Priority diagnosis diabetes, fluid & electrolytes

  1. I have to list 3 priority nursing diagnoses for a case study 21 year old male, brought to urgent care by friend, sore throat past week. Always thirsty, has tried to drink fluids and sleep but wakes q 2-3 hrs to urinate. VS: BP 90/62, P 102, R 30 deep and labored, and enlarged lymph nodes in neck, lungs CTA, heart tones regualr, no murmur or rub. Abdomen is tense and slightly tender. Skin dry, turgor poor,decreased deep tendon reflexes. He admits to feeling tired past month, thinks he has lost weight even though he has been eating "a lot". He's requesting antiobiotics to make him feel better.

    Lab results: hgb16g/dl Hct 53% RBC 5.0
    WBC 15,200/mm neutrophils 63% lymphs 27%
    Na 146 Cl 100 K 2.5 HCO3 2meq
    Glucose 782 Bun 48 Creat
    Urine specific gravity 1.035
    Ketones large and throat culture strep positive.


    I know increased Na caused by fluid deficit, Bun high from dehydration because creat ok. WBC is because of the strep.

    I've come up so far with
    Deficient fluid volume r/t excessive urinary output AEB thirst, freq urination q 2-3 hrs, temp 102, sore throat, BP 90/62. HR 30, lethargic, dry skin, deep tendon reflexes, pt complaint "feeling tired past month".

    I'm pretty sure he has non managed diabetes from labs high glucose, concentrated urine, pot is low because of hyperglycemia so my next diagnosis would be:

    Ineffective Health Maintenance r/t insufficient knowledge of effects of diabetes not being managed AEB request of antibiotics to make him better.


    I was going to use ineffective breathing pattern r/t fatigue AEB R30 deep and labored breathing. I know I can't use r/t DK, or hypglycemia, but the fatigue is because of the fluid loss, so this diagnosis i don't think i can use because fatigue will be fixed once he receives fluids.

    Maybe acute pain from ketones,(abdomen is tense)? but it doesn't state in the case study he's in pain.
    I need help please, I've spent way too long on this 4 days and I have another due on monday as well, and 2 final exams in 2 weeks. I think i'm making this too difficult.
    any help would be appreciated.







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    About intense0120

    Joined: Sep '08; Posts: 7

    5 Comments

  3. by   Daytonite
    to diagnose, apply the nursing process.

    step 1 assessment - the assessment data has been supplied for you. the only thing it hasn't done is told you that this patient has undiagnosed ketoacidosis. he does have strep throat confirmed by a positive throat culture.

    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data pulled out from the case scenario. i grouped them in consideration of some of the defining characteristics of the different nursing diagnoses and with maslow's hierarchy of needs in mind as well:
    • r 30 deep and labored
    • p 102
    • bp 90/62
    • sore throat x 1 week
    • always thirsty
    • skin turgor poor
    • thinks he has lost weight even though he has been eating "a lot"
    • abdomen is tense - this means it is in a state of being stretched, perhaps by a collection of gas or fluid and is a s/s of the ketoacidosis
    • enlarged lymph nodes in neck
    • wakes q 2-3 hrs to urinate
    • decreased deep tendon reflexes
    • feeling tired past month
    • abdomen tense and slightly tender
    • lab results:
      • wbc 15,200/mm - the infection being fought by the body
      • na 146 (normal 136-145)
      • k 2.5 - this is going to be low when glucose is high in diabetic situations
      • hco3 2meq - indicative of the acidosis
      • glucose 782 - indicative of the diabetic ketoacidosis
      • bun 48 - the effect of dehydration
      • urine specific gravity 1.035 (high) - the effect of dehydration
      • ketones large - indicates starvation going on
      • throat culture: strep positive - the infection and cause for the sore throat
    step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
    • deficient fluid volume r/t excessive urine output and elevated respirations aeb deep labored respiratory rate of 30, pulse of 102, blood pressure of 90/62, bun of 48, elevated urine specific gravity of 1.035, tense abdomen, dry skin with poor skin turgor, and complaint of always being thirsty.
    • imbalanced nutrition: less than body requirements r/t inability of body to utilize glucose aeb serum glucose of 782, hco3 of 2meq, large ketones in urine, abdomen tense and slightly tender, feeling tired over the past month and statement that he thinks he has lost weight even though he has been eating "a lot"
    • acute pain r/t inflamed and irritated throat aeb patient complaint of sore throat x 1 week.

