Would like to use nursing Dx imbalanced nutrition but not sure how!

Hello all -

I'm still kind of new to allnurses.com but am in my 3rd semester of nursing school. I have to create a care plan for a new mom with PIH; her uric acid was elevated but her protein and albumin were actually below normal. She also lost 12 pounds at her last prenatal visit when she was approximatley 36 weeks gestation.

For this care plan, if we do not have actual assessment information from the patient, we can "assume" certain things to be true. I was going to use "Imbalanced Nutrition: less than body requirements related to _______________________ as evidenced by below normal levels of protein and albumin and a 12 pound weight loss upon her last prenatal visit (she was about 36 weeks).

I'm not sure how to relate low protein and albumin to this diagnosis because I actually did not have access to the patient to ask her about the weight loss. Is there anything specific to pregnancy (other than N & V) that could cause such a weight loss and low protein and albumin?

Thank you for any help anyone can give me!

[Daytonite, BSN, RN]

it sounds to me like your diagnosis is wrong. you have to work within the parameters of what a diagnosis allows. there is actually 2 different problems here.

the low protein and albumin are related to fluid and electrolytes, not imbalanced nutrition. that should be addressed as deficient fluid volume r/t protein and albumin loss aeb [symptoms of isotonic fluid overload]. she had no edema or other indications of fluid retention? no dyspnea, nausea or vomiting?

new mom's who experience 12-pound weight losses do so because they are not eating enough food for both themselves and their growing baby because of nausea and vomiting they are experiencing as a result of the pih. or, it may just be another problem causing them anorexia that we are unaware of. so, the diagnostic statement would need to be along the lines of imbalanced nutrition: less than body requirements r/t insufficient intake aeb 12 pound weight loss upon her last prenatal visit.

[RN in 10!]

thank you for the reply daytonite!

yes, the mom did have pitting edema in both lower extremites, as well as some facial edema. she didn't n & v or dyspnea though.

your diagnoses make much more sense to me. but, here is one question i should already know the answer to, but if you could please tell me if i'm wrong that would be great!

for the dx deficient fluid volume r/t protein and albumin loss aeb [symptoms of isotonic fluid overload]; is the isotonic fluid overload the fluid moving from her blood vessels into the interstitial spaces? fluid and electrolytes was always a weak point for me :-(

thank you again for your wisdom in such a difficult subject (nursing dx!)

[Daytonite, BSN, RN]

deficient fluid volume r/t protein and albumin loss aeb bilateral pitting edema of both lower extremities and facial edema. yes, this is because of fluids moving from the blood vessels and into the interstitial spaces. this edema is an important sign and symptom of pih also known as pre-eclampsia. part of your responsibility in diagnosing someone is to also look up the pathophysiology and all the signs and symptoms of their medical condition and equate them to nursing diagnoses because they are also nursing problems that we need to care for. i don't completely understand what happened here, but in looking for what was going on with her weight loss, the pathophysiology of the pih got overlooked.

• see the http://www.brooksidepress.org/products/military_obgyn/home.htm website for obstetrical information
  

[RN in 10!]

Daytonite,

Again, thank you for sharing your knowledge. I know, this patient was very interesting. Here's her story:

Four days postpartum she began to have severe headaches and went to her doctor. Her blood pressure was 180/100 and the doctor determined that she had PIH and a spinal headache from the puncture of the spinal block. She admitted her to the hospital ASAP. She had no previous prenatal Hx of hypertension. As you know, her protein and albumin were low but uric acid was elevated. The doctor based her Dx on the elevated Uric acid level and increased high blood pressure. To make matters worse for her, her baby stayed in the NICU due to being SGA and a poor feeder. There was also major family drama going on with her husband.

The only access I had to this patient's previous Hx was what was on her chart in the computer at the hospital. She was really in no condition to talk much with me because her doctor placed her on strict bed rest, no disturbances and nothing that would upset her. She had extremely high BP in postpartum recovery (highest was 205/150) but I did not see in her chart where they started her on Mag. I just have to assume that was the case. It took about 30 minutes but her BP decreased to 133/71 while in recovery.

It's a mystery to me why her blood pressure shot up after delivery to such a dangerous level. The only other abnormal values were: (The determination of highs and lows are set by the hospital)

Potassium 3.3 Low

WBC 13.9 High

RBC 4.11 Low

Seg Neutrophils 76.7 High

Lymphocytes 16.7 Low

Seg bands 10.6 H

Does any of this shed any more light on what happened to her?

