Nursing Diagnosis Help

[KrCmommy522, BSN, RN]

Hello! I need some help figuring out what I could use for my nursing diagnosis. I only have to come up with one priority problem because I am doing shorter care plans now since I completed enough satisfactory long ones.

So my pt is a 62 yo male 1 day postop from a robotic bilateral nephrectomy. I thought that he just had the tumors removed from his kidneys but when I got there I found out he actually had both of his kidneys removed. My instructor was shocked and asked what the plan was and when I told her it was for him to be on dialysis for the rest of his life she saod to double check my info because that didn't seem right. But I double checked n the nurse said they took both kidneys and he'll b on dialysis for the rest of his life. They had a Foley in which I thought was weird since he had no kidneys n when I asked the nurse she said she thought it was weird too but the surgeon said they did it cuz sometimes there's discharge after. So when I was there I got to remove the Foley and it did have 50 mL of clear, yellow urine. My assessment on him was all WDL. His VS were WDL except his SpO2 was 95% on O2 per NC on 4 L. I would think it would have been 100% on 4L of O2. His pain level was a 4 on a 1-10 scale 1h after getting his pain med (morphine). His surgical incisions were open to air, and looked good. He has an AV fistula in for his dialysis. But you couldn't hear the bruit or thrill. When he went down for dialysis they couldn't do it because the fistula was all clotted off. So he came back up and they were going to do a new one n then he was going back down for dialysis. But I left before that.

So for my prioritt nursing diagnosis. I'm thinking acute pain r/t surgery. But I don't know anything about living without both kidneys....what nursing diagnoses could come from that? I was trying to look for info but anything I find is for unilateral nephrectomy. I also thought a priority over pain could be something about his SpO2 since he's 1 day postop on 4L O2 and its only 95%. Maybe ineffective breathing pattern r/t pain? But his RR was 16? Its just I think its weird to have an SpO2 of 95 on 4 L of oxygen. So maybe that would be priority over acute pain?

Any help would be greatly appreciated! My care plan is due Monday.

[Rose_Queen, BSN, MSN, RN]

For some people, a low/mid 90% O2 sat is their baseline. For some chronic COPDers, it could even be high 80s as a baseline.

Some resources for this would be to look at the O2 orders- my facility's protocol is titrate O2 to maintain sats equal to or greater than 94%. Therefore, unless the patient were symptomatic or was trending downward, we would not be overly concerned about an O2 sat of 95%.

What about lifestyle changes the patient may need to make? Are they new to dialysis or have they been on dialysis for a while? What was his pain level prior to the morphine? These types of questions can be a guide in determining where the nursing priorities for this patient are. Also, consider some of the ramifications of major surgery. What else may become an issue besides pain?

[tbaughm]

I am thinking fluid and electrolytes. How would these be affected?

[Mia415]

Agree - fluid imbalance and risks of complications of dialysis take higher priority than pain. 95% isnt too low, you may want to see what his normal/average spo2 has been. this sounds like an interesting and complex case, and of course if you were his primary rn you could speak to his doctors and get more detail on his risks, plan of care, etc. i am assuming he would have similar issues as people who were in total end stage renal failure (both kidneys basically not working...might be similar to not having them at all lol). hope this patient is doing well. good luck!

[KrCmommy522, BSN, RN]

I get what you are saying about looking into issues of people in total end stage renal failure. That seems like a good idea! I thought about fluid imbalance and electrolyte imbalances since he has no kidneys. However, his Na, K, and Cl levels were all WDL. His Ca was a little low (my school uses 8.2 - 10.2 as a range and his level was 7.7). His BUN and creatinine were high (5.73 and 45). His Hg and platelets were low. For Hg my school uses the range of 12-15 and his level was 11.7 so it wasn't too low, but for platelets we use 150-400,000 and his level was 105 so that's pretty low. I assume because of hemodilution? He had edema bilaterally on his lower legs.

I know I can use risk for infection r/t surgery. That would be more important than his pain because that seemed to be well controlled with the pain meds. I just need to figure out what I can use thats r/t his kidneys being removed because I think that would be priority!

I did look at his orders and there wasn't anything in there about his O2 sat levels.

[shark_nurse14, BSN, RN]

Going along with fluid and electrolytes, as well as major lifestyle changes, this patient will be on a significantly different nutrition/hydration plan than your average person/probably what he was doing before this all happened. (This is in order to maintain his fluid and electrolyte balance, since his kidneys won't be doing any work). All of his labs are expected after surgery (low hct and hg due to blood loss during surgery) and a high BUN and creat I would attribute to his already known kidney damage. You're right in saying his pain is not a priority because it is well controlled and pain is unfortunately something that happens after most (if not all!) surgeries :). I think you could argue that this patient has a knowledge deficit r/t a new nutrition/hydration lifestyle needed d/t fluid and electrolyte imbalances associated with the removal of one or both kidneys. Since the patient seems stable (from your explanation) I would be looking ahead at discharge and what needs to be done before that (teaching). Normally, I would have put a lot of other nursing diagnoses before this (and I'm sure there are a lot of "right" answers) but he seems very stable from what you've told us, so I personally would look ahead to discharge. I hope this helps! :)

[shark_nurse14, BSN, RN]

Also- to try and ease your O2 sat worries...is he a former smoker? Current smoker? Is the morphine possibly changing his respiratory status a bit? Is he taking shallow breaths because of his abdominal pain related to surgery? Lots of explanations for that sat (which isn't too worrisome) that I would look into!

[KrCmommy522, BSN, RN]

Yes! He is a current every day smoker 1 ppd. So your right, and because of his abd pain he was taking shallow breaths. Unfortunately, I only get 1 10h day with the pt. I go in and research the night before my clinical (Wednesday night) and then Thursday from 0645 to 0545 I am with the pt. So I only have access to his medical records the night before and that day. A lot of times the new labs are pending when I leave there. So I feel like I never get the whole picture. It's hard making a care plan like that. Luckily I now only have to do a short care plan, which consists of coming up with a priority nursing Dx and then nursing interventions for that Dx. So it makes it a little easier. But not having the labs all the time really complicates things!! I have my assessment that I did on the pt, I have the post-anesthesia report, and I have the SBAR with the most recent info, but that isn't always the most recent, because as I said a lot of times (like this time) labs are pending. So its sometimes harder than others!

[tbaughm]

There should be several "at risk for" diagnoses you can use for a post-op patient with no kidneys. You don't need any lab results for those. Also, the pain diagnosis that you started out with is always a priority after surgery so that one is fine too.

[Esme12, ASN, BSN, RN]

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the pateint?