nusing diagnosis/end of life

[x-tremestudent]

care plan real pt

81 year old admitted to med surg 3-19-07 from ER due to weakness difficult speech not eating after admittness on med surge pt continuall deteriated. 1 month ago pt diagnsoed with brain cancer. she has been recieving radiation but declined hospice. she has afib admitting wieght @ 198 now 132 HR runs avg of 125bpm,BP 130/57, input @ 631 Out put @ 500 admitted to ICu On 3-26-07 after placenent of peg tub LUQ mottling noted on feet edema l ft @ +2 edema r Ft @ +3 pedal pulses faint used doppler. pt decreased LOC shakes head to questions.has sister out of town came to visit and left and a best friend who signs consents patient is at full code no DNR order. pt is paralised on R side and has slurred speech Dr said due to brain cancer. my nursing diagnosis is

decreased cardia out put due to abnormal conduction secondary to afib,infective tissue perfusion R/T peripheral,renal,secondary to risk for infectionneed one more was thinking along lines of powerslesness,anticipatory grieve or death anxiety. not sure how to do goals for these or interventions and rationals. pt was sent home by ambulance pt best friend signed a DNR and agreed to hospice are pt died 4 days later never had this kind of care plan where family was not involved and pt was decreased LOC help please due tonight. thank you

[laurainri]

how about ineffective coping, fear, look at those maybe that can help. make sure you look at the related to...

[KellieNurse06]

I'd go with helplessness or powerlessness r/t disease process or impending loss also..just due to the issue of no family & no control over what is happening to herself....

[Daytonite, BSN, RN]

you do not have the symptoms to support a diagnosis of decreased cardiac output. atrial fibrillation does not result in ineffective tissue perfusion. normally, a person with atrial fib might experience some fluttering sensations in their chest, but usually when the atrial fibrillation is very rapid. the danger with atrial fibrillation is the formation of blood clots and stroke. it sounds, however, like your patient's atrial fibrillation is under control.

you have listed a very impressive list of data that you collected on this patient. your problem is that you don't know what your next step is in the care planning process. once you have your list of abnormal data, you need to start looking for nursing diagnoses that have some of those as their defining characteristics. here's a list of the abnormal data i picked out of the information you gave:

• mottling on skin of feet
  
• pedal edema
  
• faint pedal pulses
  
• not eating
  
• weight loss of 66 pounds (over what period of time?)
  
• weakness
  
• right-sided paralysis
  
• decreased loc
  
• slurred speech and shakes head (yes or no) to questions

it is from this list that you should be looking for nursing diagnoses, goals and nursing interventions. these are the patients problems and needs that you should be addressing and treating in your care plan. from that list, i can develop this list of nursing diagnoses in priority order (by maslow's hierarchy of needs):

1. ineffective tissue perfusion, peripheral r/t impaired transport of oxygen aeb mottling of the skin on the feet, pedal edema and faint pedal pulses.
   
2. imbalanced nutrition: less than body requirements r/t loss of appetite secondary to neoplastic process aeb not eating, weight loss of 66 pounds over xx period of time and weakness.
   
3. impaired physical mobility r/t neuromuscular impairment secondary to cancer of the brain aeb right-sided paralysis.
   
4. disturbed thought processes r/t neurological impairment secondary to cancer of the brain aeb altered level of consciousness.
   
5. impaired verbal communication r/t neurological impairment secondary to cancer of the brain aeb slurred speech and answers yes and no questions by shaking head in answer to questions.

what about self-care deficits? how is the patient dressing, bathing and toileting? these are basic nursing needs that need to be addressed. you have no assessment data relating to any of this.

your nursing interventions will be aimed at that list of abnormal data i listed just above. the results of your interventions will, hopefully, achieve the goals you will have developed. it all flows together quite rationally. for example, for ineffective tissue perfusion, peripheral r/t impaired transport of oxygen aeb mottling of the skin on the feet, pedal edema and faint pedal pulses you might have a goal to keep the lower legs and feet warm (i'm keeping this simple because this patient is expected to die so comfort should be among many of your goals). your nursing interventions to do that might include keeping the legs elevated on a pillow, utilizing a heating pad for comfort and keeping a thermal blanket over her legs.