Severe pancreatitis, this guy has so many problems, how do I prioritize?

ABC's first, then Maslow's. Physiologic needs take priority over psychosocial ones.

I see some potential issues unaddressed:

With the low albumin, does he have a fluid volume deficit r/t third spacing?

With the low H&H, does he have any symptoms of impaired tissue perfusion?

Is the hyponatremia severe enough that he's at high risk for neurologic complications?

Those three would be near the top of my priority if his state matches them, despite the fact that lowered H&H and hyponatremia don't exactly fit the picture of someone third-spacing (quite the opposite, in fact).

Acute pain is also up near the top. After those, your order looks good to me, though I'd personally rank the activity intolerance below the impaired skin integrity considering his large stage II.

Thank you for your reply. His hyponatremia was not yet bad enough to be causing issues. But, during my shift his intake was 700ml and his output was 2150, I did not see any evidence of third spacing but with his I & Os being that far out of whack the fluid volume deficit could be a problem. And frankly, I am not experienced with third spacing. The doc was holding his free water because of the hyponatremia.

I guess I also don't understand tissue perfusion. he did have a distended abdomen and his BP was 168/92, but the BP was already a problem for him. I can't find anything else to fit with this.

I will go with your suggestion about the skin, I'm sure you are right.

Thanks again.

Thank you for your reply. His hyponatremia was not yet bad enough to be causing issues. But, during my shift his intake was 700ml and his output was 2150, I did not see any evidence of third spacing but with his I & Os being that far out of whack the fluid volume deficit could be a problem. And frankly, I am not experienced with third spacing. The doc was holding his free water because of the hyponatremia.

I guess I also don't understand tissue perfusion. he did have a distended abdomen and his BP was 168/92, but the BP was already a problem for him. I can't find anything else to fit with this.

I will go with your suggestion about the skin, I'm sure you are right.

Thanks again.

If you were holding his free fluid, it sounds like he definitely has a problem with fluid volume excess. The hyponatremia, hypertension, and hemodilution (lowered HH) fit with this. I asked if there were any signs of impaired perfusion as with a significantly lowered H&H, there may not enough hemoglobin to meet the body's O2 needs.

If you were holding his free fluid, it sounds like he definitely has a problem with fluid volume excess. The hyponatremia, hypertension, and hemodilution (lowered HH) fit with this. I asked if there were any signs of impaired perfusion as with a significantly lowered H&H, there may not enough hemoglobin to meet the body's O2 needs.

Now I get it, that totally makes sense. I appreciate your explanation.

Daytonite, I am failing to understand the relationship between a fluid volume deficit and hyponatremia. To the best of my knowledge, I thought that a fluid volume deficit (aka dehydration) would lead to hemoconcentration and hypernatremia.

Daytonite,

While I know you have decades of experience and are the local NANDA guru, when your reply comes off as a personal attack it's hard to take any of the great points you may have. Yes, I researched pancreatitis, alcoholism and liver disease ... and I've been using Ackley's Nursing Diagnosis Handbook, and my Med-Surg book the whole time.

Thanks anyhow.

deficient fluid volume, the nanda definition is decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium. what this means and implies, and the definition is not clear about this i know, is that the changes in water and sodium are occurring together. you must know this from you study of electrolytes. what happens to water is also happening to sodium. they happen in an equal relationship. have you heard the phase that "water follows sodium" and vice versa? these two. water and sodium, are linked. you will rarely find someone who is dehydrated and hypernatremic (water and sodium in an inverse relationship). otherwise this diagnosis would never be usable.

