Nursing diagnosis help

[altheaaa07]

I NEED HELP WITH NURSING DIAGNOSIS!

CASE: Older Woman With a Chronic Cardiac Condition

Information Obtained during the First Visit/Encounter:

82-year-old woman, was admitted to a home care agency because of heart failure. She was hospitalized twice in the last six months for a toxic level of Lanoxin (digitalis) and an exacerbation of heart failure; she is no longer on Lanoxin. She lived in her small two-story home for many years. She received social security payments and some retirement income. Her daughters lived far away, but called regularly. They arranged for someone to clean her home monthly. Although her former neighbors moved away, she talked to them often and they visited occasionally. She had a friend who drove her to appointments, purchased her medications, and took her to church regularly. She told the nurse that while she misses her husband, she has adjusted since he died ten years ago and is content with her independence and lifestyle.

During the visit, she complained of significant fatigue. She said that because she tired so easily, she could not walk out on her patio. She had 3+ pitting edema in her lower extremities, decreased appetite, and dyspnea when lying down and with exertion. Her heart rate was 88 and irregular at rest, blood pressure was 104/74, and pulse oximetry was 95%. She weighed 130 pounds and was 5’4”. Francis said she lost ten pounds in the last four to five years. Laboratory data indicated mild anemia; her hemoglobin was 11.0 g/dL (NV: 11.7-13.8 gm/dl). Her last potassium level was 3.4 mEq/L.(NV: 3.5-5.0)

The home care nurse and she discussed heart failure and how she could manage the symptoms more effectively. Francis was very receptive to weighing herself daily, keeping a symptom diary and calling her providers when appropriate, using energy conservation techniques, elevating her legs regularly, and using an extra pillow to elevate her head and shoulders to decrease dyspnea while sleeping. She agreed to schedule the amount and time of her fluid intake based on the nurse’s recommendations. She was pleased that the nurse arranged for the delivery of mobile meals that were high in iron, and would receive those meals beginning the next day.

She and the nurse discussed her medications: metoprolol (Toprol XL) 50 mg daily, lisinopril (Zestril) 40 mg daily, furosemide (Lasix) 40 mg every other day, potassium 20 mg every other day, and ferrous sulfate 325 mg daily. Francis knew the names of each medication and the schedule, but not the purpose or side effects. She said that she had no reminder system and occasionally forgot whether she had taken them. The home care nurse described the benefits of using a medication reminder/organizer system; She was pleased that the nurse planned to bring a system later that week. She agreed to record notes about her medications, their actions, and their side effects in her symptom diary.

She said that since she now understood how important it was to take her medications regularly and manage her symptoms, she would try harder. She was glad that the nurse planned to call her doctor’s office, and looked forward to the nurse’s regular visits. SHe and the nurse decided to discuss additional options such as a friendly caller if she needed more help with reminders. She said her daughters would be pleased that she would receive mobile meals since they already told her to do so. She said that the nurse could call her daughters after the next visit if the nurse chose to do so; they would appreciate receiving the phone call.

so far i've come up with:

1. decreased cardiac output r/t compromised cardiac contractility and impaired regulatory mechanisms of circulation s/t Chronic Heart Failure as manifested by Complains of significant fatigue, claims she gets tired so easily, that she could not walk out on her patio, 3+ pitting edema on lower extremities and dyspnea when lying down and with exertion

2. ineffective tissue perfusion r/t to impaired transport of oxygen secondary to heart failure as manifested by Complains of significant fatigue, claims she gets tired so easily, that she could not walk out on her patio and dyspnea when lying down and with exertion

3. ACTIVITY INTOLERANCE r/t imbalance between oxygen supply and demand, secondary to Chronic Heart failure as manifested by Complains of significant fatigue claims she gets tired so easily, that she could not walk out on her patio, dyspnea when lying down and with exertion

4. HYPOKALEMIA?

5. KNowledge deficit

6. Impaired Gas exchange

7. Ineffective health maintenance due to impaired memory as manifested by forgetting when the medications were taken?

8. Fatigue

9. Imbalanced Nutrition: less than body requirements as manifested by decreased appetite, secondary to mild anemia

10. Adult failure to thrive

11. Impaired Memory

12. Social Isolation

ARE THESE RIGHT? and how do i improve the etiology and S/S? ALSO HOW DO I RANK THEM?

