Oh the concept maps!! Would you please guide me on a good dx? I'm out of ideas.

[thatchergirl, BSN, RN]

ok.. here's the patient..

med surg patient admitted with altered loc, hypokalemia, uti and dvt. hx of anxiety, depression, bipolar disorder, schizophrenia, ams, hypokalemia, uti, ari, anemia, she also claims 8 different personalities. the day i took care of her, the k+ was 3.7; h&h low 9.4 and 26.5 respectively. her ca (6.7), ph (1.5), and mag (1.2) which is also low and were replaced that day. the inr is 2. patient has a foley in. vs throughout shift were wnl. intake 1740 output 1700. no complains of pain except for a ha at 5/10 that was medicated with 325 mg of acetaminophen and after 1 hour she states pain of 1/10. left leg was edematous. patient was confused during shift and a&o x1 (self) the possible dx that i have are: 1st ill do the ineffective peripheral tissue perfusion r/t decreased blood flow to extremities aeb tissue edema and diminished peripheral pulse to right leg. the other one i'll use (my teacher said it would be a good one) is risk for injury r/t ↓ loc and with that i'll adress her hx and hypokalemia and also uti can cause confusion, right? well i was thinking risk for infection r/t ↓ h&h, but she already has one (uti) and the teacher kinda didn't like that one. another one was impaired urinary elimination r/t impairment in neurological sensing and control aeb inability to go to recognize the need to void - but i think that's more for people with spinal cord injuries because the interventions didn't really apply to my patient. so i'm feeling like out of ideas... what do you guys think of the following? we have to do it in order of priority. my teacher says " what can kill the patient first?" so i have these other options. altered loc - impaired memory r/t neurological disturbances (can't really kill you, can it?), risk for impaired skin integrity r/t immobility (risk for falls, patient was in bed and what not), and the other one fatigue r/t ↓ h&h. i don't know what to think of it anymore.

thanks.. i appreciate it!

[shortnorthstudent]

so, which of her diagnoses might kill her? altered loc, hypokalemia, uti and dvt?

the ones that stick out at me are the hypokalemia and dvt. i see that the k+ was okay when you were on shift, but what was it trending? what are they doing for it? what about the dvt? had she had one? what are her risks? what should you be doing about it?

i much prefer concept maps over a more standard care plan. i think it's much easier to see relationships among problems and potential interventions.

[thatchergirl, BSN, RN]

maybe i over exagerated on the "what can kill her first" but she means all the possible complications...

her k+ was just better that day and she had d5 1/2 ns with k+ running. for the dvt she is getting lovenox and coumadin and she has the compressing stockings as well. her risk is for a pe, stroke if the clot travels, etc...

i don't quite get what you are saying about standard care plan.. would you dissect that a little bit for me to help my brainstorming please?

[shortbus10]

Concept mapping your assessment helps you group your data according to priority. When your instructor says "What will kill you first" they mean what is the priority according to Maslow. So according to Maslow an issue with oxygenation will have priority over, something like say, pain. So by grouping the data you collect in your assessment in this way you can normally see what diagnosis will be the priority.

[Animal3]

Risk for infection d/t the foley

[hsienko]

ok.. here's the patient..

med surg patient admitted with altered loc, hypokalemia, uti and dvt. hx of anxiety, depression, bipolar disorder, schizophrenia, ams, hypokalemia, uti, ari, anemia, she also claims 8 different personalities. the day i took care of her, the k+ was 3.7; h&h low 9.4 and 26.5 respectively. her ca (6.7), ph (1.5), and mag (1.2) which is also low and were replaced that day. the inr is 2. patient has a foley in.

this person sounds like a death trap. ph is 1.5? how about risk of immediate death r/t to caustic-super-acid rust monster-type acidosis aeb ph 1.5

edit: then smile and tell your teacher ...oh phosporus...

[shortnorthstudent]

When I do a standard care plan, it starts with a nursing diagnosis and then is followed by narratives relating to ADOPIE. Very linear. On the other hand, we have been care mapping which I do freehand in bubbles and boxes connected by arrows with lots of different colors. They are much more fluid and it is easier to see the relationships between say the assessment data and the problems, and the interventions, etc.

Personally, I would probably pick a risk for diagnosis related to your last post and the DVT. DVTs are something you will be working to prevent or will be trying to manage often in your nursing career. IMO, there are great diagnoses to really dig into -- look into the assessment data you have, how it relates, what interventions are being done, what others can be done, etc.

I don't think that thinking about what will kill her first is a bad way to look at it. The idea is to learn from the care plans/care maps. The hope is to learn what to watch for, what to do to prevent potential problems, etc. Sure, your patient has pain, risks for infection, imbalanced fluid I/O and much more. But, what can you learn from this patient for your future practice.