Liebchen

Actually, his assessment is here: patient presentation.pptx

Thank you. Yes, I don't know what I was thinking. Apparently I was not. I know it is an infection, as I have it in my presentation. It is those little things that I overlook, that makes me furious with myself. I took out the risk, which then makes more sense to make it priority. Cayenne ~ I am trying to base it on his symptoms, problem is, he has so many, Edema, pain, Which is why I based his priority dx on his cellulitis. However, we are ( in our presentation) to look at the whole picture and include dx that would apply. I think I could come up with all of them just based on his cellulitis, and another dozen or so on his other problems. Thank you for your input. I appreciate it. GrnTea~ I did change to infection and took the risk out. I actually was trying to diagnose based on his symptoms and presenting complaint, which was pain and cellulitis (severe). But if I can explain my rationale, perhaps that will explain why I came up with diagnosis. I know he is in a lot of pain due to the infection. So, I thought if that was priority, taking care of infection would take care of pain. Then, if I took care of pain, that would ( as another poster suggested) would get his activity level up. Then of course, looking at the big picture, I felt it was necessary to address the excess fluid volume causing the edema. Which would help him to be more comfortable as well. Then I felt that addressing his nutrition, (long term facility, but not permanent, VA facility) would be beneficial in helping to keep the problem at bay... as far as keeping his diabetes in check and eventually, very long term, his weight. Although, as others has stated, I know that his weight will not be a priority in acute care setting. I do have the NANDA, and I use it all the time. But the NANDA does not help with prioritization. If I had a patient with just one issue, I don't think I would have all the issues I am having. But this patient has such a "cycle" of problems, that I am having a hard time addressing where to start in the cycle of prioritizing. Maslows theory was very helpful for me. It helped me to define importance, as far as "airway" or "pain". Thank you, I find all of your suggestions and statements very helpful and a great learning experience.

Yes indeed, it was very helpful. Thank you so much. I am finding that my problem with this patient is so many problems, that I could write several DX on each problem. Then I get myself into trouble. Maslows hierarchy is very beneficial, thank you. Oh, and I appreciate the links. We followed this patient from the beginning of clinical to the end (ten weeks). I have 80 hours with him, and felt like I knew him very well. I read his chart daily, and did a head to toe daily and spent the rest of the day with him, learning and listening. I think this one patient has taught me more (as far as nursing DX goes) then my entire time in school. Thanks to all of you for the dedication in helping the "babies" grow up to be real nurses. I appreciate you very much.

Ok, I have taken what you said, and I have written four DX. I think I have them prioritized correctly. Can you critique? I know you said that I should address the patients pain so I am thinking that should be top on the list, after infection. I was a bit confused, though, should I address the fluid volume, which would then take care of some edema which may reduce pain and infection? Oh my goodness.... This is why I stink at this. But then, an at risk diagnosis would not be priority, would it? 1.) Risk for infection r/t or impaired tissue integrity r/t alterations in fluid volume aeb severe peripheral edema. 2.) Acute pain r/t inflammatory process aeb patients refusal to walk and statements that he is in pain. 3.) Fluid volume excess secondary to renal failure aeb peripheral edema, elevated BUN and Creatinine and decreased GFR. 4.) Imbalanced nutrition: more than body requirements aeb BMI of 52.4

Thank you so very much, for your input. It really helps me to start my thinking process, when I have things thrown out there. We needed 3-5 nursing dx. Now, I have come up with several more.. this will be a very good thinking process for me. Thank you for all your help.

Thank you very much. This is really making me think. Blue, he does have serious renal issues, but as MattNurse stated, he is apparently in denial as it has been addressed in his chart over and over and throughout the years. He is in a VA facility and has been there for almost two months. After a team meeting, it was decided that no discharge would happen until his cellulitis was under control. He was invited to the team meeting, but would not come. All of his functional assessments, mini-mental and depression scale showed slight depression. He won't socialize with the other patients either. He sits in his room all day and watches tv. His vitals are fairly decent. BP running just a little high 135/85 sometimes lower. Temp is good. His legs are getting better. GFR keeps getting lower and that was one of my biggest concerns. When I started caring for him 8 weeks ago, his GFR was in the 40's, and now, it is 29. BUN and Creatinine is also steadily increasing. He is beginning to get nauseated several times per day. You gave me a lot to think about, and I really appreciate it. Editing to let you know, that his lungs are clear A&P. Heart sounds S1 and S2 present, no extra sounds noted. no murmurs. No oxygen.

Thank you Blue...looking it up now.

Ok, I am thinking, because his admitting DX was cellulitis and this is giving pain, this must be addressed first. So, I have come up with: Ineffective tissue perfusion r/t edema aeb redness, blisters and pitting edema. I am thinking that he has a knowledge deficit or non-compliance r/t his diabetes. Am I on the right track at all?

