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.
great so now i have to trash my whole folume excess
and yet ackley specifically says congestive heart failure dx goes with fluid volume excess
how the hell will i justify volume deficit in this pt to my teacher
she wants me to focus on electrolyte imbalances...
there is nothing in the defining characteristics of fluid volume deficit about electrolte imbalance at all
I have to be able to and shes going to ask me how i came up with heart failure when its not in his medical diagnosis they are treating him for stroke a left mca stroke.. he has CAD if i put chf in there and its not in his record shell hang me this is still school not the real world for defining characteristics the only ones that match are excess
can i put risk for fluid volume imbalance and say potassium loss is a characteristic? shell say where is your reference
..
ackley says heart failure is a condition of excess fluid volume
well great.. then I am going to make my dx fluid volume imbalance and drop the Risk for part because he has a fluid volume imbalance and focus on the low K+ because that is what she was so concerned about
None of the book diagnosis really fit this pt well
you should all be glad your not writing papers ...
i mean this guy has signs of excess and deficit
so whats a student to do ?????????
I don't have the benefit of your experience i still have to make things fit in some preplanned nursing care plan to make teachers happy... and write papers about my thinking
I *am* writing papers. I'm an LPN, still in school for my second year, and not only do I have two papers to write, and an exam to study for, but I also have to write care plans for clinicals.
I'm not using Ackley, so I have no clue what Ackley says or doesn't say. Might I suggest "Imbalanced Fluids and Electrolytes"? Deficient Fluid Volume (your fluid imbalance) is supported by his elevated sodium and BUN with normal creatinine, and imbalanced electrolytes is supported by his decreased potassium and increased sodium.
Imbalanced Fluids and Electrolytes: Deficient fluid volume related to diuresis and deficient fluid replacement, as evidenced by sodium of 149 and BUN of 70, and imbalanced electrolytes related to increased renal potassium excretion, as evidenced by potassium of 3.3.
OR
Acid/base imbalance related to impaired respiratory function, as evidenced by pH of 7.28.
I feel your pain. I struggle with nursing diagnoses too.
Aspirin can cause GI bleeding. That would be a good reason to DC that medication, and it could be a reason for his H&H to be low.
I thought you said that heart failure is not anywhere in his chart, and that you could not use it because of that?
The reason I am speculating that he has heart failure because he is receiving digoxin and Lasix, and his daily free water allotment is 1500mL. All of these are typical treatments for heart failure patients. Also, heart failure can be secondary to COPD, which we know he has.
Fluid volume excess is associated with heart failure, but not all patients with heart failure have excess fluid volume. In a heart failure patient, we can have FVE because of decreased cardiac output. One of the ways the body attempts to compensate for the decreased cardiac output is by increasing intravascular fluid volume; i.e. fluid retention. We treat fluid retention by giving Lasix, but we also have to help the heart pump better. That's what the digoxin is for. Between Lasix and digoxin, the patient can have an increased cardiac output without fluid retention. If he is receiving too much Lasix and not enough free H20, they can have a fluid volume deficit even if they have CHF. It's just not as simple as CHF=FVE.
I suspect he has deficient fluid volume because his BUN is high but his creatinine is normal, and his sodium is high. We would expect his Hct to be high as well, but I think he has had some blood loss, or is anemic for some other reason.
Because his sodium is high, this also tells me he has a concentration imbalance. Because he is losing water and is also receiving tube feeding, this makes his plasma more concentrated, which pulls water out of the cells in the body's attempt to maintain an adequate intravascular volume.
I think this guy is dehydrated. I think that what was working before is not working now because he has had a change in condition, and his medications need to be adjusted.
The potassium is low because of the Lasix.
With his acidosis, I would expect his potassium to be high, but since he is getting Lasix, he is excreting potassium more rapidly than it can build up. If he has diarrhea, he could be losing potassium there.
Also, many people with COPD live in an acidotic state and do just fine; we need to look at trends, not just one set of labs. What was he like before the CVA?
At least, those are my guesses. Labs are NOT my strong point. Good luck!
Specializes in NICU, PICU, PCVICU and peds oncology.
Also, many people with COPD live in an acidotic state and do just fine; we need to look at trends, not just one set of labs. What was he like before the CVA?
That's true. A slightly lower pH is often what drives their respiratory effort. As well, they become accustomed to a lower paO2/saO2 so excessive oxygen supplementation may actually be detrimental. All of Nancy's arguments make sense.
I also want to point out that you are a nursing student. You should not be expected to know it all. If you get "nailed" because you came up with the wrong diagnosis, learn from it and try to take in what your instructor is telling you. None of us started out knowing this stuff. It had to be learned. That's what school is for.
