What do you think is the priority diagnosis or this patient?

[ital91]

Patient has terminal cancer. Began in the bladder & is now spread to the bones. Only has a few months to live. All vital signs are with in normal limits. Has stage 2 pressure ulcers in buttocks, edema of the lower extremities, cap refill normal, most of the pain is in the back area, and also c/o leg weakness. Diminished breath sounds at the bases.

I'm thinking maintaining comfort should be priority, since pt. is end of life

so nursing dx: impaired skin integrity r/t immobility.

or should perfusion or respiratory be priority?

[Aaic]

I'd think pain would be the priority. Is patient on hospice?

[Psychcns]

What about something about maintaining comfort and wellbeing. How about psychosocial needs. I.e. Processing feelings about dying. Anything left undone. Depression. Religious feelings. I would put managing pain and maintaining comfort first. Then probably hydration and physical things, then psychosocial.

[ital91]

no, he's not in hospice

[ital91]

I also think that maintaining comfort should be utmost priority - hygiene, pain free.. etc. I'm not really good with addressing psychosocial needs. I think the last thing to talk about to someone who's dying is their illness..

[jvanwoman]

I would personally go with comfort, specifically pain.

[LeChien, BSN, RN]

You didn't mention anything respiratory related/stated cap refill is normal...so you wouldn't use respiratory or perfusion as a priority nursing dx.

I would definitely use pain/comfort, and impaired skin integrity.

[ital91]

other than the lower extremity edema, the rest of the assessment is WNL. PT. also has an ileal conduit due to the bladder cancer.

[la_chica_suerte85, BSN, RN]

Stay on top of the pain! That bone pain from mets is nothing to mess with.

If it helps, most of my instructors for clinicals where patients in the facility all had pressure sores for one reason or another would tell us specifically to ignore impaired skin integrity because they all had impaired skin integrity (but likely had way higher priority needs) and we needed to dig deeper and get more tailored in our care plans for our assigned patients.

[kaylee.]

OP mentions that the patient is NOT on hospice.

I think the priority depends on what the goals of care are for the patient, not what the nurse thinks should be the priority. If they are refusing hospice and want everything done, then you need to honor the patient's wishes. However, if interventions are futile and the pt/family are having difficulty with end-of-life decisions, then palliative care and even ethics should be on the team with expertise in working with these situations. Usually families will reach this point with counseling and clinical honesty from providers.

From an academic standpoint, with this minimal info, the question seems to be, what are the priorities for a patient/family at end-of-life. In which case the priorities would be pain, comfort and psychosocial/spiritual support. Pressure ulcers are not really part of this, because aggressive wound care is often painful and its goals (to heal wounds and prevent sores) do not promote comfort and are futile.

If the question specifically states the pt/family is NOT interested in palliative/hospice, and yet there is clinically no hope for recovery or quality of life, then this is more of an ethical question.

You have to honor the patient's wishes, and also assist them if they are having crises grappling with tough decisions.