Nursing Diagnosis

Nurses General Nursing

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Hello,

I have a patient that I need 5 nursing diagnoses on. He came into the hospital with a fever and right upper quadrant pain. He was found to have kidney stones which made him septic. He went to a general floor but was then transferred to ICU when he went into respiratory distress/hypoxia and his blood pressures dropped into the 70's. He had an ERCP with papillotomy and stone extraction. He was vented for the surgery and it took him 2 days to wean. He was put on a 100% nonrebreather and then 3L nasal cannula; however, his O2 was dropping so he had to go back up to 5L NC with humidification. His abdomen was still severely distended. He also had a history of afib but was not in afib on the day of care and was put on amiodarone as well as heparin SubQ. Lastly, he had uncontrolled diabetes and stated that he couldn't afford insulin. I am going to do Deficient knowledge (diabetes) for sure. However, would decreased cardiac outout be acceptable? What about hyperthermia due to sepsis and increased temperature? Impaired gas exchange? Thanks!

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Specializes in LTC/Rehab, Med Surg, Home Care.

Break it down and use the nursing process:

Start with your pt's symptoms:

fever and right upper quadrant pain.

kidney stones which made him septic

respiratory distress/hypoxia

uncontrolled diabetes and stated that he couldn't afford insulin

How would you justify decreased cardiac output as a nursing diagnosis? What are the signs and symptoms of decreased cardiac output?

Remember that the purpose of developing a nursing diagnosis is so that you can plan nursing care for your pt, not medical care.

So, related to the pt's fever, can you think of a nursing dx? How about r/t the pain? The kidneys? The respiratory distress? Diabetes?

Does this help give you a direction? I'm happy to help guide you, but I won't be putting up the nursing dx I think the pt. should have.

Hello,

I have a patient that I need 5 nursing diagnoses on. He came into the hospital with a He was found to have . He went to a general floor but was then transferred to ICU when he went into and his blood pressures dropped into the 70's. He had an ERCP with papillotomy and stone extraction. He was vented for the surgery and it took him 2 days to wean. He was put on a 100% nonrebreather and then 3L nasal cannula; however, his O2 was dropping so he had to go back up to 5L NC with humidification. His abdomen was still severely distended. He also had a history of afib but was not in afib on the day of care and was put on amiodarone as well as heparin SubQ. Lastly, he had . I am going to do Deficient knowledge (diabetes) for sure. However, would decreased cardiac outout be acceptable? What about hyperthermia due to sepsis and increased temperature? Impaired gas exchange? Thanks!

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Before you continue....I'll guide you, but you need to do your own homework.

Go look this up:

ERCP -

What is it for?

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I am a student myself. Let's see, just fill in the blanks according to his problems...

Pain R/T.....AEB....

Impaired gas exchange R/T....AEB......

More than body requirements (hyperglycemia)

Knowledge Deficit (diabetes or his other problems)

Risk for skin breakdown (high O2 levels given)

Infection R/T....AEB.....

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Specializes in ICU, APHERESIS, IV THERAPY, ONCOLOGY, BC.
Break it down and use the nursing process:

Start with your pt's symptoms:

fever and right upper quadrant pain.

kidney stones which made him septic

respiratory distress/hypoxia

uncontrolled diabetes and stated that he couldn't afford insulin

How would you justify decreased cardiac output as a nursing diagnosis? What are the signs and symptoms of decreased cardiac output?

Remember that the purpose of developing a nursing diagnosis is so that you can plan nursing care for your pt, not medical care.

So, related to the pt's fever, can you think of a nursing dx? How about r/t the pain? The kidneys? The respiratory distress? Diabetes?

Does this help give you a direction? I'm happy to help guide you, but I won't be putting up the nursing dx I think the pt. should have.

Your patient has multiple problems. However, the Mcgill Nursing model is helpful to break down patient's primary and secondary diagnoses. The model addresses a holistic assessment of the patient ranging from physical head to toe assessment, plus consideration of the patient and family's cognitive and social aspects influencing health.. In addition as one of the other contributors suggested, look up ERCP, what it is and what are possible side effects which can occur during the intervention. If there is R. upper quad. pain, which organs lie there or is this referred pain from another source? I would assume that your nursing assessment and plan would include

1) Consistent monitoring and nursing physical assessment ? eg bowel sounds, abdominal girth in addition to Bowel Sounds, measurements and frequency of vital signs temp. and O2 Sats. monitoring 3) How is the intake and output? What does his urine look like, and what is the result of urinalysis? What is he putting out vis a vis his intake. 4) If you are discussing cardiac outputs, I am assuming that you are cognisant of Swan Ganz and PA pressure monitoring in detail. If not, I would focus on close nursing observation which will be just as helpful and assist learning.