"water follows sodium" is a bit simplistic, i think. i understand electrolytes and fluid balance quite well: dehydration and hypernatremia go hand in hand, and the opposite can go well with fluid volume excess.

here's a source: http://emedicine.medscape.com/article/766683-overview

water homeostasis results from the balance between water intake and the combined water loss from renal excretion, respiratory, skin, and gi sources. under normal conditions, water intake and losses are matched. to maintain salt homeostasis, the kidneys similarly adjust urine concentration to match salt intake and loss.

hypernatremia results from disequilibrium of one or both of these balances. most commonly, the disorder is caused by a relative free water loss, although it can be caused by salt loading. the various ways in which these equilibria can be disturbed are discussed in causes.

hypernatremia is due to too little water, too much salt, or a combination thereof. the alteration can be in administration (too much salt or too little water) or output (too much dilute urine or extrarenal free water losses).

the most common cause of hypernatremia in elderly or institutionalized patients is lack of free water intake adequate to meet losses. thirst is the body's main defense against increased serum tonicity. the thirst drive is activated through 2 pathways, one responsive to decreased intravascular volume and the other responsive to even slight increases in serum osmolarity. most patients with an intact thirst mechanism and access to water can prevent the development of hypernatremia. even patients with a defective renal concentrating mechanism (eg, patients with di who may produce up to 20 l of urine a day) generally can keep up with water losses if they are allowed free access to water.

hypervolemic hyponatremia

total body sodium increases, and tbw increases to a greater extent. the ecf is increased markedly, with the presence of edema.

redistributive hyponatremia

water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. the tbw and total body sodium are unchanged. this condition occurs with hyperglycemia or administration of mannitol.

• hypervolemic hyponatremia occurs when sodium stores increase inappropriately.
  
  • this may result from renal causes such as acute or chronic renal failure, when dysfunctional kidneys are unable to excrete the ingested sodium load. it also may occur in response to states of decreased effective intravascular volume.
    
  • history of hepatic cirrhosis, congestive heart failure, or nephrotic syndrome, in which patients are subject to insidious increases in total body sodium and free water stores
    

  [*]consumption of large quantities of beer or use of the recreational drug mdma (ecstasy)

so with this patient, it is quite possible that his hyponatremia is occurring within a clinical picture of fluid volume excess. also, his hypertension and lowered h&h do not fit a picture of volume deficit- you would have hemoconcentration, hypotension, and tachycardia in such a picture.

the patient of this care plan belongs in the first category. these tube feeding formulas are vitamin and electrolyte balanced. he is getting his vitamins and electrolytes daily, but not enough water. one shift's i&o was 700 ml in and 2150 ml out. did you catch that this man also has elevated blood sugars? the renal threshold for glucose is about 180 mg/dl and after the blood sugars get higher than that (this man's was captured at 250) the kidneys start dumping glucose via the kidneys and it needs water to do that. is some of that 2150 ml output urine loaded with glucose that the kidneys are getting rid of? who knows? it was probably never tested. it should be. the pancreas on this man is messed up. who knows what his alpha and beta cells are doing? his glucose should be monitored every which way and sundays. i have no doubt that the 700 ml intake that the op had during her shift was nothing more than the jevity and perhaps a few mls of water utilized for medications given through the j-tube. there are 250 ml in a can of jevity. that is not even 3 cans of jevity. would you be satisfied with 2.8 cans of this as your sole diet in a shift, assuming this is an 8-hour shift, and no supplemental water? this has been going on for, roughly, a month give or take some days since the j-tube was inserted and these jevity feedings started. [not criticizing you, faithful64, because we probably don't have the full picture here, but just pointing out some things to think about.] here are the symptoms from the nanda diagnosis for this problem:

does that help explain things for you? there is a lot going on with this patient. you wouldn't believe how common it is to have this kind of patient in the hospital. alcohol is a legal substance and this is what happens when people abuse it regularly. they don't even have to be addicted to it. they either get problems with their pancreas or problems with their liver.

I accept your apology Daytonite, and don't mean to be thin-skinned. I appreciate the time you took to critique my plan. I do hate that about the in internet, when you can't see and hear the other person it can be hard to "read" their meaning.

I just wrote a lengthier reply, which I wasn't finished with, but I hit something and it disappeared, so I think it may be showing up here eventually. Thanks again.