Priority diagnosis diabetes, fluid & electrolytes

Daytonite, BSN, RN · Apr 25, 2009

to diagnose, apply the nursing process.

step 1 assessment - the assessment data has been supplied for you. the only thing it hasn't done is told you that this patient has undiagnosed ketoacidosis. he does have strep throat confirmed by a positive throat culture.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data pulled out from the case scenario. i grouped them in consideration of some of the defining characteristics of the different nursing diagnoses and with maslow's hierarchy of needs in mind as well:

r 30 deep and labored
p 102
bp 90/62
sore throat x 1 week
always thirsty
skin turgor poor
thinks he has lost weight even though he has been eating "a lot"
abdomen is tense - this means it is in a state of being stretched, perhaps by a collection of gas or fluid and is a s/s of the ketoacidosis
enlarged lymph nodes in neck
wakes q 2-3 hrs to urinate
decreased deep tendon reflexes
feeling tired past month
abdomen tense and slightly tender
lab results:
- wbc 15,200/mm - the infection being fought by the body
- na 146 (normal 136-145)
- k 2.5 - this is going to be low when glucose is high in diabetic situations
- hco3 2meq - indicative of the acidosis
- glucose 782 - indicative of the diabetic ketoacidosis
- bun 48 - the effect of dehydration
- urine specific gravity 1.035 (high) - the effect of dehydration
- ketones large - indicates starvation going on
- throat culture: strep positive - the infection and cause for the sore throat

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

deficient fluid volume r/t excessive urine output and elevated respirations aeb deep labored respiratory rate of 30, pulse of 102, blood pressure of 90/62, bun of 48, elevated urine specific gravity of 1.035, tense abdomen, dry skin with poor skin turgor, and complaint of always being thirsty.
imbalanced nutrition: less than body requirements r/t inability of body to utilize glucose aeb serum glucose of 782, hco3 of 2meq, large ketones in urine, abdomen tense and slightly tender, feeling tired over the past month and statement that he thinks he has lost weight even though he has been eating "a lot"
acute pain r/t inflamed and irritated throat aeb patient complaint of sore throat x 1 week.

- - - - - - - - - - - - - - -

deficient fluid volume r/t excessive urinary output aeb thirst, freq urination q 2-3 hrs, temp 102, sore throat, bp 90/62. hr 30, lethargic, dry skin, deep tendon reflexes, pt complaint "feeling tired past month".

the problem with your supporting evidence is that

lethargic

was not used in the scenario and you could get dinged for that just on the semantics of it. also, i was thinking the decreased

deep tendon reflexes

were related to dehydration as well, but i am not sure. i thought they might be related to hyponatremia (the decreased sodium level), but couldn't find that as a symptom connected to hyponatremia.

ineffective health maintenance r/t insufficient knowledge of effects of diabetes not being managed aeb request of antibiotics to make him better.

while

ineffective health maintenance

is a diagnosis one could use with someone in diabetic ketoacidosis, the dehydration (deficient fluid volume) and hyperglycemia (imbalanced nutrition) have to be treated first. then, there is the little problem of why the guy showed up in the urgent care in the first place. . .his sore throat (acute pain) because the doc treats the infection. those are the 3 nursing problems we can treat.

now, you haven't constructed this diagnostic statement correctly. the related factor is incorrect. first, diabetes is never mentioned in the scenario. second, insufficient knowledge of a medical disease or medical condition is not a related factor for this diagnosis. this diagnostic problem is about the patient being

unable to identify, manage, and/or seek out help to maintain their health

. this patient has just come to an urgent care for help. by showing up he is seeking help. if he has insufficient knowledge of diabetes, then

deficient knowledge, diabetes r/t lack of information

needs to be diagnosed and used. the related factor explains

why

the patient qualifies for the diagnostic label. likewise, a

request of antibiotics to make him better

does not show that he is

unable to identify, manage, and/or seek out help to maintain their health.

he knew he was sick and he asked for what he knew something about. that's not

ineffective health maintenance.

