Under a time crunch

[comingback]

I am a struggling student and need help with a careplan....

Let me run through the clinical scenario and then let you know my question:

Mr. White, a 69 yr old male, was admitted with a diagnosis of dehydration and a pressure ulcer over a fractured right hip. He reported that he fell at home where he remained on the floor for 30+ hours before he was discovered and admitted to the hospital.

The admission assessment: Temp 36.5 C; BP 80/50; Pulse 98; Resp 24; weight 116 lbs; Height 5'8". Clothes are dirty with urine. Patient grasps at your arms and pulls at the bedrails yelling, "Let me up, my cat is out there!" He cannot tell you where he is or why his hip hurts. When you ask him to tell you today's date, he again wants to get up and feed the cat that is in the other room.

Ok, so I have the obvious nursing diagnoses of Fluid Vol Deficit, Pain, Skin Integrity, Risk for Injury, etc. but my dilemma is...

Without a mental assessment I'm unsure as to whether this patient has an underlying impaired mental state or if I should attribute all of his delusion to dehydration and/or shock. Need some advice!

[martymoose, BSN, RN]

with a b/p that low who's to say that might be why he's not mentating correctly. Or he could be in renal failure, or have a PE, rhabdo, etc. He needs to be stabilized first.

I guess you could say nsg dx : delirium as evidenced by .............acute injury, ?(as he is not currently aox4, and any of the above situations could make him that way until resolved.)

HTH.

[Esme12, ASN, BSN, RN]

Clearly he is confused....a delirium etiol to be determined. What were his labs? What was the BUN ? CPK? Na?

[comingback]

Thanks for the input. I appreciate it. Having lab results would definitely help put some of the puzzle together but this is all I have to work with. The patient has so many problems, I could have a long list of nursing diagnoses. Would decreased Cardiac Output probably be my first priority?

[nurseprnRN, BSN, RN]

Figuring out the etiology of his confusion is not looking for a nursing diagnosis, it's looking for a medical diagnosis. In terms of developing a nursing care plan, not your problem. We are not in the business of developing secondary medical diagnoses, but nursing diagnoses. This is not to say that it would certainly be nice to know, and we do, in fact, think about the effects of medical diagnoses in planning care. But for your present assignment, the reason for his delirium is not your issue now.

As to your choice of priorities, back up a second and think: If you had just met this man, just walked into his room, what would be your first concern? Safety, perhaps? Wound? Pain? Fluid deficit? Check, check, check, and check.

I don't see anything wrong with the four nursing diagnoses you already thought about, but I don't see decreased CO as a first priority even though his BP is low from probable dehydration (being on the floor for 30 hours will do that to you). You might also think about fear, falls, failure to thrive, comfort, anxiety, and sleep-- what do you see in his behaviors or potential that would involve any of those?

[polka-dot, RN]

He is screening positive for sepsis....infection makes old folks delirious. I agree...stabilize first, worry about mentation later. If you don't know his mental status baseline, it's hard to say if he's got dementia or if this is acute. I guess you could say "alteration in mental status" as your nursing dx...but I'd be super worried about sepsis, rhabdo and blood clots/PE at this point.

[Esme12, ASN, BSN, RN]

Is this a real patient? Or one of those "scenarios"......After lying on the floor for 30 hours with nothing to eat or drink....what would be your first concern? Fluid deficit?

[comingback]

Thanks for all the comments and for helping me step back and look at what a real life situation would call for. This was my first post and I have to say THANK YOU for making feel so welcome here!