Specializes in med/surg, telemetry, IV therapy, mgmt.
hi, mark3274, and welcome to allnurses! :welcome:
did you read page 4 of your ackley/ladwig nursing diagnosis book? this is what is says about determining nursing diagnoses for patients:
(from page 4 of
nursing diagnosis handbook: a guide to planning care
, 7th edition, by betty j. ackley and gail b. ladwig)
"when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.
highlight or underline the relevant symptoms.
make a short list of the symptoms.
cluster similar symptoms.
analyze/interpret the symptoms.
select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.
the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."
your posts and thinking are so scattered that i had to go through the entire thread and copy and paste all your posts onto a word document to sort through what information you've provided. i get the impression that you are trying to write this care plan from the nursing diagnosis book you are using as a reference and that is not what it's purpose is for at all. writing a care plan is a logical and rational exercise that follows a five-step process, the nursing process. the nursing process is a problem solving method.
first of all, nursing diagnoses, as ackley and ladwig have pointed out are based upon the patient's symptoms or responses to their problems not on what their medical diagnoses are. the medical diagnoses provide etiological and pathophysiological clues of what is at the bottom of what is going on is all. the most important thing you do with the patient is your assessment. all the data you collect is important and is needed because it is the foundation of any care plan. nursing diagnoses are nothing but labels (see that ackley and ladwig also refer to them as such) for patient problems. students get too hung up on these labels. what you really need to concentrate on is the patient's abnormal symptoms that surfaced during your assessment. i've been a nurse for 32 years and i know this patient is loaded with symptoms yet you've only listed a handful. you need to go back through your assessment information again because there are big gaps missing here. you also need to stop reading what ackley and ladwig are telling you about medical diagnoses and start looking at pathophysiology references. you need to look up information about the patient's medical problems which include:
a left mca stroke
cad
one of the copd disorders
you need to read up on cad (coronary artery disease) because that is where your patients heart failure is coming from and why he is on lasix and digoxin. and, you aren't going to find this in ackley and ladwig's book!
now, based on going through all the information you posted, these are your patient symptoms i was able to extract out. i suspect there are a lot more symptoms that you haven't listed, but this is all i have to work with at the moment:
potassium - 3.3 high (normal is 3.5 to 5.0) [low potassium levels affect the heart! not fluid volume]
sodium 149 high (normal is 136 to 145)
bun 70 (normal is 10 to 20)
you mention low hemoglobin and hematocrit but don't give the values
copd (there are 4 conditions in the category of copd)
chronic obstructive asthma
chronic obstructive bronchitis
emphysema
chronic bronchitis with emphysema
which one does your patient have? this information would have been in his history and physical, nursing admission assessment or possibly in a respiratory consult or doctor's progress notes of the chart
[*]rhonchi and crackles in his lungs
[*]he's a smoker
[*]no gag reflex
[*]has a jejunostomy tube in place and is getting continuous tube feedings of jevity
[*]needs to be straight cathed to get any urine out of him
i have questions. . .what was this patient's respiratory assessment? any dyspnea, cough, sputum production? what do his blood gasses look like? these things are biggies in a copder, yet you have nothing pertaining to his respiratory status other than he has rhonchi and crackles in his lungs. with no gag reflex he's still in danger of aspiration of his own secretions. also, why is he being straight cathed? is he incontinent (there's a nursing diagnosis for that) or have urinary retention (there's a nursing diagnosis for that too)? or is it because he just has poor output because of an impending renal problem? does this patient have any edema? did you assess his ability to move about and walk? copders usually have mobility or activity tolerance problems. since this patient had a stroke, does he have any paralysis or paresthesias? this would affect his ability to perform his adls. we nurses are big on assisting patients with their adls.
from the symptoms i could glean from your posts i get these nursing diagnoses in priority order:
ineffective airway clearance r/t smoking and copd aeb rhonchi and crackles in his lungs
decreased cardiac output r/t altered contractility and heart rate aeb rhonchi and crackles in lungs and decreased potassium levels
impaired urinary elimination r/t ??? aeb ??? [you need to supply more assessment information about this problem]
risk for aspiration r/t absence of gag reflex and presence of j-tube with continuous tube feedings
risk for imbalanced fluid volume r/t continuous tube feedings and impending renal failure [this is where you address your abnormal sodium and bun and perhaps some of the output problem. the low h&h will most likely be due to an underlying renal problem.]
since you are a new member, be aware that there are student forums where there is care plan information:
mark3274
67 Posts
ok he did not have a hemmorgenic stroke
and
great so now i have to trash my whole folume excess
and yet ackley specifically says congestive heart failure dx goes with fluid volume excess
how the hell will i justify volume deficit in this pt to my teacher
she wants me to focus on electrolyte imbalances...
there is nothing in the defining characteristics of fluid volume deficit about electrolte imbalance at all
I have to be able to and shes going to ask me how i came up with heart failure when its not in his medical diagnosis they are treating him for stroke a left mca stroke.. he has CAD if i put chf in there and its not in his record shell hang me this is still school not the real world for defining characteristics the only ones that match are excess
can i put risk for fluid volume imbalance and say potassium loss is a characteristic? shell say where is your reference
..
ackley says heart failure is a condition of excess fluid volume
so how do i get deficint fluid volume?