ampela

The old "critical thinking" still stands-- nursing students need to be able to develop these skills by the time they become nurses in the field. This is a great story. Thanks for sharing.

The BNP was 573 upon admission, mid-hospital stay was 284, and close to discharge was 454. My rationale behind the ineffective tissue perfusion was that due to her multiple comorbidities (anemia, CHF, GI bleed and DM) I was worried about her extremities and what her quality of life would be without them. But it makes sense to deal with excess fluid as that exacerbates the breathing problem. Thank you!

*Edited from above-- Readiness for Enhanced Coping R/T acknowledgement of inadequate assistance at residence AEB one caregiver present to take care of patient and spouse, recognition of individual limitations and need for external resources, and acceptance of social support from family and community. Re-prioritization: I am thinking along the lines of ABC- 1. Ineffective Breathing Pattern 2. Ineffective Tissue Perfusion 3. Excess Fluid Volume 4. Decreased Cardiac Output 5. Readiness for Enhanced Coping 6. Readiness for Enhanced Knowledge

For some reason I thought it was to turn the patient to one side. Ugh need to read it more carefully. Thanks for clarifying! The answer was A.

I think it's D. You want to maintain her airway and breathing first in case she aspirates. What was the right answer? I've had issues with nursing exam first but fortunately my instructor takes into account the class answers and throws it out if more than half got it wrong. But she keeps most of the questions though. Remember on NCLEX we don't have the luxury of having someone look over the questions and throw it out..

I find it helpful to just close all the lights in the room including blinds and curtains. For consensual response: shine the light in one eye, look for constriction; then do it again (shine the light in the same eye) but this time watch for constriction in the other eye. For accommodation have the patient look at your pen light as you move it close to the patient. The eyes should converge equally on the pen light.

Thanks for replies. Decreased Cardiac Output is the patient's underlying issue that will in turn cause Ineffective Peripheral Tissue Perfusion, Ineffective Breathing Pattern, and Excess Fluid Volume. The patient has Deficient Fluid Volume due to her anemia.. I hesitate to put Decreased Cardiac Output or Excess Fluid Volume as my priorities because one instructor focuses on what will become life-threatening first, while the other focuses on what will impact the patient most. In one class simulation what we all thought in class was Excess Fluid Volume the instructor said it was Ineffective Breathing Pattern because it was life-threatening. The patient's lungs sounded clear on auscultation but a bit diminished at the bases. No crackles, wheezing, stridor was heard. The patient was on room air and she has no dyspnea at rest. The BUN and CR was 41 and 1.6, and the Hgb was 9.9 and Hct was 30.4. Electrolytes: sodium was 136, potassium was 4.1, chloride was 97, calcium was 8.9, and magnesium was 2.2. PT/INR was 13.9/1.1, and PTT was 31. The diuretic treatment seems to be working well as she has had 6 lbs weight loss since admission. As far as I can tell, there hasn't been any aggressive treatment for her chronic kidney disease other than encouraging fluids and controlling her diet. Readiness diagnoses: Readiness for Enhanced Coping R/T inadequate caregiver to patient ratio at residence (1:2) AEB one caregiver present to take care of patient and spouse, acknowledgement of need for social support from family, friends, and community, acknowledgement of individual power in disease management, and need for community resources. Readiness for Enhanced Knowledge R/T recent episode of exacerbation of chronic heart failure AEB expressed interest in learning, inquisition on disease process, verbalized understanding of disease process, initiative in ambulation, and monitoring of own daily weight. I agree that my diagnoses still need to a lot of editing- thanks for reading!

I apologize for the abbreviations- PPM is permanent pacemaker, F/C is foley catheter, and HLD is hyperlipidemia. CAD is coronary artery disease and CKD is chronic kidney disease. I am in my intermediate-advanced med/surg class and I am using Carpenito's Nursing Diagnosis and Doenges's Nursing Pocket Guide in addition to Brunner and Suddarth's Textbook of Med/Surg Nursing. Thank you for replying!

Since the patient has a history of chronic anemia, then the priority would be making sure that there is adequate perfusion. So therefore Ineffective tissue perfusion should be prioritized? I am torn between GI and Cardiovascular systems but this case study is focusing on cardiovascular.... Btw the vitals are WNL and SpO2 is 98% on room air. No SOB at rest, and grade 1/6 murmurs.

I have trouble prioritizing nursing diagnoses.. This is for a case study in med/surg class. My patient has multiple medical history but she was admitted for anemia, acute exacerbation of chronic heart failure, and GI bleed. Past medical history include chronic diastolic heart failure with hx of PPM, CAD, HTN, HLD, hypothyroidism, CKD, and multiple GI problems including hx of rectal CA with transanal resection. There was little bleeding when she was admitted but she stated that it has lasted for last 2 weeks, and she had pantoprazole drip, Lasix IVP, and blood transfusion. She is A/O x 4, standby assist, has dependent edema 1+ in BLE, weak peripheral pulses in BLE, and has a F/C. Her labs are WNL except for low H/H levels, low RBCs, high BNP, and high BUN/Cr. Her lipid panel shows slightly high LDL and low HDL but otherwise normal. Troponins are negative. Chest X-ray shows moderate pulmonary congestion. The bleeding has stopped when I assessed her 4 days later and it seems to me that controlling her fluid retention seems number one because she complained of shortness of breath and weakness upon exertion x 2 weeks and she had a weight gain of 20 lbs but has since lost 6 lbs. The main plan of care is to continue diuresis. My focus is on the cardiovascular system. I have ordered the nursing diagnoses in the following order (there are more but at least one physiological, one psychosocial, and one educational): 1. Excess fluid volume R/T compromised circulatory mechanism secondary to chronic diastolic heart failure AEB orthopnea, shortness of breath, dependent edema in bilateral lower extremities, decreased peripheral pulses in lower extremities, weight gain, pulmonary congestion, and decreased H/H levels 2. Ineffective tissue perfusion R/T compromised circulatory system and decreased hemoglobin concentration in the blood secondary to anemia, gastrointestinal bleeding and chronic heart failure AEB dyspnea, dependent edema on bilateral lower extremities, weak peripheral pulses at lower extremities, rough and hard skin in lower extremities. 3. Ineffective breathing pattern R/T compromised circulatory system secondary to pulmonary congestion AEB shortness of breath, orthopnea, pulmonary congestion, dyspnea upon exertion. 4. Decreased cardiac output R/T altered preload, afterload, and contractility of the heart secondary to chronic heart failure AEB shortness of breath, orthopnea, fatigue, weight gain, dependent edema in bilateral lower extremities, decreased peripheral pulses in the lower extremities, and diminished breath sounds in the bases of the lungs 5. Readiness for enhanced coping 6. Readiness for enhanced knowledge I know that you should always prioritize diagnoses that would have the most impact on the patient (airway, breathing, circulation) but in this case it's controlled (patient can maintain own airway, only has dyspnea upon exertion, and has a PPM and HF is controlled by meds). Should I re-prioritize? Thank you for any input!!