Help with a couple of nur dx with pneumonia

  1. I'm a first year nursing student and I'm having trouble with my care plan. My patient is a 21 year old male who has pneumonia. I'm having a little trouble coming up with a couple of nursing diagnoses.
    1. He has a glucose level of 163 but he doesn't have diabetes. Is there a nursing diagnsis that i can use to address this?
    2. His 24 hour intake was 3878ml and output was 1232ml (although its not a whole 24 hours becuase he hasn't been there for a full 24 hours). Would you consider his intake and output appoximately? I'm saying no its not, but if thats the case, what nursing diagnosis should i use or is there one? Most of his input is from his IV intake. His oral intake was fairly low and i'm already using risk for deficient fliud volume? Is this right?

    I need some help!
    Thanks in advance
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    About brs72007

    Joined: Nov '08; Posts: 5

    8 Comments

  3. by   deftonez188
    Second year student here - i'll help as best I can.

    With the BS, I wonder if he's receiving breathing treatments like a steroid because I previously had a diabetic patient (I realize yours isn't) who was also receiving steroids treatments with the bubbler (I think that's what respiratory calls it ha!) - this caused a significant blood sugar elevation on its own. Also, the stress of the illness with sympathetic stimulation could cause that increase in his blood sugar...but that's just a guess.

    The Dx of Deficient Fluid Volume is good, you might even want to use PC: Electrolyte Imbalance if you're still seeking other dx's. I would say if that were his intake and output for 24 hours, he might have come in with a deficit and his body is taking its time to rebalance. Continue to monitor urine output, assess mucous membranes for hydration, skin turgor, whether eye sockets appear sunken, possible mental status changes, current labs particularly sodium and potassium, and potential sources of lost fluid not couned (ex emesis or large draining wound).

    Just my guesses, I don't know it all yet either
  4. by   brs72007
    Thanks for your input deftonez188. I was thinking about the same thing with his BS levels (stress, breathing treatments) too. Is there any nursing dx for that though?
  5. by   deftonez188
    I'm sure there are better one's than these but:
    1. PC: Adrenocorticosteroid Therapy Adverse Effects - remembering back to endocrine, the cortisol secreted d/t therapy with steroids is involved normally in the stress response, it manipulates the body in ways to provide it with increasing glucose to deal with the stress of a situation, example: infection - this in and of itself if being received could be responsible for the rise in glucose associated.

    Just a guess. Isn't all of medicine? >

    2. PC: Hyperglycemia - it's pretty broad and you could utilize it in a way you see fit. This would be acceptable considering it names the current problem without straight diagnosing anything. I have seen docs do it - example a patient who possibly had Barretts syndrome was written up as 'impressions of Barretts syndrome' but with formal diagnosis of Hypocalcemia, Hyperphosphatemia, etc. If they can do it, so can you - we aren't here to assign something that isn't there

    Hope this helps.
  6. by   suehernando
    I am almost finished with school, I can give you suggestion from my experiences in clinical.
    An easy one would be risk for infection r/t inadequate primary defenses(e.g. decreased cilary action)
    The deficient fluid volume is a good one. I know that are school is doing care mapping, which is based off of your patho. Is the client taking any of the following cortisone, thiazides and "loop" diuretics
    Asked a friend and got ineffective airway clearance r/t the presence of tracheobronchial secretions secondary to infection and impaired gas exchange r/t altered oxygen supply and alveolar- capillary membrane changes secondary to inflammatory process in the lungs. I hope that it helps from one student to the next. Good luck.
  7. by   brs72007
    Thank you for the info suehernando! He isn't on any of those meds you listed but i'm using the deficient fluid volume for his fever, infection, increased metabolic rate, and increased respirations. Do those fit for the dx? As for the risk for infection one, since his already has the infection... i didn't think i could use that one?
  8. by   Daytonite
    he has a glucose level of 163 but he doesn't have diabetes. is there a nursing diagnsis that i can use to address this?
    this is just a lab reading. nursing diagnoses are also based upon the patient's responses to their medical conditions. what other signs and symptoms did this patient have? if he were hyperglycemic, did he also have any urinary frequency, polyuria, polydipsia orthostatic hypotension, signs or symptoms of dehydration, weakness, fatigue, mental status changes, polyphagia, nausea and vomiting, or blurred vision? hypoxia will sometimes cause an elevation in blood sugar. do you have a set of abgs on this patient? does the patient have an iv with d5w infusing? was his labwork drawn while the iv was infusing? possibly from the arm the iv was in? was his labwork drawn while he was eating or within an hour of eating?
    his 24 hour intake was 3878ml and output was 1232ml (although its not a whole 24 hours becuase he hasn't been there for a full 24 hours). would you consider his intake and output appoximately? i'm saying no its not, but if thats the case, what nursing diagnosis should i use or is there one? most of his input is from his iv intake. his oral intake was fairly low and i'm already using risk for deficient fliud volume? is this right?
    did you consider all fluid losses? what about insensible losses through the respiratory track because of the pneumonia (tachypnea)? how much sputum is he coughing up? does he have any diarrhea? i didn't see a set of vital signs. is he breathing rapidly? what makes you think he is at a risk to become dehydrated? does he have any signs or symptoms of dehydration?
    this patient has pneumonia. where is your respiratory assessment of this patient? a care plan should be constructed by following the steps of the nursing process. that begins by doing a thorough assessment of the patient. assessment consists of:
    • a health history (review of systems)
    • performing a physical exam
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    i cannot help you diagnose this patient's nursing problems when the only data you have posted is
    • pneumonia - which is a medical diagnosis
    • glucose - 163
    • 24 hour intake 3878ml/output 1232ml
    you are missing
    • lung sounds
    • assessment of sputum or cough
    • abgs
    • pain assessment
    • vital signs
    • assessment of the patient's ability to perform activity
  9. by   ricelad637
    Wow, you just blew everyone out of the water! I am in my first semester as well and getting used to the nursing process. We haven't really gotten into ABG's yet and the whole thorough assessment that you recommended but I really like the format in which you answered their question. I learned a whole lot about assessment by just reading this single post, thank you for you contribution. I just think that first semester that they teach you so much of the basics that they don't really get a chance to go into depth just yet, like you did, but just a question to Daytonite, did you learn these nursing priorities in assessing someone with pneumonia from applied knowledge through school? Or is this something you picked up while working? I would just like to know if there is a book out there that is similar to a pathophysiology book that describes a medical condition, signs n symptoms, and medical treatments, but in addition has a nursing process focus and priority assessments and interventions? (Just like the way you answered the original posters question)
  10. by   Daytonite
    Quote from ricelad637
    . . .just a question to daytonite, did you learn these nursing priorities in assessing someone with pneumonia from applied knowledge through school? or is this something you picked up while working? i would just like to know if there is a book out there that is similar to a pathophysiology book that describes a medical condition, signs and symptoms, and medical treatments, but in addition has a nursing process focus and priority assessments and interventions? (just like the way you answered the original posters question)
    i have been an rn for over 30 years that primarily worked with medical/surgical patients. i not only learned about pneumonia in nursing school, but had many, many patients with it. pneumonia, and there are many types of it, is a common co-morbidity (complication of medical care).

