What is his WBC count?

[NotReady4PrimeTime, RN]

Um hmm, increased BUN and normal creatinine is also an indicator of a high protein intake... all signs are pointing away from fluid overload. The low H&H could also be from iron deficiency, B12 deficiency, malabsorption... or he may have anemia of chronic disease. Any idea what kind of strokes he's had? That might add another layer to the mystery.

[Virgo_RN, BSN, RN]

Good thinking! I was thinking maybe he had some blood loss, but hemorrhagic stroke had not occurred to me. See why nursing is so collaborative? Two heads are so much better than one!

Also don't forget his age. It's normal for H&H to decrease as we get older. Though with COPD, I'd expect his H&H to be higher, but he's been through a lot physiologically, so that compensatory mechanism might not be working so well for him anymore.