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.
process papers are wonderful..I know they have there purpose but on the other hand every hospital in our area uses a care map... Nurses no longer sit and write out a dx for each pt there is a flow sheet you follow and mark off if the outcome was meet or not or moving towards being met.
plus with each nurse having about 5 pts in our area they simply would not have the time to write a individual plan for each and every pt.
decresed cardiac output takes higher priority than the K+ imbalance
over a period of a few days his bp ranged as follows
97/52- 152/69
pulse ranged 59-75
respirations ranged from
14-26
sp02 range 90-98
and really the 98 was when he was on bipap only
so because the caridac comes before fluid balance my instructor will not be able to say hey ya flunk .. because i will list risk for fluid volume imbalance as a lesser dx just do not have to write a care plan for it so i can say well I was going to address the fluid volume but we could only pick 2 priority dx for the paper and cardiac comes before physiological so I had to pick that before fluid volume
Specializes in med/surg, telemetry, IV therapy, mgmt.
mark3274. . .your posts and thinking is so scattered I don't know how you are going to get this assignment completed. You are stuck and stalled at Step #2 of the nursing process and no where near trying to figure out the etiologies of the symptoms which is what you are attempting to do. You need to get yourself organized. Follow the directions on page 4 of your Ackley/Ladwig nursing diagnosis book. You have not been doing that and this is why you are so confused. Sit down and make a list of all your patient's symptoms like I did. You just posted a few more of them that you can add to that list. You have to stop doing that. Make one complete list. Look at an assessment form to refresh your memory as to what you observed in this patient so you don't forget anything. You also need to read up on CAD, COPD and stroke and compare the textbook symptoms of these diseases against the symptoms your patient had to see if you missed picking up on any of them during your assessment. I'm still betting there are a lot more symptoms that you are forgetting about. A person with CAD, COPD and a stroke has a lot of problems and I'm sure you are missing them. Do you understand what I'm talking about when I use the word symptom? It is an objective or subjective change in the body or a body function--an abnormal assessment item. Then, using that list match symptoms with likely nursing diagnoses by comparing the defining characteristics listed under those nursing diagnoses. They are listed at the very beginning of each of the nursing diagnoses in the Ackley/Ladwig book. Only then, can you start looking at and trying to figure out the etiologies of the symptoms. The symptoms are not going to go away or change, but you have got to get yourself a complete listing of them before you can do anything else with this care plan.
With green mucus that needs to be suctioned you now have Ineffective Airway Clearance R/T smoking and COPD AEB rhonchi and crackles in his lungs with thick tenacious green mucus.
Specializes in med/surg, telemetry, IV therapy, mgmt.
decresed cardiac output takes higher priority than the K+ imbalance
over a period of a few days his bp ranged as follows
97/52- 152/69
pulse ranged 59-75
respirations ranged from
14-26
sp02 range 90-98
and really the 98 was when he was on bipap only
so because the caridac comes before fluid balance my instructor will not be able to say hey ya flunk .. because i will list risk for fluid volume imbalance as a lesser dx just do not have to write a care plan for it so i can say well I was going to address the fluid volume but we could only pick 2 priority dx for the paper and cardiac comes before physiological so I had to pick that before fluid volume
Specializes in med/surg, telemetry, IV therapy, mgmt.
Ineffective airway clearance R/t cva and copd
You can't use a medical diagnosis (the CVA) as a related factor in a nursing diagnostic statement. Read a NANDA reference that tells you what you can use as a related factor for this diagnosis.
Specializes in med/surg, telemetry, IV therapy, mgmt.
glad to hear that!
in the future, please post for help with student assignments in either the nursing student assistance forum (https://allnurses.com/forums/f205/) or the general nursing student discussion forum (https://allnurses.com/forums/f50/) where people who are more inclined to helping students hang out, ok? there are also lots of helpful weblinks to help you with information you might need in studying your nursing assignements.
mark3274
67 Posts
he was a chronic smoker for over 60 years his resp assessment
was dsypnea use of accessory muscles to breath
chest rise uneven
rhonchi
neeed to be suctioned
thick green mucus suctioned out of airway that was very difficult to remove
ph 7.28
cheyne-stroke breathing when he sleeps
bi pap on at night--
no gag reflex at all none