Help with Nursing Care Plan, PLEASE??

  1. i'm working through my nursing care plan and i've reached a point where i think i've begun to overthink things and may have just gone off the deep end. maybe typing it all out will shake something loose. thanks for reading along and any advice.

    general info
    71 year old african american male,
    hx - end-stage renal disease, hypertension, diabetes mellitus-type 2, osteoarthritis, av fistula left upper arm for hemodyalisis 3x week,
    measures - on fall prevention program, 2l o2 via nc, diet-80 gm pro 2gm na 2 gm k+, strict i&o
    admitted for febrile illness (after hemodyalisis treatment) productive cough (green sputum) diminished breath sounds anterior rll and lll accompanied by rhonchi and wheezes. by the time i was assigned this pt, he had already received iv antibiotics and was afebrile for 24 hrs, with a non-productive cough, and no wheezes or rhonchi present on auscultation. rll and lll still had slightly diminished anterior breath sounds, and x-ray/diagnostic testing had ruled out pneumonia
    signs and symptoms present on my physical assessment
    hard & distended abdomen (received hemodyalisis later that day)
    non-prod cough
    diminished breath sounds anterior rll and lll
    labored breathing (accessory muscle use)
    loss of appetite
    cool distal extremities (cap refill good < 2 sec)
    hr- 74
    resp- 22
    temp- 97.5
    sao2 - 99%
    lab values of importance:
    bun 55
    creatinine 13
    phosphorous 8.2
    rbc 3.98
    hgb 12.4
    hct 37.8
    rdw 17.1

    here's where i'm just not seeing the forest for the trees, i am looking at all his symptoms and having the hardest time knowing what to put as his "problem" in my care map. i have to have three nursing diagnoses for this patient and it has to be focused on "renal" (one out of five categories we must do a care plan on this term). the diagnoses themselves i see that just jump out at me are,
    1. [font=christiana-bold, sans-serif]excess fluid volume related to inability of kidneys to excrete fluid as evidenced by oliguria
    2. [font=christiana-bold, sans-serif]fatigue related to effects of chronic uremia as evidenced by verbalization of an un remitting lack of energy
    3. [font=christiana-bold, sans-serif]risk for infection related to invasive procedures (yes, i also think risk for falls is important but chose this one based on his being well enough for discharge the next day)

    i feel good about my goals, outcomes, and interventions for these diagnoses, and i won't waste more space by listing those. the problem (the only one i keep penciling in) is "renal failure" but . . . isn't that his medical diagnosis? ugh! thanks for the time taken to read through my madness, sleepdeprivedmomma
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    About sleepdeprivedmomma

    Joined: Jun '09; Posts: 8; Likes: 6
    from US


  3. by   Daytonite
    well, the diagnosis that jumped out at me was a respiratory one, ineffective airway clearance. i recognized the symptoms immediately: non-productive cough and diminished breath sounds anterior rll and lll. the labored breathing with accessory muscle use is ineffective breathing pattern. however, if i read your post correctly, you must focus on the renal system, right?

    every nursing diagnosis just like every medical diagnosis has a list of patient behaviors called cues or symptoms that we can observe and are characteristic of that specific nursing problem. nanda calls these cues or symptoms defining characteristics. a related group of cues and symptoms (defining characteristics) becomes a specific nursing problem and is given a label called a nursing diagnosis. only abnormal data can be used as cues or symptoms. the cues and symptoms you posted that might have anything to do with the renal nursing diagnoses are:
    • oliguria - this is really a medical term and is diminished urination. my experience with esrd patients is they often produce no urine.
    • fatigue
    • bun 55
    • creatinine 13
    • phosphorous 8.2
    • hgb 12.4
    • hct 37.8
    did you read about esrd? anemia is one of the complications. our renal failure patients often complained of nausea as well because of the buildup of toxins in their system. since diabetes is often an underlying cause the complications of diabetes are usually there as well including a number of pareses and neuropathies. these patients have fluid imbalances; one day they are fluid overloaded and the day after dialysis they are dehydrated. their skin has an unmistakable bronze hue to it which may be a tad difficult to notice in black patients but it can be seen in their eyes and nails. they may have pruritis. if you speak with them about it, they will tell you that that mentally they are just not thinking as clearly as they used to and that is because of the toxin buildup. the dialysis doesn't get all the toxins out.

    did you review the medications that this patient was on? that is a good clue as to some of the problems that the doctor has had to address with him.
    • ineffective tissue perfusion: renal r/t hypoventilation and decreased hemoglobin aeb oliguria, bun of 55, creatinine of 13, and phosphorous of 8.2.
    • excess fluid volume r/t renal dysfunction aeb weight gain with water and fluid intake and no urine output.
    • fatigue r/t renal dysfunction and anemia aeb lack of energy [need for rest, lethargy] and decreased hemoglobin and hematocrit levels. - an alternative is to use activity intolerance but you need respiratory and cardiac symptoms such as elevated rates of each with activity and patient needing to stop activity and sit down.
    when you have a medical diagnosis break it down into its component signs and symptoms first because we can only use those to decide upon nursing diagnoses.
  4. by   NurseKitten
    If he's a chronic ESRD'er on long term hemo, nausea shouldn't be a problem. It usually abates. If he's complaining of fatigue, anemia may very well be the culprit, made worse by the infection. (BTW, it's not just the uremia that causes it, although it is one of the factors.) Your interventions could focus on teaching coping techniques and ways to accomplish ADL's with minimal energy expenditure.

    You could also use the anemia pathway if you were talking about risks for altered tissue oxygenation, given that he has decreased oxygen carrying capacity coupled with decreased oxygenation across the alveolar membrane.

    Holler if you still need help.
  5. by   sleepdeprivedmomma
    Thank you both. Honestly your help has made this a relatively sane process. I'm finishing up now. I did want to clarify something though.
    I think I may have mistakenly guided you to think that I'm working on the Critical Thinking Flow Sheet. I've gotten that taken care of and am now hacking my way through this concept map.

    There's the copy of the concept map I am filling out. Just for future reference for anyone looking at this, we have to list assessment data, then formulate the "problem", have three goals with their own outcomes, three nursing diagnosis with three interventions each, and then, somewhere (I'm assuming at the bottom) list evaluations of those interventions. Of course, this Concept Map is different from the one they trained us with last semester as, I'm sure, next semester's be different from this one. I guess they're just trying to help us get used to bureaucracy and the joy of dealing with admin.
  6. by   Daytonite
    there is no bureaucracy involved. this concept map is merely helping you to work through the steps of the nursing process. nursing diagnoses, goals/outcomes and nursing interventions are all based upon the abnormal assessment data that you collect about the patient. that is all part of the nursing process. i attempt to explain this all the time to students on this thread: - help with care plans. a concept map is one type of care plan. there are several others. they all incorporate the use of the nursing process.