nursing diagnosis

[gaajr1, RN]

I have a question regarding nursing diagnosis.

My patient is 69yrs; married, Spanish speaking (can say yes/ no and very short phrases; needs translator),

Admitting diagnosis: renal failure diabetes

History: HTN, NIDDM, osteoarthritis (however has no problems-pain etc)

3yrs back diagnosed with renal failure

15 yrs diabetes

rr 18; BP 148/80; HR 77; sinus rhythm 75; pulse OX 99%

fistula-bruit/thrill-patent

mentally alert

crackles bil lower lobes

peripheral pulses-equal

Appetite good

Accucheck 126; given 3 units insulin

Input 250ml

output 275 ml

last dialysis 10/10

legally blind in rt eye; left vision 60%; wears glasses at home

ADL's -self

Meds;clonidine

clopidogrel

enteric coated aspirin

furosemide

hydralazine

losartan

oscal D

nifedipine XL

sevelmar HCl

dextrose 5w 50ml

Tylenol

epoetin alfa

insulin human R

nitroglycerine

General obs: very alert, does everything by self, has good family suppport, cooperative. During the day when BP shot up the family let us give the bp meds but if it was around 140s they didn't want us to give.

I have to write 3 diagnosis and here is what I have but I'm really not sure if I'm going the right way.

1. Imbalanced nutrition:less than body requirements r/t disease process

2. Impaired verbal communication (don't know how to substantiate this)

3. knowledge deficient

please let me know. I really appreciate the help. Thanks!

[gaajr1, RN]

Okay how about these:

Fluid volume excess r/t decreased renal perfusion AEB .....(high bp, crackles, electrolyte levels)

Decreased cardiac output r/t ....AEB bp 186/92; crackles in lower lobes (but I have no more objective data)

I'm not sure, I feel I'm going in circles!

[Daytonite, BSN, RN]

are you just guessing at these nursing diagnoses or is there some rational thinking you are doing to arrive at them? diagnosing is a rational process. did you try using the nursing process to work out what the diagnoses here are?

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• (chronic) renal failure
  
• diabetes (type ii)
  
• htn
  
• legally blind in rt eye; left vision 60%; wears glasses at home
  
• osteoarthritis
  
• treatment: av fistula for dialysis
  
• medications
  
  • clonidine (carapres - antihypertensive)
    
  • losartan (cozaar - antihypertensive)
    
  • hydralazine (apresoline - antihypertensive)
    
  • nifedipine xl (ccb - antianginal/antihypertensive)
    
  • nitroglycerine (coronary vasodilator)
    
  • clopidogrel (plavix)
    
  • enteric coated aspirin
    
  • furosemide (lasix - diuretic)
    
  • oscal d (calcium replacement)
    
  • sevelamer hcl (phosphate binder)
    
  • tylenol
    
  • epoetin alfa (for anemia - stimulate rbc production)
    
  • insulin human r - on sliding scale insulin coverage

look up the causes, signs/symptoms of chronic renal failure and type ii diabetes. you are going to find that all of her medical conditions are related to the diabetes. part of the reason you are having difficulty with the related factors of diagnoses you want to use is because you do not know the pathophysiology of renal failure, htn or diabetes. when you learn about those, the reason for her problems will start to make more sense. everything going on medically with this patient is interlinked.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - what adls is this patient able to do? why is she in the hospital? what is being done for her in the hospital that couldn't be done in her home?

• bp 148/80 and 186/92
  
• crackles both lower lobes
  
• spanish speaking (can say yes/ no and very short phrases; needs translator)
  
• family active in care (what else is being done for this patient that she doesn't do for herself?)

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - do you have a nursing diagnosis reference? a nursing diagnosis reference will contain suggestions for the related factors for a diagnosis. your choices are:

• decreased cardiac output r/t ....aeb bp 186/92; crackles in lower lobes (but i have no more objective data)
  • this patient is on 3 medications for her blood pressure and a vasodilator. why does she have hypertension? is it a cardiac or renal cause?
    
  • cardiac output consists of blood volume (she has chronic anemia from the renal failure), heart rate and force of the heartbeat. why is the doctor dilating her cardiac arteries with nitroglycerin? if the heart tissue itself doesn't get enough blood it becomes hypoxic and can't do its job and chest pain and hypoxia result. the heart is the pumping station for the circulatory system. if it starts to do a lousy job (weak heartbeats with decreased force) because it is hypoxic or it's cells are not getting enough nourishment, blood starts backing up and congestion results. the lungs are one place that get the result of that--congestion. the high blood pressure is in large part due to the renal failure, but the heart is responding to it.

  [*]fluid volume excess r/t decreased renal perfusion aeb .....(high bp, crackles, electrolyte levels)

  • related factor: renal dysfunction
    
  • the htn is a renal perfusion problem and there is a different diagnosis for that. see [color=#3366ff]ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral

  [*]imbalanced nutrition: r/t disease process

  • eating less than body requirements is due to not getting enough food or the body not being able to digest or absorb the food it gets

  [*]impaired verbal communication (don't know how to substantiate this)

  • impaired verbal communication r/t foreign language barrier aeb limited use of english to "yes and no" to simple questions and need for english/spanish translator

  [*]knowledge deficient, specify

  • the related factor for this is almost always because of a lack of knowledge - you must also specify the teaching need in the diagnostic label, i.e. deficient knowledge, wound care.
    
  • what needs to be taught here?

try diagnosing this patient again, but after you have read about diabetes, chronic renal failure and hypertension.

[gaajr1, RN]

Daytonite, I deserve the wake up call. God knows what I was thinking! I will work on it and thanks a lot as always for being so patient.