Nursing Dx

[thatchergirl, BSN, RN]

ok.. here's the patient..

med surg patient admitted with altered loc, hypokalemia, uti and dvt. hx of anxiety, depression, bipolar disorder, schizophrenia, ams, hypokalemia, uti, ari, anemia, she also claims 8 different personalities. the day i took care of her, the k+ was 3.7; h&h low 9.4 and 26.5 respectively. her ca (6.7), ph (1.5), and mag (1.2) which is also low and were replaced that day. the inr is 2. patient has a foley in. vs throughout shift were wnl. intake 1740 output 1700. no complains of pain except for a ha at 5/10 that was medicated with 325 mg of acetaminophen and after 1 hour she states pain of 1/10. left leg was edematous. patient was confused during shift and a&o x1 (self) the possible dx that i have are: 1st ill do the ineffective peripheral tissue perfusion r/t decreased blood flow to extremities aeb tissue edema and diminished peripheral pulse to right leg. the other one i'll use (my teacher said it would be a good one) is risk for injury r/t ↓ loc and with that i'll adress her hx and hypokalemia and also uti can cause confusion, right? well i was thinking risk for infection r/t ↓ h&h, but she already has one (uti) and the teacher kinda didn't like that one. another one was impaired urinary elimination r/t impairment in neurological sensing and control aeb inability to go to recognize the need to void - but i think that's more for people with spinal cord injuries because the interventions didn't really apply to my patient. so i'm feeling like out of ideas... what do you guys think of the following? we have to do it in order of priority. my teacher says " what can kill the patient first?" so i have these other options. altered loc - impaired memory r/t neurological disturbances (can't really kill you, can it?), risk for impaired skin integrity r/t immobility (risk for falls, patient was in bed and what not), and the other one fatigue r/t ↓ h&h. i don't know what to think of it anymore.

thanks.. i appreciate it!

[SuesquatchRN, BSN, RN]

Her left leg is edematous with a diminished pedal pulse because of the DVT. If the clot moves that'll kill her before anything else, no?

[nurseprnRN, BSN, RN]

you have it backwards, although you are in good company because most students do too. you don't pick a nursing diagnosis and then go looking for rationales for it. does your physician say whe first you appear in the office, "you have cancer, now i will check labs and other diagnostic tests"? no, of course not. data first, diagnosis after. and you cannot make a nursing diagnosis from a medical one. although we may use some of the same data, a medical diagnosis itself is not nursing assessment data.

you look at your patient and see what is wrong first, then make your nsg diagnosis after that. you have no data to support impaired urinary elimination--she has a foley, right?

she has edema not because of diminished arterial flow -- commonly described as "perfusion,"-- but because of decreased venous flow from the deep venous thrombosis. what are your data for that, besides the medical diagnosis? you need to assess temp and perfusion by looking at capillary flow-- do you know how to do that? one diminished vein will not affect arterial pulses unless it's the femoral vein, in which case things will back up thru the whole leg, but even then. which vein is thrombosed?

low hemoglobin and crit will not put her at risk for infection. that is why your instructor didn't like it. the pt can stilll be at risk for an infection even if she has one --she could be susceptible to another, perhaps-- but h&h aren't the reasons. when you look in your nanda neg diagnosis book (which you and every student should have stat) you will not see low h&h as defining characteristics for infection risk. it's the defining characteristics that enable you to make the diagnosis, see? low h&h could cause fatigue but how do you know she has fatigue? you don't say. some people tolerate anemia just fine. does she or not?

i know this is harder than you thought. nursing is a whole new profession to you, and there is a lot to learn.

[NCRNMDM, ASN, RN]

This is just food for thought. I realize that her electrolyte levels are low, but they are being corrected, and will soon be at the correct levels. Since she has a history of renal insufficiency (I assume that's what ARI stands for in your post, that's all I've ever seen it stand for) couldn't she be at risk for a future electrolyte imbalance? In addition to the ARI, she has a history of hypokalemia, so it seems that she is more at risk for electrolyte imbalance than most people. If I were in your position, I would use risk for electrolyte imbalance secondary to renal insufficiency and PMH of hypokalemia. If I didn't use it, I would at least consider it.

[NightNurseRN13]

"Altered LOC - impaired memory r/t neurological disturbances (can't really kill you, can it?)"

Yes, it really can! Altered LOC is a biggy when it comes to safety!! Not to mention the other psychological issues she has going on.

Also, You can be at risk for infection even if you already have one.

[3boys_n_a_dog]

all of the nursing diagnosis books have list of defining characteristics, interventions and outcomes. i think that would be a great tool for you moving forward. when doing my care-plans this book has been a savior. [h=1]nursing care plans: diagnoses, interventions, and outcomes [paperback][/h][color=#004b91]meg gulanick (author), [color=#004b91]judith l. myers (author). i got it from amazon for $4.00!

i wish you luck!