Glioblastoma Care Plan -- HELP!

[ldyjstce]

i am in a complete panic because i am so very unsure of what to do. i am in my final semester of nursing school and have been presented with a problem of which i am unsure how to proceed. i have a week to write a care plan on the following patient: 51 y/o, male, presented to the er w/ l sided weakness and dysphagia on 1/21. hx includes dx of glioblastoma (late 2008), dm, htn, suspected mi, and suspected cva and generalized seizures. the reason i stated "suspected" is that these are believed to have happened post-admission. there has been no definitive testing done by his md because he is considered terminal with a limited time left. his gcs hovers around an 8 on a good day.

i was assigned to him for 2 days this week. after my last day of care, the md has given the ok to admit him to the hospice wing of the hospital. because of his loc, i don't know where to go with this. i have to take 5 high-level nursing dxs and flesh them out through each system, head to toe. i was able to speak with his wife and daughter and learned some history with which i supplemented his chart information.

he is on d5 1/2 ns at 30ml/hr and receives morphine q30" prn pain. his wife is the one who lets the staff know that he is in pain and she bases her thoughts on the fact that he will raise his hand and rub his right temple (site of the tumor). he is, of course, npo and receives a dose of lasix qday. he is incontinent of bladder and has not had a bm in > 1 week. his wbg stays around 200+ even with insulin therapy and receives keppra tid for seizure prevention. his o2 sats began to drop by about 6% at the end of my first day and they continued to hover around 89-91%.

the md placed him on flagyl for 24' because of the pt's horrendous halitosis despite intensive oral care. his md believed that there may have been some type of oral anaerobic bacteria contributing to his malodorous breath.

his hr and rr remained strong. at the end of my second day, i did notice babinski reflexes.

here is my problem: when the pt is non-communicative d/t his illness and the md has basically turned his care into palliative, what do i do to come up with proper proper primary nursing dxs? i have some thoughts, but i don't really consider them "high-level" dxs.

any thoughts as to how to get the brain in gear? i know that he is at: risk for impaired skin integrity d/t incontinence & dm; risk for injury d/t prior seizure activity; risk for ineffective airway clearance (not sure exactly how to word it); risk for unstable glucose (d/t dm); risk for fluid volume imbalance. . . .

i am so frustrated and overwhelmed by this. if i had had a pt. that was more communicative and not terminal, i would feel much more confident, but this is the first pt. i have had in nursing school who is terminal and the first who is non-communicative.

anyone have any guidance?

thanks, in advance!

[Valerie Salva, BSN, RN]

Hospice, morphine, pain? sounds like pain would be an excellent NDX. Pain is now considered to be the 5th vital sign and pain assessment and control are very important. Also, the pt has low sats- remember A-B-C?

This pt may be non-verbal, but all pts communicate- with their V/S, their labs, grimacing facies, muscle rigidity, guarding, and by pointing at their head "site of tumor".

This pt is on palliative care- what is the number one goal of palliative care? These things show what your "high level" NDX and goals should be.

[ldyjstce]

Yes, I know about the 5th VS and yes, I know that non-communicative patients "communicate" through these VS. I thought that I had mentioned that his pain was one of my high priority nursing dxs, but unfortunately, I forgot to post that -- I have that one written out and completed. My care plan is to be approximately 80+ pages and is to include a minimum of 5 high priority nursing DXs and they cannot all be risk for dxs.

A-B-Cs and VS are the pinnacle of ANY nursing care, we all know this -- yes, including me! Just a bit of further information: the MD stopped ordering labs over 7 days prior, his VS (sans sats) were stable and WNL. At the time I was caring for him, he was on a regular floor and he was to be transferred to hospice after my care for him ended.

Again, any direction would be helpful as I have never dealt with a pt that could not ambulate, verbalize, etc. This is a LEARNING experience for me.