    - - - - - - - - - - - - - - -

    deficient fluid volume r/t excessive urinary output aeb thirst, freq urination q 2-3 hrs, temp 102, sore throat, bp 90/62. hr 30, lethargic, dry skin, deep tendon reflexes, pt complaint "feeling tired past month".
    the problem with your supporting evidence is that lethargic was not used in the scenario and you could get dinged for that just on the semantics of it. also, i was thinking the decreased deep tendon reflexes were related to dehydration as well, but i am not sure. i thought they might be related to hyponatremia (the decreased sodium level), but couldn't find that as a symptom connected to hyponatremia.
    ineffective health maintenance r/t insufficient knowledge of effects of diabetes not being managed aeb request of antibiotics to make him better.
    while ineffective health maintenance is a diagnosis one could use with someone in diabetic ketoacidosis, the dehydration (deficient fluid volume) and hyperglycemia (imbalanced nutrition) have to be treated first. then, there is the little problem of why the guy showed up in the urgent care in the first place. . .his sore throat (acute pain) because the doc treats the infection. those are the 3 nursing problems we can treat.

    now, you haven't constructed this diagnostic statement correctly. the related factor is incorrect. first, diabetes is never mentioned in the scenario. second, insufficient knowledge of a medical disease or medical condition is not a related factor for this diagnosis. this diagnostic problem is about the patient being unable to identify, manage, and/or seek out help to maintain their health. this patient has just come to an urgent care for help. by showing up he is seeking help. if he has insufficient knowledge of diabetes, then deficient knowledge, diabetes r/t lack of information needs to be diagnosed and used. the related factor explains why the patient qualifies for the diagnostic label. likewise, a request of antibiotics to make him better does not show that he is unable to identify, manage, and/or seek out help to maintain their health. he knew he was sick and he asked for what he knew something about. that's not ineffective health maintenance.
    ineffective breathing pattern r/t fatigue aeb r30 deep and labored breathing.
    i thought about using this too until i considered that you could only use 3 diagnoses and you needed to include as much of the data as possible. his breathing is really one other way he is losing fluid--insensible fluid loss through the lungs.
    acute pain from ketones,(abdomen is tense)?
    the ketones are an end product of fat metabolism (the starvation going on because the body cannot utilize the glucose). the abdominal tension and pain are due to the dehydration and electrolyte imbalances as well as an underlying autonomic neuropathy that has not been established yet.
  4. by   intense0120
    Thank you so much for breaking this all down for me. I knew a priority usually includes pain, and right in front of my eyes was the sore throat....so simple, and yet I didn't see it. Every time I read a response from you throughout this site, I can only pray to someday be as good as you.
    Thanks again.
  5. by   Daytonite
    You are welcome. It takes time and experience to nail the critical thinking behind these things down. Just keep hanging in there. It is important that you keep making the effort. Believe it or not, I was terrible as a student trying to fathom these things out until something finally "clicked". Good luck with your next case study.
  6. by   Hramth01
    Hmm I am working on a similar problem!! Here is mine...

    Case 2: S.J.

    SJ, 14 years of age, has just been admitted to the hospital because of uncontrolled diabetes mellitus. She responds to questions but is drowsy if not stimulated. Her skin is flushed and dry. Her eyeballs are soft, and she reports blurred vision.
    Vital signs are: BP 106/88, P 128, R 32, T 100F (38.1C). The physician is writing orders now. SJs sister states that the client has been under a great deal of strain caused by a family conflict. The admission laboratory results show:

    1. Hct 59%; RBC 5 million/mm3; Hgb 14g; erythrocyte indices WNL

    2. WBC 15, 000/mm3. No shift to the left.


    3. Platelets normal


    4. Urinalysis: SG 1.040; glucose 2%; acetone moderate

    5. Serum osmolarity 316 mOsm; urine olsmolarity 1,400 mOsm

    6. BUN 40 mg/dL; serum creatinine normal at 1.0 mg/dL

    7. Lytes: K 5.8 mEq/L

    8. ABGs: pH 7.30; PCO2 30 mmHg; PO2 98 mmHg; Bicarbonate 15 mEq/L

    9. Random blood sugar 450 mg/dL; plasma ketone 4+ in 1:1 diluted sample
  7. by   Daytonite
    Quote from hramth01
    hmm i am working on a similar problem!! here is mine...

    case 2: s.j.

    sj, 14 years of age, has just been admitted to the hospital because of uncontrolled diabetes mellitus. she responds to questions but is drowsy if not stimulated. her skin is flushed and dry. her eyeballs are soft, and she reports blurred vision.
    vital signs are: bp 106/88, p 128, r 32, t 100f (38.1c). the physician is writing orders now. sjs sister states that the client has been under a great deal of strain caused by a family conflict. the admission laboratory results show:

    1.hct 59%; rbc 5 million/mm3; hgb 14g; erythrocyte indices wnl

    2.wbc 15, 000/mm3. no shift to the left.


    3.platelets normal


    4.urinalysis: sg 1.040; glucose 2%; acetone moderate

    5.serum osmolarity 316 mosm; urine olsmolarity 1,400 mosm

    6.bun 40 mg/dl; serum creatinine normal at 1.0 mg/dl

    7.lytes: k 5.8 meq/l

    8.abgs: ph 7.30; pco2 30 mmhg; po2 98 mmhg; bicarbonate 15 meq/l

    9.random blood sugar 450 mg/dl; plasma ketone 4+ in 1:1 diluted sample
    so, the first thing you need to do is:
    determine what is abnormal among all that data you have presented. a problem is only a problem when the data supporting it is abnormal information: when data is normal it isn't a problem. go through all the information and make a list of everything that is abnormal.

    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data pulled out from the case scenario. all nursing diagnoses consist of lists of abnormal data called defining characteristics.
    after you do that and you are still having trouble diagnosing the nursing problems, come back with your questions.

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