Nursing diagnosis

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Hello all, I am a third year nursing student and a little stuck with my care plan. My patient's primary diagnoses are renal failure and bipolar. She also has lost about 34 pounds in the past eight months however her appetite has been pretty normal thru her hospital stay. This is what I am thinking for her diagnoses: Altered nutrition: less than body requirements related to decrease po intake secondary to renal failure as evidenced by pounds wight loss in the past 8 months. Does this make sense even though her intake is quite good right now and she has stopped loosing weight? would I lose any marks?

She is also suffering from ulcerative colitis. My second diagnoses I was thinking: risk for skin breakdown related 5-6 loose stools per day secondary to ulcerative colitis related to? she does not currently have any skin breakdown and she is continent and independent, just not sure what to put for AEB?

she does not have any social issues and her bipolar pretty well controlled with meds. We are required 4 diagnoses so I will be talking about bipolar and I kinds have an idea what to write but if someone can help me with above two diagnoses I would truly appreciate it. Thanks

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Specializes in Med-Surg, LTC, Psych, Addictions..

The risk for skin breakdown diagnosis does not have an AEB because it isn't an actual problem yet.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

could the weight loss be from the ulcerative colitis and diarrhea? what else could diarrhea cause? How does her renal failure impact her life? what are her labs? Is she on dialysis? What meds does she take?

What did your assessment show?

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Thanks for your reply and thanks for the idea,I actually think I might use her colitis and not her renal failure. Imbalanced Nutrition: less than body requirement related to diarrea secondary to UC as evidenced by 34lbs weight loss in the past 8 months. I think this makes more sense now. Her labs mostly look ok, creatinine is obviously high but it has been coming down gradually. Shes not on dialysis and most of her meds are for colitis and bipolar. The problem is her assessment did not show much thats why I kinds went with weight loss. I might have to look for another diagnoses instead of risk for skin breakdown as there is no AEB and our teacher needs AEB. Maybe deficient fluid volume that could increase risk of dehydration?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

but what meds? Is she on lithium for example....is she on steroids? What would she also be at risk for with renal failure? She makes urine then? Is she vulnerable to fluid overload? Deficient volume due to diarrhea but again what evidence do you have?

What is her skin turgor? is it poor? is there edema? Does she have renal failure for sure? How is her creatinine decreasing without dialysis or ws the creatinine elevated from dehydration?

Something doesn 't make sense here.

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Shes not on lithium , shes on effexor, and olanzapine. Yes shes on prednison as well. She has a foley catheter and I emptied it for 800cc clear urine. No edema, no crackels noted on my assessment. Her skin turgor was certainly poor and her skin is dry and flaky. Her admitting creatinie was 670 and today it was 140. Shes been getting normal saline continuesly 100 cc /hr and i think she got quite a few boluses in ER. I tried to look why she was dehydrated to begine with but cant seem to figure it out. she also has diabetes but it is in control. she will be at risk of dehydration for sure but to what extent i dont know. so would deficient fld volume make sence? related to poor skin turgor and dry mucouse membrane secondary to renal failure as AEB creatinine level of 670?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Shes not on lithium , shes on effexor, and olanzapine. Yes shes on prednisone as well. She has a foley catheter and I emptied it for 800cc clear urine. No edema, no crackles noted on my assessment. Her skin turgor was certainly poor and her skin is dry and flaky. Her admitting creatinie was 670 and today it was 140. Shes been getting normal saline continuously 100 cc /hr and i think she got quite a few boluses in ER. I tried to look why she was dehydrated to begin with but cant seem to figure it out. she also has diabetes but it is in control. she will be at risk of dehydration for sure but to what extent i don't know. so would deficient fluid volume make sense? related to poor skin turgor and dry mucous membrane secondary to renal failure as AEB creatinine level of 670?

creatinine was 670 and today it was 140
Are you sure this is the lab? What country are you from? What does 3rd year student mean? Is this your first care plan?

There is something missing from this story.....IV hydration doesn't magically correct renal failure unless that failure was from extreme dehydration and acidosis.

So now this patient has diabetes, ulcerative colitis, and bi-polar disorder that was admitted with renal failure (chronic or acute) with weight loss.

Is this an insulin dependent diabetic? What does the prednisone do to her sugars?

Start from the beginning and tell me your assessment of this patient....not what Nursing diagnosis you think they should have....tell me about this patient....from the beginning.

For example....this is a XXyear old female patient with a history of.........she presented to the ER with......her color is ......

So I can figure out what is up with this patient

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Thats okay I already submitted the care plan. Did you mean why the numbers are high for creatinine? because we are in Canada and normal creatinine is 59-106. It is not my first care plan but I cant just put my whole assessment here I just needed help with diagnoses. My assessment was 5 pages but I do appreciate your help because you made me think about stuff that I did not pay attention to. I just was not sure what you mean what third year mean? I am in third year graduating next year, hope that answers your question. Again thanks for the help and I will for sure be coming back here :)

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This is what I am thinking for her diagnoses: Altered nutrition: less than body requirements related to decrease po intake secondary to renal failure as evidenced by pounds wight loss in the past 8 months. Does this make sense even though her intake is quite good right now and she has stopped loosing weight? would I lose any marks?

You didn't say anything about her having a decreased PO intake, and if she does, what makes you think this is related to (caused by) her renal failure?

Ulcerative colitis is a big deal. What do you know about weight maintenance in that?

Risk diagnoses are just as real as active problems, but your thinking they work the same (as evidenced by your search for AEB for one) indicates a knowledge deficit on your part. To address this, I prescribe the NANDA-I 2012-2014 (current edition), $29 at Amazon c free 2-day shipping. You must look at the nursing dx to see how this works, and there is no other work about nursing dx that does this-- all others are secondary sources.

And at this point, I would seriously worry less about losing (note spelling) marks than really understanding the nursing process. If you get that, the marks will take care of themselves. Get the book.

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