    i believe i learned the nursing process in nursing school back in the 70s although i do not recall any formal lectures about it. when i went back to school for my bsn the nursing process, prioritization and nursing diagnosis was talked about. however, it wasn't really until i began seriously answering student questions here on allnurses that i went back and started reviewing maslow's hierarchy of needs. things evolved and have changed in the way nursing is taught since i was first in nursing school back in the early 70s. as i saw student questions about the nursing process i was able to draw upon my years of experience to show how this process can be put into practical use. and the fact is that over the years, with experience, one does learn to do these assessments and nursing interventions in priority order. if you don't, you end up making mistakes on the job and go home and cry--at least i did. that is learning by the school of hard knocks and one of the things i am trying to do is help many of you avoid a few of those tearful sessions.

    the nursing process is something which really doesn't take that long to explain and is actually derived from the scientific process. nursing adapted for its use. it is, however, primarily a problem solving method and its steps can be applied to any problem you have that needs some kind of resolution. this is an analogy of the 5 steps applied to a common problem of life. . .
    you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).
    the process can be applied to any situation requiring a solution. we need to learn it because as rns one of our functions is as a problem solver. a care plan is identification of a patient's nursing problems and strategies to do something about them. this is what those 5 steps look like broken down specifically for writing a care plan or even a case study:
    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) [font=arial unicode ms]
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (https://allnurses.com/nursing-studen...al-227507.html)
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
      • use: https://allnurses.com/forums/f205/me...es-258109.html - medical disease information/treatment/procedures/test reference websites
      • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda international nursing diagnoses: definitions and classifications 2009-2011 published by nanda international for $34.99. http://www.nanda.org/marketplace/nan...lications.aspx
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
      • always sequence actual nursing problems before potential (risk for) or anticipated problems
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements: see post #157 on thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.
    these websites also address and have information about the nursing process:
    yes, there are books and websites that have the signs/symptoms and medical treatments of these medical diseases and conditions as well as what we nurses should assess and treat. these are some of the reference books and websites that i use to do this:
    books:
    • nurse's 5-minute clinical consult: diseases from lippincott williams & wilkins - lists basic pathophysiology, signs, symptoms, complications, diagnostics, basic medical treatment, nursing diagnoses/outcomes/interventions/monitoring, and patient teaching - only lists, and nothing goes into depth.
    • nurse's 5-minute clinical consult: treatments from lippincott williams & wilkins - companion to nurse's 5-minute clinical consult: diseases and goes into specific nursing care of surgically performed treatments. includes many major surgical procedures and the nursing care for them.
    • nurse's 5-minute clinical consult: procedures from lippincott williams & wilkins - companion to nurse's 5-minute clinical consult: diseases. includes many independent nursing procedures, key steps involved, complications, patient teaching and documentation.
    • pathophysiology: a 2-in-1 reference for nurses by springhouse, springhouse publishing company staff - i have been recommending this book for a long time. it only includes medical diseases organized by body systems and gives the pathophysiology in easy to understand language, signs and symptoms, complications, how the disease is diagnosed, how the docs treat it and then most importantly, the nursing considerations (nursing interventions).
    • nursing care plans: guidelines for individualizing client care across the life span, 7th edition, by marilynn e. doenges, mary frances moorhouse and alice c. murr - this care plan book has very specific abnormal assessment information that is found during examination of patients with the medical diseases that are care planned in this book. you can view the table of contents on a website such as amazon or barnes and noble. the problem with care plan books is that they only include popular and commonly encountered medical diseases and not lesser seen conditions. their companion book for ob maternal/newborn plans of care: guidelines for individual care, 3rd edition, by marilynn e. doenges and mary frances moorhouse has the same assessments in it for all kinds of ob conditions.
    websites:

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