[Daytonite, BSN, RN]

Diagnosing is based upon the assessment data, so that information you were given must be read carefully. There were a lot of clues given in the scenario.

The construction of a 3-part diagnostic statement follows this format:

P (problem) - e (etiology) - s (symptoms)

• Problem - This is the nursing diagnosis. A nursing diagnosis is actually a label. To be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. The appendix of taber's cyclopedic medical dictionary has this information.
• Etiology - Also called the related factor by nanda. This is what is causing the problem. It is the reason the problem exists and reasons can be many and varied. Ask yourself "Why did this happen?" or "How did this problem come about?" "What caused this to become a problem in the first place?" and dig deep. Consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. Pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. It is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. You can sneak a medical diagnosis in by listing a physiological cause and then stating "Secondary to (the medical disease)" if your instructors will allow this.
• Symptoms - Also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. They can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. They are evidence that prove the existence of the nursing problem. If you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. These symptoms will be the focus of your nursing interventions and goals.

The nanda taxonomy lists suggestions for etiologies for all the nursing diagnoses.

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

With regard to the nursing diagnoses you came up with, they would be sequenced in this order, but I do not agree with them all.

1. Decreased cardiac output r/t compromised cardiac contractility and impaired regulatory mechanisms of circulation s/t chronic heart failure as manifested by complains of significant fatigue, claims she gets tired so easily, that she could not walk out on her patio, 3+ pitting edema on lower extremities and dyspnea when lying down and with exertion
   • complaints of fatigue belong with your diagnosis of fatigue.
   • claims of getting tired easily and could not walk out on her patio are a symptom of activity intolerance.
2. Ineffective tissue perfusion r/t to impaired transport of oxygen secondary to heart failure as manifested by complains of significant fatigue, claims she gets tired so easily, that she could not walk out on her patio and dyspnea when lying down and with exertion
   • it is unnecessary to use this diagnosis when you have already diagnosed decreased cardiac output. decreased cardiac output is specifically used for ineffective tissue perfusion of the cardiac tissue.
3. Impaired gas exchange
   • i would not diagnose this. there is no evidence of this problem other than dyspnea which is really a result of a heart problem.
4. Activity intolerance r/t imbalance between oxygen supply and demand, secondary to chronic heart failure as manifested by complains of significant fatigue claims she gets tired so easily, that she could not walk out on her patio, dyspnea when lying down and with exertion
   • dyspnea when lying down is not a symptom of this diagnosis.
   • activity intolerance is when someone's heart rate and breathing increase during activity to the point where the person must stop and sit down. these two things can be noted by observation, taking ekg evidence or abgs.
5. Imbalanced nutrition: less than body requirements as manifested by decreased appetite, secondary to mild anemia
6. Adult failure to thrive
   • there are no symptoms of this. failure to thrive is a serious condition of anorexia with weight loss and mental deterioration as in alzheimer's disease and that is not what is going on here.
7. Fatigue
8. Ineffective health maintenance due to impaired memory as manifested by forgetting when the medications were taken?
   • etiology (related factor): forgetfulness
   • symptoms: forgetting whether or not she has taken her medications resulting in accidentally overdosing self
9. Impaired memory
   • you've already covered this with ineffective health maintenance. the scenario doesn't really tell you how else her forgetfulness is affecting her life, does it?
10. Social isolation
    • is she really isolated? she has a friend who drives her to appointments and takes her to church. the scenario says her neighbors still come and visit her.
11. Knowledge deficit
    • the scenario tells you the subjects of the knowledge deficit: purpose and side effects of medications. medication reminder system and management of disease side effects.
    • etiology (related factor): lack of information
    • symptoms: confusion and forgetfulness about when she has taken her medications and what each medication does and unfamiliarity with the signs and symptoms of worsening heart failure
    • correctly written diagnosis: deficient knowledge, purpose and side effects of medications. medication reminder system and management of disease side effects

Hypokalemia? - This is a symptom and not a diagnosis. The scenario tells you she is getting dietary supplements daily to replace her potassium, so the hypokalemia can be seen as a symptom of imbalanced nutrition as well as contributing to the decreased cardiac output because it affects the heart.

I would diagnose impaired home maintenance r/t heart disease aeb need for assistance to clean home.