[Daytonite, BSN, RN]

a nursing care plan focuses on the patient's nursing problems and this man has plenty of actual problems, not just "risk for", or potential, problems. he is terminal and can do practically nothing for himself, so he is almost totally dependent on the nursing staff for his care. you have to stop thinking like a doctor and start thinking like a nurse. our job is to help patients cope with their responses to their medical and life conditions. end of life care is a challenge because the goals are a little different. the goal is to support the deterioration of the patient's condition.

all care planning begins with assessing the patient. that assessment not only includes doing a physical exam, but also assessing their ability to perform their adls and how much help they need with those. in this case, a lot of this man's adls must be done for him and there are self-care deficit nursing diagnoses that reflect that problem. if he is incontinent, there are incontinent diagnoses to choose from and you can include your skin care with your interventions for that. rather than using risk for injury there is another actual problem diagnosis named ineffective protection that you can consider using. communication problems fall under impaired verbal communication. if he cannot ambulate there is a diagnosis called impaired bed mobility you might want to check out.

if you have a nursing diagnosis reference (the taxonomy is contained in the appendix of recent editions of taber's cyclopedic medical dictionary) you can leaf through all the diagnoses, read their definitions, and see that there are lots of choices to go with based on this man's assessment data besides the ones that you have probably just worked with in the past. diagnosing is not guesswork.

your goals and nursing interventions then are based upon the assessment data that are evidence of each diagnosis. you treat these abnormal assessment items (symptoms) just as a doctor treats the various symptoms of disease when you write your nursing interventions. your goals are what you expect will happen as a result of those interventions being performed. and, as i said above, they can support his deterioration or they can also support the stabilization of his condition.

[ldyjstce]

I think you hit the nail on the head! I have to quit thinking like a doctor and remember to think like a nurse. All I saw were "risk for"s and what you stated makes my brain turn in a different direction. I can't "fix" or "heal" him, therefore I must "help" him with his final days. Right? I meet with my instructor tomorrow -- I will let you know what comes from the meeting. Thanks again!!

[ldyjstce]

As it goes in the medical (and legal) field . . . my instructor changed the pt. for whom I was doing a care plan [and the one who was discharged halfway through the first day]. Soooo very much my luck. She assigned me 6 diagnoses she would like for me to include:

1. Risk for Ineffective Airway Clearance
   
2. Ineffective Tissue Perfusion: Cardiac
   
3. Risk for Unstable Blood Glucose
   
4. Risk for Ineffective Protection
   
5. Risk for Fluid Volume Imbalance [she told me to use these exact words and nothing more. Odd?]
   
6. Fatigue
   

First thing I am to do is rank these in order; I have attempted to do so above. Am I thinking correctly (ABC, VS, Maslow) with regard to my rankings?

Thanks!

[Daytonite, BSN, RN]

"Risk for" diagnoses are potential problems and are not considered as much a priority as actual problems. Actual problems are always sequenced first. I'm glad you recognized that some of these are not official NANDA diagnoses.

1. Ineffective Tissue Perfusion: Cardiac
   
2. Fatigue
   
3. Risk for Ineffective Airway Clearance
   
4. Risk for Fluid Volume Imbalance
   
5. Risk for Unstable Blood Glucose
   
6. Risk for Ineffective Protection
   

[ldyjstce]

Thank you! I thought that was the case, but was unsure!

Another quick question, she has me doing the dx of "risk for ineffective protection" based on the pt's decreased WBC count. This is a new dx for me -- I haven't used it in the previous 3 semesters. I don't understand why this would not be a "risk for infection" instead. Any insight on what I may be missing?

[Daytonite, BSN, RN]

it is another diagnosis that can be used in place of risk for infection except that risk for ineffective protection is not an official nanda diagnosis, but ineffective protection is. it is a safety and protection diagnosis. it's definition is decrease in the ability to guard self from internal or external threats such as illness or injury (page 219, nanda international nursing diagnoses: definitions and classifications 2009-2011). the taxonomy lists the related factors for this diagnosis (they would become your risk factors for risk for ineffective protection) as:

• abnormal blood profiles (e.g., leukopenia, thrombocytopenia, anemia, coagulation)
  
• alcohol abuse
  
• cancer
  
• drug therapies (e.g., antineoplastics, corticosteroids, immune, anticoagulant, thrombolytic)
  
• extremes of age
  
• immune disorders
  
• inadequate nutrition
  
• treatments (e.g., surgery, radiation)
  

remember that the goals "risk for" diagnoses are that the problem doesn't occur and that the nursing interventions are limited to:

• strategies to prevent the problem from happening in the first place
  
• monitoring for the specific signs and symptoms of this problem (look up the signs and symptoms of leukopenia--low wbc count)
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  

[ldyjstce]

Ahhhhhhhhh . . . I didn't think it was a NANDA dx! Thank you for your help. You have no idea how much it means!!