4)What of resp. distress is this sec. to abdominal distension, sepsis, shortness of breath, decreased Oxygen saturation? 5) Is there perif. edema, pitting of limbs and if so how much +, ++. is it increasing or not? 6) What is his cognitive level, oriented, sleepy confused?? 7) How is his bloodwork, basic electroytes, protein levels and enzymes?

8) His socio-economic state requires closer assessment. What are his habits and living conditions. If he cannot afford insulin, how unstable is his present diabetic state and for how long. 9) What is his family situation.

Just a few suggestions which I hope will help.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

first of all, there is a thread in the student forums to help with the construction of care plans that you should be looking at: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

second, i answer student care plan questions all the time and you will find hundreds of my posts on them. i will give you some guidance on how to proceed with this, but i am not going to give you all the answers.

a care plan is about determining a patient's nursing problems (we give them names called nursing diagnoses) and developing strategies to do something about them. to accomplish this, we use the nursing process which is the problem solving tool we have. we should be using step#1 and #2 to determine the patient's nursing problems. step #3 is where the planning is done (outcomes are determined and nursing interventions ordered). step #1, assessment, is crucial to the entire process and what happens in the remainder of the care planning is dependent on what is discovered during assessment of the patient.

step #1 - assessment. assessment consists of:

  • a health history (review of systems) - came into the hospital with a fever and right upper quadrant pain and found to have kidney stones. he became septic. he went into respiratory distress/hypoxia ended up in icu with blood pressures in the 70's and on a ventilator. he was eventually weaned from the vent and placed on a 100% nonrebreather and then 3l nasal cannula.
  • performing a physical exam - you have really given no physical exam information other than his abdomen was distended and i am not sure that it is a current finding. does he still have pain? what are his lung sounds, abdominal assessment, cardiovascular assessment now? does he have any edema? what is his urine output and urine looking like now? what does his i&o look like? all of this is assessment information that helps to determine what nursing problems are present. one of your nursing diagnoses mentions hyperthermia yet you mention no fevers or physical signs of his fevers (flushed skin, tachycardia, chills).
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - assisting with adls is what we nurses do and also why patients are in hospitals. what can't he do for himself? what are we doing for him? there are 4 self-care deficit diagnoses. do any apply here? he dropped a big social and economic bombshell when he said that he couldn't afford insulin. that is a problem that has to be addressed before his discharge.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - the signs, symptoms and complications of medical diseases are also defining characteristics of nursing problems (nursing diagnoses). to answer one of your questions, yes, decreased cardiac output would apply here, but you need to read about his different medical problem to see where it applies and how.
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - he's had an ercp, is on amiodarone and heparin. these drugs have actions and side effects that need to be monitored and accounted for in a plan of care. he was on a ventilator. has he got a sore throat from being intubated? a cough? do we just ignore that?

step #2 - determining the nursing problems. from all the information gathered above a list of everything that is what we call abnormal needs to be developed. that list becomes the evidence of all the nursing problems. our job is to sort the evidence out into groups. some of them can be grouped together because they will be evidence of the same problem with the same name (nursing diagnosis). other problems may only have one piece of evidence to go with the problem. the next thing is to figure out the name of the problem (nursing diagnosis) that goes with the evidence and that is the diagnosing. it is all very precise and logical. you may need a nursing diagnosis reference to help you with the naming. one can be found in the appendix of current copies of taber's cyclopedic medical dictionary, nanda international nursing diagnoses: definitions and classifications 2009-2011 which is published by nanda and any number of commercial published nursing diagnosis books. every nursing diagnosis has a definition, defining characteristics (signs and symptoms) and related factors (causes) to help us in diagnosing. diagnosing is not meant to be guesswork.

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deficient knowledge (diabetes)

i don't see your reasoning for this if it is based on him stating that he couldn't afford insulin. not having the money to buy medication is what my nursing program would have called an artifactual/material resource problem. that is a social problem.

hyperthermia due to sepsis and increased temperature?

hyperthermia
, the nursing diagnosis, is defined as
body temperature above normal range.
the related factor (due to) can never be a medical diagnosis.
increased temperature
is the evidence of this problem and not the cause of it.
hyperthemia related to increased metabolic activity as evidenced by elevated temperature of ____.

impaired gas exchange?

where's your evidence? abnormal abgs? signs and symptoms of hypoxia or hypercarbia? confusion? dyspnea?

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