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

hypocaffeinemia, BSN, RN · Jan 31, 2009

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.

faithful64 · Jan 31, 2009

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.

hypocaffeinemia, BSN, RN · Jan 31, 2009

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.

faithful64 · Feb 1, 2009

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, BSN, RN · Feb 1, 2009

did you research alcoholism, pancreatitis and liver failure? did you research complications of tube feedings? this patient's hyponatremia is a complication of his tube feedings (the staff fail/forget to give the patient extra water down the feeding tube thinking the feeding formula is providing enough fluid). no you cannot combine diagnosis #3 and 4.

1. activity intolerance r/t pain, weakness, prolonged hospitalization

aeb

unable to turn self in bed

2 person assist bed to chair

2 person assist ambulate 30 steps leaves pt exhausted

activity intolerance

is a nursing diagnosis that addresses a cardiovascular and pulmonary physiologic need for oxygen and that puts it at the top of the priority list when sequencing diagnoses. it's definition is

insufficient physiological or psychological energy to endure or complete required or desired daily activities

(page 134,

nanda international nursing diagnoses: definitions and classifications 2009-2011

) and your evidence is that he became completely exhausted after walking 30 steps with pt and a nurse

not

that he is unable to turn himself in bed (that is

impaired bed mobility

) or needs assistance to get from the bed to a chair (that is

impaired physical mobility

). you need to get a nursing diagnosis taxonomy reference and read these diagnoses, their definition, related factors and defining characteristics (symptoms) before diagnosing someone. if you have a copy of

taber's cyclopedic medical dictionary

you will find the taxonomy in the appendix of the dictionary. otherwise, many of the most commonly used nursing diagnoses and their nanda taxonomy can be found on these two websites:

pain is an inappropriate etiology to use for this particular diagnosis. this diagnosis is all about the patient being deconditioned (out of condition). they have heart and lung changes in response to activity which can and should be observable as shortness of breath, pulse elevations, ekg changes, blood pressure elevations, noticeable fatigue (your patient had this) and weakness. it is not enough that they just can't turn in bed or need two people to assist them with an activity. the elevated pulse, blood pressure, sob and/or fatigue has to be there as well. you have to establish that link and you haven't done that except with the ambulation episode.

you know those low hct 23.2 and hgb 8.1 results? they made the patient anemic, fatigued and contribute to his hypoxia with activity. they bear mentioning here because they affect the oxygen carrying capacity of the blood and the stress activity puts on his heart and lungs.

2. imbalanced nutrition less than body requirements r/t npo staus and increased metabolic demands

aeb:

j tube feeding jevity

weight loss 33 lbs

large stage 2 pressure ulcer, buttocks

the problem is what? the evidence is the patient is losing weight. why? people lose weight because they take in fewer calories than their body require. this man is overweight so he requires more calories. the docs are not going to feed his overweight. he is on controlled calories because he is getting tube feedings so this weight loss is not unexpected. so, is it a problem?

the patient may be npo but he is being fed! what increased metabolic demands does he have and what are the symptoms of them?

"

j tube feeding jevity

" is a treatment and cannot serve as objective assessment data to support the existence of your nursing problem. and i'm sitting here trying to make the connection between "

a large stage 2 pressure ulcer, buttocks

" and how it proves there is an

intake of nutrients insufficient to meet metabolic needs

(page 74,

nanda international nursing diagnoses: definitions and classifications 2009-2011

)

.

answer. . .it doesn't.

what you do have is

deficient fluid volume r/t decreased fluid intake aeb hyponatremia and not receiving adequate supplemental water

and it would occupy position #2 on a list of diagnoses

.

the nursing staff isn't adding enough water to this guy's feeding. look up the signs and symptoms of hyponatremia and see if you missed any of them in the patient.

3. acute pain r/t inflammation and distention of pancreas

aeb:

states pain 7/10

rx morphine sulfate

ct results, cystic lesions throughout pancreas

lab values as above

your etiologies are ok. i have problems with your evidence. (1) where is the pain located? what makes it worse or better? (2) morphine is a treatment so you can't use it as evidence that pain exists. the patient probably was guarding his abdomen which is where the pain is, right? did he moan or try to position himself to make the pain hurt less? those are symptoms of pain. (3) ct results showing lesions in the pancreas don't add up to pain. (4) neither do lab values prove the existence of pain. if they did, ers all over the country would be drawing blood to assess these labs to determine if patients were telling the truth about their pain. see the defining characteristics that nanda lists for pain.

4. impaired skin integrity r/t imbalanced nutrition, prolonged bedrest

aeb 20 cmx 15 cm excoriation on his buttocks

the 20 cmx 15 cm excoriation on his buttocks is a stage i decubitus ulcer. decubitus are common to nursing care and you need to learn about them and their care. read up:

http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx
- pressure ulcer training tutorial (includes photos)
http://www.hill-rom.com/usa/pdf/ctg285.pdf
- guidelines for staging of pressure ulcers
http://www.medicaledu.com/staging.htm
- staging of ulcers
http://ame-medical.com/staging_ulcers_guidelines.pdf
- staging pressure ulcers

how do you suppose this excoriation happened? (definition of excoriated from

webster's new world dictionary of the american language

, college edition:

verb.

to strip, scratch, or peel off the skin; abrade; chafe). "

imbalanced nutrition, prolonged bedrest

"are

not

the cause of any kind of excoriation. sheering force is. laying in wet or humidity first before applying sheering force contributes. somewhere on allnurses is a previous thread i posted to that has an explanation on how maceration softens up the skin setting it up for infection and excoriation.

