prioritizing diagnosis

melissax · Oct 20, 2011

Hi there,

I thought your first two nursing dx were really great but I have a few suggestions.

There isn't a problem with the urine output. 30-40 mLs per hour is the normal range for a average adult and therefore would not constitute a nursing dx.

The first nursing dx: you could also add the r/t is course lung sound bilaterally. Also, how much blood is the patient coughing up? Could you do a nursing diagnosis related to this???

The second nursing dx: you need to develop more on the r/t data. Did you do a MS assessment??? What were the results???

The third nursing dx: not correct! try finding another diagnosis.

As you stated above you must follow the ABCs so remember that when placing your nursing diagnosis in the order of importance! Also, have you tried speaking with your professor so that you can find out what needs to be done in order to be successful on the paper? This may help clarify some things and improve your grade! Hope I've helped :) .

-Mel

nurseprnRN, BSN, RN · Oct 20, 2011

oh, my. let's do this one at a time.

"here is my patient's pertinent info to give you guys a better idea of what was going on with him:

assessment data:hemoptysis, absent cough, elevated wbc, course lung sound bilat., edematous extremities, temp is controlled to wnl;

the above data is what led me for my first priority nursing dx as ineffective airway clearance r/t artificial airway; sedative meds...(any suggestions of anymore i could use based on the data i gave above?)

he doesn't have ineffective airway clearance because he has an artificial airway-- you've got that backwards. he has the artificial airway because he can't breathe effectively, and you have to do a lot of things for him to let him keep breathing on the vent to stay alive. he's coughing up blood and he can't cough, so which is it? his wbc is up-- why? is it in his lungs, or does he have another reason (or maybe multiple ones)? so-- what are your assessment and care priorities for someone who has such a crappy chest?

assessment data: bedfast, opens eyes; tracks and follows simple commands; musculoskeletal weakness; trace pedal edema of the extremities

the above data is what led me to my 2nd nursing dx as impaired bed mobility r/t sedation causing meds; musculoskeletal weakness secondary to underlying disease (hx of chf and esrd)

*commenst and suggestion would be greatly appreciated

he sounds like he has a lot of good reasons to be bedfast, but sedation-causing meds are only part of the cause. i think that just saying he is unable to move himself around in bed well is a really inadequate assessment of the problems he's facing. what sort of things can happen to someone who is bedbound for a prolonged period? what would you, the nurse, do to assess for these complications, and do to treat them as a nurse (i.e., not just following a medical plan of care, what some people call "doctor's orders," but what you would write for "nurses' orders")?

assessment data: hx of esrd, chf, chromic renal failure, generalized edema of extremities; course breath sounds; high blood pressure

the above data is what led me to 3rd nursing dx as excess fluid volume r/t decreased urine output secondary to chf; sodium retention secondary to esrd

again, there are a lot more serious things that can happen to you if your kidneys fail than fluid retention, and it sounds as if you've got the chicken-egg thing backwards here, too. he's fluid-overloaded because he has renal failure (not because he doesn't put out urine-- he doesn't make urine because he has esrd) (and this causes a lot of other significant lab abnormalities besides just serum sodium changes-- find out what they are, and learn what the nursing implications are for them. chf is a result of fluid overload, not a cause of it. figure that out, too.

it looks to me, given what you say here, that you don't have a very good handle on what renal failure is, why he's on a ventilator, and what nursing should be doing for him first and foremost. i realize that this is what you're asking us to tell you, but i think you need to study a few more aspects of this very sick man's medical diagnoses and nursing care for expected complications of them before we do that. and no, 30-40cc/hour of urine is a bare minimum and not acceptable "just because." if he's in chf and edematous, he should be putting out a lot more pee. why isn't he? then what?

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

what are your thoughts on all this?

CheKaysMom · Oct 20, 2011

thank you soooo much! I have been researching more on my client's condition...the topic of mechanical ventilation is new to me. I will look more into my assessment data and perhaps post an upgraded one. Than you for the very constructive and detailed response. This will help me great deal when i finalize my nursing careplan. After reading your comments, I have realized that I get my "related to" facts with my "as evidenced by" facts...thanks again

CheKaysMom · Oct 20, 2011

:) Hi Mel!!! Thank you for sharing your thoughts with me. It seems to me that I have a lot of research to do to gain better understanding of my client's care. I will keep your suggestions in mind and perhaps post an upgraded one. I've also figured out why the urine output is not normal. It's because it is way lower compared to his intake (approx. 1000ml/8hr)...thank you sooo much again =)

xtxrn, ASN, RN · Oct 20, 2011

Just my observations... (and GrnTea went into more detail)

-- hemoptysis = coughing up blood..... but assessment = no cough. Confused about how both could be in the assessment; did he have hemoptysis at one point, and then it cleared? Or is he getting bloody sputum with suctioning, and that's being called hemoptysis?

--"impaired bed mobility"-- what are the bed's goals ? Impaired physical mobility r/t confinement to bed focuses on the patient - not the bed :up: And, impaired mobility is the mother load of potential nursing diagnosis- it effects nearly every body system.

-- ESRD & CHF.... both have symptoms of edema....but how is the CHF treatment effected by the renal failure? How does the patient get rid of the fluid? Dialysis? Or still able to take diuretics with good results? Electrolytes and protein levels are going to be a mess.

Is he on dialysis? What are the potential problems with that (access devices, dietary needs, skin condition, etc).

Good luck :)