Priority Nursing Diagnosis HELP!

[mamatovanda]

Hi-

I am having a hard time deciding which diagnosis to use for this patient. I believe it's Risk for Ineffective Respiratory Function but I'm not 100% committed.

Here's the info:

82 year old male patient admitted to an acutre care facility for shortness of breath and an elevated temperature of 101 for 3 days. He responds slowly but appropriately to all questions. His skin is warm, dry, thin, and flaky. Skin turgor greater than 3 seconds. Capillary refill is greater than 3 seconds. Respirations are short and shallow, lung sounds with bilateral crackles, and pulse ox of 92%. Bilateral lower extremities with 1+ pitting edema. Toenails yellowish, thick. He states the food is very bland and he eats 50% of all his meals. Last BM this a.m. was moderate amount of formed hard stool. vital signs upon admission: T.101 F, P. 84, RR 24, B/P 160/80.

We were told to only have one diagnosis, so, obviously I am searching for the main diagnosis.

I'm concerned that my book says that this is not on the NANDA list. I've reviewed Ineffective Airway Clearance, Ineffective Breathing Patterns, and Decreased Cardiac Output and didn't feel like they were related enough to this case.

Thanks for your help!!!

[bevtag]

How about impaired gas exchange r/t changes in alveolar membrane, pulmonary vascular resistance, possibly aeb dyspnea, decreased mental acuity, somnolence, abnormal ABGs (you could address delayed cap refill, thickened toenails, 1+ pitting edema). Sounds like he's dehydrated, as well, but ABCs are always first.

Good luck!

[ParkerBC,MSN,RN, PhD, RN]

I don’t think I would do any “Risk for” for this patient as your patient clearly exhibits signs of actual Dx.

Here are some things to consider:

1. Your patient’s cap refills are > than 3 seconds, which indicate potential tissue perfusion concerns.

2. Skin turgor is indicative to dehydration, which really isn’t a surprise given your patient’s age.

3. Respirations are short and shallow. This concerns me. If his respirations are short and shallow, he will eventually begin holding onto the CO2, thus making him acidotic. ABG’s would confirm.

4. Bilateral crackles and pitted edema. Given the Temp, I wonder if your client has the Flu or Pneumonia. The pitted edema indicates fluid retention/fluid shift. CBC would confirm.

5. If only eating 50% of meals, nutrition isn’t good, so pressure ulcers will be a concern given the description of his skin. Check albumin level.

So, nursing Dx’s:

1. Imbalanced Nutrition: less than body requirements

2. Ineffective Tissue Perfusion

3. Excess Fluid Volume

4. Impaired Gas Exchange

[Turd Ferguson]

I agree with everything the above poster says, but I would have Impaired Gas Exchange listed as 1 instead of 4. You've got to stick to your ABC's!

1. Impaired Gas Exchange

2. Ineffective Tissue Perfusion

3. Imbalanced Nutrition

I wouldn't really go with Excess Fluid Volume given his >3 sec cap refill and loose skin turgor. The crackles in his lungs do indicate fluid but it doesn't necessarily mean he is fluid overloaded, it's just in the wrong spot.

[MrsMig, BSN, RN]

I agree with everything the above poster says, but I would have Impaired Gas Exchange listed as 1 instead of 4. You've got to stick to your ABC's!

1. Impaired Gas Exchange

2. Ineffective Tissue Perfusion

3. Imbalanced Nutrition

I wouldn't really go with Excess Fluid Volume given his >3 sec cap refill and loose skin turgor. The crackles in his lungs do indicate fluid but it doesn't necessarily mean he is fluid overloaded, it's just in the wrong spot.

Ditto!! This would be my approach for sure!

[CCL RN, RN]

Pts today are sick enough that there is never a need for an "at risk" nursing Dx. I went my whole nursing school career having NEVER used one in a single care plan.

That being said, I like the PPs Dx of ineffective gas exchange.

[ParkerBC,MSN,RN, PhD, RN]

I agree with everything the above poster says, but I would have Impaired Gas Exchange listed as 1 instead of 4. You've got to stick to your ABC's!

1. Impaired Gas Exchange

2. Ineffective Tissue Perfusion

3. Imbalanced Nutrition

I wouldn't really go with Excess Fluid Volume given his >3 sec cap refill and loose skin turgor. The crackles in his lungs do indicate fluid but it doesn't necessarily mean he is fluid overloaded, it's just in the wrong spot.

Just for the record, I was not listing the Dx. in order. Rather than giving you the answer, I was providing some thought provoking examples. Simply giving the answer doesn't allow you the opportunity to learn.

You're correct...the crackles in the lungs doesn't necessarily mean fluid overload. Since I don't have values to look at, it's really hard to say.

[art1stic]

Fluid overload could be one His blood pressure is high, he has edema, and crackles.

How was the urine output per hour? Is he retaining fluid.

How was his skin besides skin turgor? Any presence of breakdown or ulcers?

Temperature is slightly elevated possible infecting due to pneumonia? Where's the cultures

What are his labs?

We need more assessment data!

[ParkerBC,MSN,RN, PhD, RN]

Fluid overload could be one His blood pressure is high, he has edema, and crackles.

How was the urine output per hour? Is he retaining fluid.

How was his skin besides skin turgor? Any presence of breakdown or ulcers?

Temperature is slightly elevated possible infecting due to pneumonia? Where's the cultures

What are his labs?

We need more assessment data!

I guess I could have looked at the BP, ehh? Good questions!