[Daytonite, BSN, RN]

ob was not the area that i worked in. i was a med/surg nurse and worked in a stepdown unit for a number of years as well. what i do know is how to apply the nursing process to care planning. what you need to do when writing this care plan, and as a student, is research pid (eclampsia). even though you didn't have access to the patient, you can still look at the textbook information and whatever information you were able to get from the patient's chart to put together a care plan. nursing problems (nursing diagnoses) are based upon signs and symptoms or the abnormal data that come out of the assessment of the patient. the value of looking up textbook information about pid is that you can compare the textbook signs and symptoms with what you found from her chart. some of the information you are now posting is the symptoms of her pih. you need the pathophysiology information to help in choosing the related factors (etiologies) for the nursing diagnoses that you will use. this is what i am doing in creating the nursing diagnosis statements for you and you really need to be doing this. i can demonstrate it for you this time, but it won't help you the next time you need to do a care plan. you also aren't learning anything about pih if you aren't going back and learning about pih for yourself so you can make some connections about why this patient has the leg and facial edema. if you do not understand how this patient's loss of protein and albumin is creating her edema, now is the time to research it and answer why in your mind because it is not just an ob related reason. this is going to come up again with patients who have renal and liver problems. that is part of the responsibility of being a student. you can take the time to learn this now or wait until it is covered in a class lecture and include studying it during the anxiety and panic to study in preparation for a test. personally, i always had to tie up loose ends and i needed to know the answers at the time i was taking care of a patient. you also want to know how serum uris acid fits into this picture. i found that information, but it is really you that needs to know its importance.

four days postpartum she began to have severe headaches and went to her doctor. her blood pressure was 180/100 and the doctor determined that she had pih and a spinal headache from the puncture of the spinal block. she admitted her to the hospital asap. her uric acid was elevated. the doctor based her dx on the elevated uric acid level and increased high blood pressure. to make matters worse for her, her baby stayed in the nicu due to being sga and a poor feeder. there was also major family drama going on with her husband.

the doctor didn't want her to have a seizure and a subsequent stroke. to care plan this, follow the steps of the nursing process. i realize that you couldn't collect all the information. so, you collect what you can. i would have scrutinized the information in her chart. . .

step 1 assessment

- assessment consists of:

• a health history (review of systems) - this can come from the chart
  
  
• performing a physical exam - you can read the doctor's history and physical as well as the nursing admission assessment in the chart
  
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - pid
  
  
  • http://www.merck.com/mmpe/sec18/ch263/ch263j.html
    - pre-eclampsia and eclampsia
    
    
  • http://www.webmd.com/baby/guide/preeclampsia-eclampsia
    - pre-eclampsia and eclampsia
    
    
  • http://www.medicinenet.com/pregnancy_induced_hypertension/article.htm
    - pre-eclampsia
    
    
    (pregnancy induced hypertension)
    
    
  • http://www.fpnotebook.com/cv/ob/svrphmngmnt.htm
    - severe pih management (this is the medical management)
    
    
    • http://www.fpnotebook.com/renal/lab/urcacd.htm
      - uric acid
      
      
    • http://www.webmd.com/a-to-z-guides/uric-acid-in-blood#aa12026
      - uric acid in blood
      
      

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - serum uric acid tests have the following functions:
  • assist in the diagnosis of gout
    
    
  • determine the cause of renal calculi
    
    
  • evaluation of the extent of tissue damage in the presence of infection, starvation, excessive exercise, malignancies, chemotherapy, radiation therapy
    
    
  • evaluation of the extent of liver damage in eclampsia
    
    
  • monitoring the effect of drugs that are known to alter uric acid levels
    
    

step #2 determination of the patient's problem(s)/nursing diagnosis part 1

- make a list of the abnormal assessment data

• pitting edema of both lower extremities
  
  
• facial edema
  
  
• 12 pound weight loss - was this weight taken before or after delivery of the baby?
  
  
• severe headaches
  
  
• blood pressure was 180/100 due to puncture of the spinal block
  
  
• uric acid was elevated
  
  
• baby stayed in the nicu with sga and is a poor feeder
  
  
• major family drama going on with her husband
  
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2

- match your abnormal assessment data to nursing diagnoses with those defining characteristics.

• deficient fluid volume r/t protein and albumin loss aeb bilateral
  pitting edema of both lower extremities and facial edema
  
  
• imbalanced nutrition: less than body requirements r/t insufficient intake aeb 12 pound weight loss upon her last prenatal visit.
  
  
• acute pain r/t imbalanced volume of spinal fluid aeb spinal headache
  
  
• fear r/t stress of hospitalization and spousal problems
  , or
  anxiety r/t stress of own and baby's health aeb
  [some specifics about that personal and family drama going on with her husband that you may have picked up in the charting]
  
  
  • anxiety
    is more a physical related diagnosis with the patient having physical signs and symptoms with
    fear
    being more of a psychosocial or behavior and feeling related one.
    
    
  [*]
  risk for injury r/t seizures

[RN in 10!]

Thank you for your advice. I struggle with finding a way to learn the more difficult concepts (F & E, cardiac) but I'm trying!

Thanks again!