Priority Nursing Dx help PLEASE!!

[chicklet74]

I really need help with this nursing dx. I need 2 PRIORITY (my instructor is really strict on the prioritization on these) nursing dx. We have to submit at least 3 perfect care plans in order to pass to the next level. I've gotten my first two so I'm super paranoid about the 3rd. (My first two were extremely easy to come up with - this one, not so much.

Pt. is a 48 year old female who was admitted to the ED because she was unarousable so her main admission dx was "change in mental status". She has: chronic renal insufficiency, thrombocytopenia, schizophrenia, depression, and is less than 5 years post op for a left mastectomy. Early this morning, she was unarousable, wouldn't respond to verbal stimuli or shaking. Resisted pupil check. Her vitals were 164/78, R - 24, HR - 68. Pulse ox was 95% on room air. During the time she was sleeping, I observed heavy snoring and brief periods of apnea. She also had several jerky movements while unresponsive to us. She has no listed history of sleep apnea. A little later, she was more awake and willing/able to communicate with us. Her CBC listed low RBCs, low hemoglobin and low hematocrit (I'm guessing because of the renal insufficiency). Lymphocytes and monocytes were both high but I haven't exactly figured out why yet. Creatinine was also high, but again, I guess because of the lack of kidney function.

I'm hesitant to use any nursing dx r/t her apnea periods because she hasn't been diagnosed medically with sleep apnea.

[OCD_Mom]

Fatigue is also a NANDA for Renal Failure and I personally know from my son's past condition that he slept like a log. A low Hgb and Hct will also cause greater fatigue and remember even though her RBC are sat at 95% does not mean that O2 is adequate for her needs if there are not enough cells to carry O2, you had mentioned a slightly elevated resp. Also if she is on dialysis fatigue will be even more so. Elevated WBC can also be related to renal issues as it also effects your immune system. I am just beginning Block 2 however these are personal experiences I have had with renal failure for 3 years prior to transplantation of my son. I did refer back to my NANDA book for confirmation on these bits I posted.

[chicklet74]

Wow, after hours of agonizing over this last night, I ended up choosing Fatigue as my first one and then, because of her diminished cognitive status, Ineffective protection because of the risk for injury. Thanks for sharing that information because now I feel like I chose correctly.

[OCD_Mom]

Your welcome at least someone can benefit from my personal hell I experienced a few years ago. j/k I love my children and I probably wouldn't be where I am today had I not had these experiences, right?! Good luck!