Please help me with my written assessment - academic essay

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I have my assignment due in the next 2 weeks and having trouble picking my nursing priorities. I found this forum and hope you guys can share or help me out :)

Here is my scenario

Nick is 50 years old male with heavy drinker. Recently had motorcar accident. He has 3 ribs L side fractured, a pneumothorax, and a lacerated small bowel. He is now on 3 days post op. He had laparotomy with oversewing of the small bowel laceration. He has an intercostal catheter and epidural line analgesia

On assessment: Urine output decreasing, Abdominal girth increasing, he is agitated, pain ++ and increasing SOB (shortness of breath)

The assignment question

* Identify and discuss 3 most important specific priorities of care for Nick and provide rationales.

My priorities of care was: 1. Maintain breathing or airway clearance. 2. Control pain for his post op. 3. Maintain nutrition or maintain bowel function???

Please help me out with the 3 priorities ? thank you very much

Specializes in critical care.

OP, my understanding of your first post is that that is what you walk into the room to find. It's up to you to decide what you need to find out, with the little info you've been given.

Encouraging you to think to yourself and helping to point you in the right direction is not yelling.

Esme, I bow down to your patience.

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Thank you esma.... I will try to finished my assignment then let you know about my assignment outcome. ah and one more thing.. i dont want to post my assignment or answer on here due to confidential and hope you understand :). but i will let you know the outcome. thanks once again

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Btw esm, i just done the rationale for my breathing ineffective priority. I just realized that my outcome just similar with your given hints. I will move on my second priority soon and continue. thanks once again

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you esma.... I will try to finished my assignment then let you know about my assignment outcome. ah and one more thing.. i dont want to post my assignment or answer on here due to confidential and hope you understand :). but i will let you know the outcome. thanks once again
I wouldn't want you to post it here your work is your work. and people cheat unfortunately. Just if you have questions or ideas about whats next you have an excellent start now.
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Btw esm, i just done the rationale for my breathing ineffective priority. I just realized that my outcome just similar with your given hints. I will move on my second priority soon and continue. thanks once again
You are welcome....Just call me Es....:)
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Gimme an S .... Gimme an E .... Gimme a P .... Gimme an S .... (more! What comes next?) Is that enough of a hint?

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Hi Es, I am finished my 1st priority: Ineffective breathing pattern and 2nd priority: Acute/chronic pain rationales. However, i'm unsure whether those explanation are on the right track or not. Do you have any email so i can send it to you privately? so you can help me to have a look?

My last priority is fluid deficit ineffective fluid volume, risk for deficient fluid volume due to internal hemorrhage, but still unsure if my final priority is really important.

I guess my final priority could be infection or risk of ineffective tissue perfusion

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Oh dear, I hope you don't think I was yelling. I was trying to be cute and funny. I'm not sure I came across correctly, I thought this case looked incredibly fascinating and I was looking forward to how the care plan came out. Sorry.
:shy: I don't get annoyed often but if I do....I let you know so we can clear the air!

My teen said this yesterday "Stop yelling at me....."....I said ...I'm not yelling....THIS IS YELLING!!!!!!!!!!:D

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Hi Es, I am finished my 1st priority: Ineffective breathing pattern and 2nd priority: Acute/chronic pain rationales. However, i'm unsure whether those explanation are on the right track or not. Do you have any email so i can send it to you privately? so you can help me to have a look?

My last priority is fluid deficit ineffective fluid volume, risk for deficient fluid volume due to internal hemorrhage, but still unsure if my final priority is really important.

I guess my final priority could be infection or risk of ineffective tissue perfusion

Ineffective breathing pattern is ok. NANDA I define this as....inspiration and/or expiration that does not provide adequate ventilation

Defining Characteristics ( he is agitated, and increasing SOB, ribs L side fractured, a pneumothorax) Alterations in depth of breathing; altered chest excursion; assumption of three-point position; bradypnea; decreased expiratory pressure; decreased inspiratory pressure; decreased minute ventilation; decreased vital capacity; dyspnea; increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe

Related Factors (r/t) ( ribs L side fractured, a pneumothorax, Abdominal girth increasing )

Anxiety; body position; bony deformity; chest wall deformity; cognitive impairment; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological immaturity; neuromuscular dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; spinal cord injury

Now....I would think the next life threatening issue would be volume. You have a decreased U/O indicating the patient has a deficit that is compromising end organ perfusion.

