RN DX prioritization...HELP!!!!

[2007_RN]

All right I have gone into total and complete brain fry! I have written this awesome case study on a patient and have all of the RN diagnoses but just can't seem to figure out the BEST order. Could ya help??? I know Maslows and I know ABC's...Just can't seem to figure this out because they are all physiological.

History: This guy is 65 years old, End stage COPD, 152kg. Came into ER in respiratory failure and intubated. Found to be in SVT and electrocardioverted. He had pleural effusion and the CT scan showed a suspicious mass in his chest. Thoracotomy performed and 1 liter of adipose tissue was removed from his pleura. That was back in mid-July. He is still in the ICU with hyperthermia, still intubated and switched to a trach at the end of August

Can you help me put these in the right order?

1.)Impaired gas exchange related to ventilation/perfusion mismatching or pulmonary shunting as evidenced by low PO2 & high CO2 in ABG and adventitious breath sounds on auscultation. (Respiratory)

2.)Risk for aspiration related to dysfunction of normal protective mechanism (cough reflex) due to high levels of sedation. (Respiratory)

3.)Ineffective breathing pattern related to musculoskeletal fatigue as evidenced by unsuccessful weaning of mechanical ventilation. (Respiratory)

4.)Decreased cardiac output related to alterations in preload as evidenced by impaired tissue perfusion (edema, decreased urinary output) (Cardiac)

5.)Excessive fluid volume related to renal dysfunction as evidenced by third spacing in the extremities and crackles auscultated in the lungs. (Cardiac)

6.)Decreased cardiac output related to changes in afterload as evidenced by labile blood pressures. (Cardiac)

7.)Activity intolerance related to imbalance between nutritional supple and illness demand as evidenced by increased blood sugars. (Endocrine)

8.)Imbalanced Nutrition: Less than body requirements related to increase in metabolic demands evidenced by low albumin. (Endocrine)

9.)Risk for infection due to circulatory changes and delayed healing of decubitus ulcers and post chest tube site. (Endocrine)

[UM Review RN, ASN, RN]

i apologize but please allow me to get ot for a bit. maybe it will tie in w/the ops' care plan anyway.

what does a ncp look like for one w/sepsis?

icu nurses, care to educate?

i ask, because when my mother was transferred to the icu for sepsis- yes, she was vented, had 3 or 4 different pressors going, a few abx, tpn, albumin, blood....the nurses worked non-stop on her for 2 wks.

so while they are doctors' orders- it's the nurses who maintain these patients.

they are continually titrating gtts and putting out fires.

i was w/her for days, went home for a few and was called back because she had deteriorated even more.

her vasculature had collapsed, had gross ascites...i just can't imagine not having a careplan in place.

the responsiblities of the icu nurse are immeasurable.

the implications of sepsis would make a remarkable, remarkable care plan.

but i suppose when one doesn't have personal experience, it would be challenging to write.

so....any input would be appreciated.

i for one, would love to be educated.

leslie

i learned to look for sepsis whenever a patient's bp was low and they simply didn't seem to be improving. the s/s are very vague at times, and this is difficult to diagnose. therefore, why it is so important for us nurses to be aware of the constellation of symptoms, because early intervention is so crucial.

i also had an opportunity to identify a relative who was septic--his wife and i were talking on the phone. i could hear him in the background saying nonsensical things, when normally he was a/o x3. she thought maybe he'd had a stroke or was getting more forgetful. i had her take his temp--it was 103. had her call 911 and get him to er. he was uroseptic. i was quite surprised that he survived as he has end-stage ms.

anyhow, that prompted me to learn more about it, and there are some excellent resources available now that there is a campaign to identify and treat sepsis victims.

here are the websites i found. some of this stuff was over my head to a certain degree, but still i think i picked up on enough to get the gist of it.

http://www.sepsis.com/index.jsp[/url]

http://www.ihi.org/ihi/topics/criticalcare/sepsis/

if i find any more of these, leslie, i'll just pm them to you.

to the op: as i mentioned earlier, you might feel that some of these articles are a little too medical in nature or a little over your head right now, but try reading them, even if you have to struggle a little, or better yet, i'd print out a couple and ask your instructor to go over them with you all, because this is a very important problem among our patient population and you will be seeing a lot of this in your career.

[Daytonite, BSN, RN]

here are a couple of other links with information on sepsis you might want to check out as well:

http://www.survivingsepsis.com/index.html - surviving sepsis, a web site for everything you want to know about sepsis, signs and symptoms, common sources of sepsis, septic shock and treatment. links at the left side of the page take you to the various pages of this site. includes links for more information on sepsis, some of which are extensive sites by drug manufactures on the treatment of sepsis.

http://www.ccmtutorials.com/infection/index.htm - critical care medicine tutorial on sepsis (for medicine)

http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/sepsis/sepsis.htm - all about sepsis, also called sirs (systemic inflammatory response syndrome). it's definition, prevalence, pathophysiology, signs and symptoms, diagnosis, treatment and outcome