Nursing Diagnosis Help!

[2bNurse-88]

Hey Everyone! I'm in desperate need of help with 2-3 nursing diagnoses for the following patient:

27-year old man admitted with an uncontrollable fever. Transfered from LTC. History of a gun shot wound to left chest. Had a cardiac arrest after the GSW, developed hypoxic encephalopathy. Has a trache, and gastro tube. History of MRSA in sputum.

Objective Data:

Thin, cachectic man in moderate respiratory distress

Unresponsive to voice, touch, or painful stimuli

Vital signs: Temp:40, Heart Rate:120, Resp: 30, O2 stats 90%

Chest auscultation revealed crackles and scattered wheezes in left upper lobe

Chest x-raym exam: Infiltrate in left upper lobe

I need to come up with Nursing diagnoses in priority order, and actions.

Any help would be greatly appreciated, i'm so used to doing non-complex p/t diagnoses, this is a tough one for me.

[Daytonite, BSN, RN]

nursing diagnoses, like medical diagnoses, are based upon evidence that you have collected that support their existence. the first thing you do is sift through your data to see what abnormal data (evidence) you have and then determine what nursing diagnoses they belong with. here are some hints for you:

• history: uncontrollable fever, history of a gun shot wound to left chest, cardiac arrest after the gsw, developed hypoxic encephalopathy, has a trache, and gastro tube. history of mrsa in sputum. [hypoxic encephalopathy is an oxygenation problem to the cerebral tissue and, thus, the coma. there is a nursing diagnosis for this.]
  
• unresponsive to voice, touch, or painful stimuli (coma)
  
• chest auscultation revealed crackles and scattered wheezes in left upper lobe [there is a nursing diagnosis for this, the cxr evidence, tachypnea, and tachycardia]
  
• chest x-ray exam: infiltrate in left upper lobe
  
• thin and cachectic [there is a nursing diagnosis for this]
  
• temp:40 [there is a nursing diagnosis for this]
  
• heart rate:120 (tachycardia)
  
• resp: 30 (tachypnea)
  
• question: how are his adls (bathing, dressing, mobility, eating, toileting, and grooming) being met? [because of the coma and inability to perform his own adls there will be self-care deficit nursing diagnoses]
  
• invasive procedures (trach, gastric tube) = a risk for infection and the patient already has mrsa in his sputum. once a patient has an infection there is always a risk of the infection becoming septic. this is also risk for infection.
  

diagnoses need to be sequenced in priority by maslow's hierarchy of needs:

1. physiological needs (in the following order)
   
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
   • the need for food and water
     
   • the need to eliminate and dispose of bodily wastes
     
   • the need to control body temperature
     
   • the need to move
     
   • the need for rest
     
   • the need for comfort
     

[*]safety and security needs (in the following order)

• safety from physiological threat
  
• safety from psychological threat
  
• protection
  
• continuity
  
• stability
  
• lack of danger
  

[*]love and belonging needs

• affiliation
  
• affection
  
• intimacy
  
• support
  
• reassurance
  

[*]self-esteem needs

• sense of self-worth
  
• self-respect
  
• independence
  
• dignity
  
• privacy
  
• self-reliance
  

[*]self-actualization

• recognition and realization of potential
  
• growth
  
• health
  
• autonomy