Pls help with prioritizing diagnosis

Esme12, ASN, BSN, RN · Feb 19, 2013

Hi everyone!
I am writing a 7pg critical thinking paper but kinda worried my diagnosis arent on point...
My patient, 81 yr old male, came in the hospital with complaint of difficulty breathing with rapid, shallow breaths. His admittance diagnosis was hypoxia, respiratory distress caused by aspiration pneumonia. He has a history of CAD, HTN, DM, gout, spinal cord infarction, CVA, oral candiasis.
*The guidelines of the paper requires us to pick a patient with an already existing complication/illness with a new stressor...so im using the patient history of CVA = causing dysphagia = causing aspiration pneumonia...not far fetched right?
Getting back to patient's assessment. Pulmonary: lung sounds decreased bilaterally, o2 sat 95% on 2L NC, productive cough for clear sputum, patient self suction with yankaver, respirations normal nonlabored. Neuro: minimal movement in R and L leg. GU: foley for neurogenic bladder draining amber urine. Diet: NPO high risk of aspiration.
VS: bp 138/68, T 98.6, HR 86, RR 16, Pain 6/10 chest
*Guidelines requires 4 nursing diagnosis
1. Ineffective airway clearance r/t excess tracheobronchial secretions
2. Impaired gas exchange r/t insufficient oxygenation as a result of inflammation
3. Risk for aspiration r/t impaired swallowing (this one is confusing me. My instructor told me this is a priority i guess to prevent further aspiration?)
4. Imbalanced nutrition r/t NPO status?
I believe that these four are the priority. Do i have them in the right order? Does it sound correct?
I also found out very late after i developed my priority list that the patient has sepsis! but I couldnt find a nursing diagnosis specifically for sepsis. I would think that would take the #1 spot? .. sepsis can lead to death but all of the other diagnosis can too...im thinking ABCs and airway would be #1 right?
As you can tell, there is a lot of doubting going on
Any input would be greatly appreciated!

You prioritize according what can kill them first......with this patient and his dysphagia....... Impaired Swallowing would be the priority that affects the airway and would be first. The impaired swallowing makes him at risk for aspiration.

I would switch them....slightly

*Guidelines requires 4 nursing diagnosis

1. impaired swallowing r/t dysphagia AEB aspiration

2. Ineffective airway clearance r/t excess tracheobronchial secretions

3. Impaired gas exchange r/t insufficient oxygenation as a result of inflammation

4. Imbalanced nutrition r/t NPO status?

5. which leaves at Risk for aspiration r/t dysphagia AEB impaired swallowing

Make sense? The swallowing causes aspaRisk for aspiration r/t impaired swallowing ration that causes airway issues that leads to impaired gas exchange.......

mrd0618 · Feb 20, 2013

wow! great thank you!

so should i just leave the sepsis alone?

Esme12, ASN, BSN, RN · Feb 20, 2013

What does sepsis do? Is there any evidence in your assessment that proves sepsis. Hypotension, hyperthermia, shock.

Care of the Patient with Sepsis

Care of the Critically Ill Patient

Caring for the ICU Patient at the End of Life

http://www.ccmtutorials.com/intro/overview/page_02.ht

You need to mention it in your explanation of the disease proceses and co-morbidities/complications...but if the spesis is resolved it i not a patient problem at this time.

The biggest thing about a care plan/map is the assessment. The second is knowledge about the disease process. First to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. The medical diagnosis is what the patient has and the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse.

Think of them as a recipe to caring for your patient. Your plan of care. check out this thread https://allnurses.com/nursing-student-assistance/help-nursing-diagnosis-814050.html

nurseprnRN, BSN, RN · Feb 20, 2013

Sepsis is not a nursing diagnosis. Nursing diagnoses do not come from medical diagnoses, they come from nursing assessment of patient condition and the effects of the illness on the patient that can be addressed by nursing independent of medical plan of care.

There are a good many effects of sepsis that you might observe in your care of the patient that would lead you to one or more nursing diagnoses. What did you observe of this patient?

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications (and there are more, and many that an individual patient might have independent of his medical diagnosis). They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a nursing diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way

anashenwrath, ASN, RN · Feb 20, 2013

You hit it on the head at the end: use your ABCs when prioritizing. Anything that compromises the Airway is priority--and the risk for aspiration r/t dysphagia is most acute, and therefore the biggest priority. Airway obstruction r/t secretions would be next, bcs even though there is potential to block the airway, it's more likely going to contribute to dysphagia and hypoxia. Sort of the difference between an embolism (sudden) and thrombus (gradual).

Now look at things that affect the patients ability to breathe that aren't directly related to the airway. So that pneumonia, for example, isn't directly affecting his airway, but it is may be compromising his ability to take in deep breaths and cough. I'd have the gas exchange in the #3 slot.

C --> circulation. What is keeping this patient from being perfused. Lots of vascular diseases. I would consider this before looking at nutrition. O2 sat of 95% on cannula? That's just at the cusp WHILE he's getting supplemental O2. Not good! how was his cap refill? how did those toes feel? He's not moving his legs a lot, so that blood isn't getting moved!

Sepsis is not a nursing dx, but it can cause lots of things that the nurse would want to appropriately assess and intervene with. Here is how your train of thought could work: "What does sepsis DO to the body (remember to identify the type of sepsis!), what would I expect to see in a patient with sepsis? Did my patient exhibit any of these or is he at risk for any of them? Could they have been related to the sepsis? Honestly, the vitals you give don't seem like this patient is really having any complications r/t sepsis: his HR and BP are stable, etc. You might have some risks there, but don't obsess over the medical dx: what did you see as a nurse?

mrd0618 · Feb 20, 2013

Thanks!

For circulation, would this nursing diagnosis work?

Ineffective peripheral tissue perfusion r/t immobility

Esme12, ASN, BSN, RN · Feb 20, 2013

Ineffective peripheral tissue perfusion.....

Definition: 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; paraesthesia; 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

Does your patient fit this definition....do you have the evidence to support this?

nurseprnRN, BSN, RN · Feb 21, 2013

What did you observe about this patient that leads you to believe his poor circulation is caused by his immobility? That's what you said. (Hint: Esme has given you all the acceptable defining characteristics and related factors in the NANDA-I 2012-2014)