Hello, If anybody can give me a few suggestions, I would appreciate it. I have a care plan due, and I have to come up with 3-5 nursing diagnosis based on my patients problem list. I really struggle with this. I have struggled with care plans from day one. I have some ideas, but because I stink at it, I can't, for the life of me, figure out what I should pick. Below is my patients problem list. He is a 57 year old male. Obese (52.4 BMI) He presented with a severe case of cellulitis bilaterally in the lower extremities w/pitting edema, blisters and lots of drainage. His medical dx is Cellulitis secondary to chronic venous insufficiency. This is where I begin to struggle. The problem list. Cellulitis Obesity type ll diabetes Chronic Kidney disease stage lV hypertension obstructive sleep apnea compensated systolic dysfunction Congestive Heart Failure atypical seizures I (think) that I want to make his cellulitis top priority....as this is a mess and causing him great pain. He is on lasix for the extreme swelling and water retention. They are using a cream on his legs (castor oil) and elevating as well as fluid restriction to 1.5 liter per day. However, he is non-compliant with his diabetic diet, which I feel that if he would lose some weight, ( his BG is very good) he may have a bit more control over his hypertension and his obstructive sleep apnea. His labs are a mess.. When I first saw his labs, I thought I should concentrate on this... —Calcium 8.4 L (8.5 - 10.5) —Sodium 130 L (135-145) —Potassium 5.3 H (3.5 -5.0) —Glucose 118 —BUN 43 H (7-21) —Creatinine 2.3 H (0.6 -1.2) —GFR 29.9 L (90 -120) He says, he is not having trouble with his kidneys and never has, and that the Dr. has never addressed this issue with him. However, they just sent him for a renal scan. The results are pending. He is, by his own admission, and evidenced to be very sedentary. He watches tV all day, and even though we have tried to encourage him to walk, at least to the day room for lunch, he insists on taking his wheelchair. However, when he did walk the last time, the length of the hall, he swelled up, and then spent time recovering from that ( a day) and then refused to walk anymore. So do I concentrate on the cellulitis part of his problems? Do I address his diet? Hypertension? lack of activity? They are all so closely related, I don't know where to start? They all seem so very important. Please help.

Wow, not sure if that was meant to be rude or not. Hard to read tone. I do have a diagnosis book, but I am having trouble relating it to the entire family. I have to include, mom, dad and baby and any other family members into the diagnosis. Thanks for your input...

Sorry for the repeat. I put this in the wrong place earlier. Please help me. I have successfully done my required three care plans for the quarter clinicals. However, we now have to do a family care plan with four nursing diagnosis. I am coming up blank. I just need some suggestions. My baby was very healthy, but they do have some situational issues... They don't have a home and live with the husbands mother. They do have a three year old and an 18 month old. I have come up with : ineffective coping r/t changes in family composition AEB sibling rivalry Parental fatique r/t effects of newborn care on sleep patterns AEB parents verbalizing lack of energy and rest. interrupted family processes r/t situational transitions AEB newborn addition to the family. Can I get advice or suggestions please?

Well, it is very hard. If you have a good support system and you are willing to make sacrifices and you want this more than anything, you can do it. I will warn though, it will take sacrifices. Your life as you know it will end. Family time will be minimal to none. All of your spare time will be spent in study sessions. Your social life will be over for the duration of school. But, if your husband is willing to play mommy and daddy and you have a strong support system, then I would advise you to do it now while your kids are young. I waited until my son was 23, and now I regret it. I could have been working in my dream job for years. Go for it, and good luck!!

Please help me. I have successfully done my required three care plans for the quarter clinicals. However, we now have to do a family care plan with four nursing diagnosis. I am coming up blank. I just need some suggestions. My baby was very healthy, but they do have some situational issues... They don't have a home and live with the husbands mother. They do have a three year old and an 18 month old. I have come up with : ineffective coping r/t changes in family composition AEB sibling rivalry Parental fatique r/t effects of newborn care on sleep patterns AEB parents verbalizing lack of energy and rest. interrupted family processes r/t situational transitions AEB newborn addition to the family. Can I get advice or suggestions please?

Thank you!! I will make that correction. I really appreciate your input.

corrections have been made. does this look better? diagnosis 1: risk for imbalanced nutrition r/t poor feeding behaviors aeb newborns inability to properly latch. diagnosis 2: risk for infection r/t circumcision. diagnosis 3: risk for respiratory distress r/t thermoregulation diagnosis4: ineffective thermoregulation r/t immaturity aeb newborns inability to maintain body temperature above 97.5 priority dx: ineffective thermoregulation r/t immaturity aeb newborns inability to maintain body temperature above 97.5 long term goal: newborn will maintain thermal homeostasis with axillary temperature of 97.8 - 98.6 by time of discharge. short term goals: 1.) newborns temperature will increase to 97.8 within one hour. 2.) mother will be able to return demonstrate understanding of kangaroo care and other methods of warming baby, as well as demonstrate her ability to assess babes axillary temperature by discharge. 3.) newborn will be free of s/s of respiratory distress r/t thermoregulation ( increased respirations, lethargy) by the time baby warms to 97.8. interventions: 1.1)nurse will place baby in gradient warmer. 1.2)nurse will move baby away from drafts and cold surfaces 1.3)nurse will make sure baby’s head is covered and swaddled when baby is away from warmer. 1.4)nurse will maintain environmental temperature between 89.6 and 92.3 (f) in newborns room. 2.1.) nurse will teach mother the effects of heat loss on baby. 2.2.) nurse will demonstrate to mother how to apply kangaroo care. 2.3.) nurse will teach mother how to assess axillary temp of newborn. 3.1.) nurse will assess newborn respirations q 30 minutes while baby is at risk, and q 4 hours afterwards. 3.2.) nurse will monitor vital signs q 30 minutes while baby is at risk and q 4 hours afterwards. 3.3.) nurse will monitor for s/s of respiratory distress r/t thermoregulation ( lethargy, increased respirations, hypoxia and low bg levels.)