ineffective breathing pattern r/t fatigue aeb r30 deep and labored breathing.

i thought about using this too until i considered that you could only use 3 diagnoses and you needed to include as much of the data as possible. his breathing is really one other way he is losing fluid--insensible fluid loss through the lungs.

acute pain from ketones,(abdomen is tense)?

the ketones are an end product of fat metabolism (the starvation going on because the body cannot utilize the glucose). the abdominal tension and pain are due to the dehydration and electrolyte imbalances as well as an underlying autonomic neuropathy that has not been established yet.

intense0120 · Apr 26, 2009

Thank you so much for breaking this all down for me. I knew a priority usually includes pain, and right in front of my eyes was the sore throat....so simple, and yet I didn't see it. Every time I read a response from you throughout this site, I can only pray to someday be as good as you.

Thanks again.

Daytonite, BSN, RN · Apr 26, 2009

You are welcome. It takes time and experience to nail the critical thinking behind these things down. Just keep hanging in there. It is important that you keep making the effort. Believe it or not, I was terrible as a student trying to fathom these things out until something finally "clicked". Good luck with your next case study.

Hramth01 · Jul 26, 2009

Hmm I am working on a similar problem!! Here is mine...

Case 2: S.J.

SJ, 14 years of age, has just been admitted to the hospital because of uncontrolled diabetes mellitus. She responds to questions but is drowsy if not stimulated. Her skin is flushed and dry. Her eyeballs are soft, and she reports blurred vision.

Vital signs are: BP 106/88, P 128, R 32, T 100F (38.1C). The physician is writing orders now. SJs sister states that the client has been under a great deal of strain caused by a family conflict. The admission laboratory results show:

1. Hct 59%; RBC 5 million/mm3; Hgb 14g; erythrocyte indices WNL

2. WBC 15, 000/mm3. No shift to the left.

3. Platelets normal

4. Urinalysis: SG 1.040; glucose 2%; acetone moderate

5. Serum osmolarity 316 mOsm; urine olsmolarity 1,400 mOsm

6. BUN 40 mg/dL; serum creatinine normal at 1.0 mg/dL

7. Lytes: K 5.8 mEq/L

8. ABGs: pH 7.30; PCO2 30 mmHg; PO2 98 mmHg; Bicarbonate 15 mEq/L

9. Random blood sugar 450 mg/dL; plasma ketone 4+ in 1:1 diluted sample

Daytonite, BSN, RN · Jul 26, 2009

hmm i am working on a similar problem!! here is mine...
case 2: s.j.
sj, 14 years of age, has just been admitted to the hospital because of uncontrolled diabetes mellitus. she responds to questions but is drowsy if not stimulated. her skin is flushed and dry. her eyeballs are soft, and she reports blurred vision.
vital signs are: bp 106/88, p 128, r 32, t 100f (38.1c). the physician is writing orders now. sjs sister states that the client has been under a great deal of strain caused by a family conflict. the admission laboratory results show:
1.hct 59%; rbc 5 million/mm3; hgb 14g; erythrocyte indices wnl
2.wbc 15, 000/mm3. no shift to the left.
3.platelets normal
4.urinalysis: sg 1.040; glucose 2%; acetone moderate
5.serum osmolarity 316 mosm; urine olsmolarity 1,400 mosm
6.bun 40 mg/dl; serum creatinine normal at 1.0 mg/dl
7.lytes: k 5.8 meq/l
8.abgs: ph 7.30; pco2 30 mmhg; po2 98 mmhg; bicarbonate 15 meq/l
9.random blood sugar 450 mg/dl; plasma ketone 4+ in 1:1 diluted sample

so, the first thing you need to do is:

determine what is abnormal among all that data you have presented. a problem is only a problem when the data supporting it is abnormal information: when data is normal it isn't a problem. go through all the information and make a list of everything that is abnormal.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1

- make a list of the abnormal assessment data pulled out from the case scenario. all nursing diagnoses consist of lists of abnormal data called defining characteristics.

after you do that and you are still having trouble diagnosing the nursing problems, come back with your questions.