It is not fluid deficit ineffective fluid volume/risk for deficient fluid volume It is just Deficient Fluid Volume as per NANDA I......Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level (Urine output decreasing, Abdominal girth increasing)

Defining Characteristics/due to

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Related Factors (r/t)/as evidenced by

Active fluid volume loss; failure of regulatory mechanisms

He is AT RISK for bleeding because you actually do not "see" blood. Risk for Bleeding described by NANDA I : At risk for a decrease in blood volume that may compromise health

Risk Factors

Aneurysm; circumcision; deficient knowledge; disseminated intravascular coagulopathy; history of falls; gastrointestinal disorders; impaired liver function; inherent coagulopathies; postpartum complications; pregnancy-related complications; trauma; treatment-related side effects.

An at risk can be a priority IF that risk is significant and can cause the patient harm. For example an abdominal trauma patient with a drinking history. (Nick is 50 years old male with heavy drinker=liver and Recently had motorcar accident=trauma.)

What evidence do you have for ineffective tissue perfusion. Which is actually Ineffective peripheral Tissue Perfusion and defined by NANDA I as : Decrease in blood circulation to the periphery that may compromise health

Defining Characteristics

Absent pulses; altered motor function; altered skin characteristics (color, elasticity, hair, moisture, nails, sensation, temperature); blood pressure changes in extremities; claudication; color does not return to leg on lowering it; delayed peripheral wound healing; diminished pulses; edema; extremity pain; paresthesia; skin color pale on elevation

Related Factors (r/t)

Deficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility); deficient knowledge of disease process (e.g., diabetes, hyperlipidemia); diabetes mellitus; hypertension; sedentary lifestyle; smoking

I don't see anything for this diagnosis.

And last....acute pain. Nothing is chronic here...it is all related to trauma and surgery.

Your patient is at additional risk for.......

Risk for Infection due to small bowel lacerations spilling stool into the abdomen (peritonitis)

Risk for impaired Liver Function (heavy drinker)

You might consider.....Impaired Gas Exchange from the pneumothorax which I think also strongly applies.

  • Presence of free air in the intrapleural space
  • Spontaneous pneumothorax is due to atraumatic rupture of alveolus, bronchiole, or bleb.
  • Primary spontaneous pneumothorax (2/3 of incidences):
    • No underlying pulmonary pathology present
    • Rupture of small subpleural cyst or bleb
    • Primarily young, healthy patients (20–40 yr old) with tall, thin body habitus

    [*]Secondary spontaneous pneumothorax from underlying pulmonary pathology (see Etiology)

    [*]Tension pneumothorax:

    • Air continues to enter pleural space through bronchoalveolar disruption and becomes trapped via “ball-valve” mechanism.
    • Intrapleural pressure increases.
    • Venous return to right heart decreases, resulting in decrease in cardiac output.
    • Mediastinum shifts toward uninvolved side, mechanically interfering with right atrial filling.
    • Ventilation compromise and ventilation/perfusion mismatch result in hypoxemia

Respiratory Distress

NANDA-IDefinition

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Defining Characteristics

Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

Related Factors (r/t)

Ventilation-perfusion imbalance; alveolar-capillary membrane changes

You prioritize according to Maslows hierarchy of needs....what will kill them first.

You can PM me here....I am admin so you can PM me without 15 posts.

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Specializes in critical care.

I'm need to express some gratitude. Esme that was wonderful. I love coming here and learning stuff. ❤️

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You are welcome...:inlove:..essentially it is just knowing how to start and follow a logical path. Learning how to think like a nurse....it's just ...different.

Give me something that the work has been attempted and I will lead you to where you need to be. I love this stuff. I am not crazy about care plans per se...but that is another thread...but they make sense to me.

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Hi esma, Ive finished my assignment. I not sure how to send it to you privately because i dont want to show my assignment in public here. Do you have any email so i can send it to you there? I am not very sure if im on the right track with my assignment. Please help me to have a look?

thank you esma.

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