5. powerlessness r/t physical condition prolonged hospitalization

aeb [???]

powerlessness

is a psychosocial diagnosis whose definition is

perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening

(page 190,

nanda international nursing diagnoses: definitions and classifications 2009-2011

). you generally see powerlessness in people who are depressed. is this man depressed? it's etiology, if this is truly present, is most likely related to the inability to control the alcoholism (the underlying cause of the pancreatitis), the insufficient coping skills in dealing with the stress (that lead to the drinking in the first place) and feelings of low self-worth. the evidence is basically that the patient feels shame that their behavior got them ill and now they are depressed over it:

the patient tells you they have no control or influence over situations
the patient tells you they have doubts about their worth as a person
they may be reluctant to even talk about these things
they have guilt about their past or current behavior
they do not participate in care or decisions when opportunities are presented to them
they have distorted perceptions about their self-image

is this man's platelet count decreased? if so, he is at risk for injury r/t altered clotting factors.

hypocaffeinemia, BSN, RN · Feb 1, 2009

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, BSN, RN · Feb 1, 2009

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.

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.

there are 4 primary causes for dehydration and fluid loss:

decreased sodium intake:
- insufficient dietary intake
- deficient sodium in iv fluids
- n/g feeding with inadequate fluid

[*]increased sodium loss:

addison's disease
fever
diarrhea
vomiting
excessive use of diuretics
chronic renal insufficiency
nephrotic syndrome

[*]excessive body water gains:

excessive oral intake
excessive iv water intake
chf
siadh (syndrome of inappropriate secretion of adh)
osmotic dilution

[*]third-space losses of sodium:

ascites
peripheral edema
pleural effusion
ileus or mechanical bowel obstruction
hidden fluid in body cavities

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:

change in mental state
decreased blood pressure
decreased pulse pressure
decreased pulse volume
decreased skin turgor
decreased tongue turgor
decreased urine output
decreased venous filling
dry mucous membranes
dry skin
elevated hematocrit
increased body temperature
increased pulse rate
increased urine concentration
sudden weight loss
thirst
weakness

when i created my sodium chart, i listed these signs and symptoms for hyponatremia:

increased pulse (tachycardia)
weak, thready peripheral pulses
flat neck veins
increased respiratory rate
decreased blood pressure (hypotension)
decreased body weight
thick, slurred speech
anorexia
nausea/vomiting/abdominal cramps
oliguria
anuria
lethargy/malaise
headache
confusion
muscular twitching
seizures
coma
respiratory arrest

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.

faithful64 · Feb 1, 2009

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.

hypocaffeinemia, BSN, RN · Feb 1, 2009

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.

however, the patient presented in the op has hyponatremia, which can be associated with either fluid volume excess or fluid volume deficit (you are correct on this point): http://emedicine.medscape.com/article/767624-overview

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:

i agree with you on your assessment of possible osmotic diuresis, need for glucose monitoring, however, i dare say we do not have enough information in this picture: 700ml input during one shift (8 hours? 12hours?) is more than adequate if the patient's fluids were being limited due to a fluid volume excess. the out-of-proportion i&o might even be expected due to both the osmotic diuresis and especially if the patient was being treated with diuretics. without more information, this clinical picture is just as likely.

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've seen and treated these patients for years in the prehospital and emergent setting, so i am aware of how common they are. i've seen alcoholics go each way-- volume depletion and severe volume overload to the point of severe pulmonary edema, massive ascites, and hyponatremic seizures.

Daytonite, BSN, RN · Feb 1, 2009

it is not a personal attack, believe me. i don't have the energy to personally attack anyone. i assume that when students post and ask for help that they are opening themselves up to help. if you look at my list of posts you will see that i sometimes answer 3 or 4 care plan posts a day and some of them, like this one, take me several hours of work. i wouldn't have spent the 2 or 3 hours that i did setting up the reply that i gave you if i wanted to attack you. i am trying to show you what you had was incorrect and where your thinking was faulty on some things. don't you want to know that? don't you want to know "why" something is right or wrong? this is the reason people ask me to review their work. because i will take the time to look at every word. i have the time to do that. my writing style just happens to come across as being blunt. for that, i apologize. my intentions are good, i promise. there were some issues that needed to be addressed in your work. you can take the criticism or leave it. i sincerely want to see you do well. i want to help you turn those light bulbs on upstairs in your brain. and, i think you want to do well or you wouldn't have asked for assistance. this critical thinking stuff is not easy. there are people out there who will try to bamboozle you into thinking that these care plans are easy to do and they are so very wrong.

faithful64 · Feb 1, 2009

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.