Yet another student needing concept map help...ESRD

[DanielleJean2008]

80 yo male Pt yesterday has ESRD, is on dialysis 3x wk, chronic AFib, sleep apnea, s/p heart valve replacement, chronic constipation and was admitted of I&D of R ankle fracture with cellulitis positive for MRSA.....MEDS: Heparin, Coumadin, Digoxin, Sensipar, cochicine, Inderal...some other pain meds prn...

HEENT- Normocephalic. atraumatic. PERRL, R 2/1 L2/1, Ears centered, nontender, no discharge from canal. Oral membranes pink moist, assisted with desperately needed oral care, saw about 7 bottom row missing teeth, and about 4 top row missing. No dentures. NO oral sores or bleeding. Trachea midline with no tenderness. Nasal passage clear without deviation or tenderness. Pt. extremely hard of hearing, wears hearing aid in L ear, better hearing in Rt side.

NEURO- AAO x3, GSC 15, is competent to answer questions and relate any needs. Can follow pen in all field of vision. Pain checks every hour, pt. notes a "dull ache" in Rt foor, denied pain medication (Lortab, Dilaudid). No HA, N/V, dizziness. Some numbness reported in medial aspect of left foot. Feeling came back when we later sat him up to let feet dangle (testing feeling when dangling) and assised to restroom.

GI- Pt. on Renal diet, ate 75-100% of breakfast and lunch. Did not have a bowel movement today, but is taking Colace for chronic constipation. Negative uremic fetor (ammonia odor). No N/V. BS active x4. Abdomen soft, flat and nontender

CV- Increased BP of 180/91 at 0830, then decreased to 155/87 by 1030. Apical pulse 91, irregularly-irregular. All other pulses assessed are equal bilaterally. Unable to assess Rt. d. pedis pulse due to wound wrapping- no edema or swelling distal to pulse site, toes are warm and move freely with no patient distress. All heart sounds are clear with no bruit or murmurs heard. Previous dx of chronic AFib, confirmed by telemetry. Prophylaxis of thrombus formation s/t AFib- Heparin (1000units/hr)(new order). Fingernail beds quick cap refill, toenail beds had fungal infections but refill seemed to be quick (close to the proximal nail bed). Has dialysis access on L side of chest and an unworking AV fistula in L forearm.

RESP- Sleeps with Bi-Pap for sleep apnea. Pt reports no chest pain, cough or dyspnea. Sputum collected, frothy white, no odor, minimal (when Lungs are clear to auscultation bilaterally. Lung frame Pectus Carinatum woth no abberations or bruising. Previous sternotomy scar with dialysis catheter in place Rt. side of chest.

GU- No incontinence, up with BRP, needs assistance. Pt is circumcised, no edema or ecchymosis in scrotal/perineal area. No discharge emitted from urethra. Urine is free-flowing, clear, deep yellow, no precipitate, non-malordorous. Intake of 1200 oral fluid, 350ml LR, and 240mL Heparin/NS together DOC (0700-1500). Lasix was given 10/26 in am for 3rd shift spacing and dialysis ordered for 0900 same day. On DOC, dialysis reported 3900 mL fluid taken off of pt. Dialysis orders received DOC for 10/28 0900. Gout managed with medication

MS- ROM freely moving joints but for some stiffness in R hip. Pt had h/o hip fracture of this hip. Didn't asses R ankle r/t wound and healing surgical site. can bear minimal weighto n affected foot, but declined to walk (test balance), toes distal to point move freely without pt. distress. Hand grips bliaterally +5, L leg lift/resistance +5, R leg lift/resistance +4. Resting hand tremors present, possible restless leg described.

Integ-2 0 on Braden scale. Pt has history of edema in lower extremeties, has no edema on DOC.

WOUND- Has extensive gauze dressing on R ankle s/t I & D closure on 10/24. Wound bed was cultured to have +3 organisms and identified to be MRSA. R ankle is wrapped with ACE bandage, patient can slightly move R ankle, toes are freely moving. No reddness or edema in toes that might indicate tight wrapping of site. Pulse +2 at p. tibial, pt has complaint of "dull ache" of surgery site.

IV- NEW IV site x2 on R forearm, #1 with LR running at 75mL/hr, #2 running with Heparin and NS. IV site is clean, no edema, redness or infiltrate. Has transparent dressing and tape for stabilization. No skin breakdown evident with tape adhesion. Old IV site R antecubital, minimal bruising, was D/C'd to different site by RN previous shift to include 2 new, easier access sites.

After that lovely rundown...I have Concept Map to prepare...

1. Risk for Decreased Cardiac output r/t Cardiac dysrythmias

2. Fluid Volume Excess

3. .....?

I am so stuck...Pt had no real issues yesterday. Must have 3 diagnosis, and full with interventionetc on the top priority...

Thanks,

BTW, I know how to write care plans, but CM plug me, must have adequate info from DOC to validate Dx...

[aerorunner80, ADN, BSN, MSN, APRN]

Do you have a nursing diagnosis book? If so you need to take your data, brainstorm for potential nursing diagnoses, look up the defining characteristics in your book, see if they fit and throw them out if they don't. The prioritize (ABC's/Safety, etc).

I can see a good handful or more of nursing dx just based off the info you gave but you need to learn to see these on your own.

If we give you all the answers, you won't learn how to do it on your own.

If lung sounds are clear and there is no edema on the day you care for them, where else are you getting your NDx of Fluid Volume overload from? Was there a recent wt change (greater than 1k?)

What was his last weight? He should be daily weights since he's dialysis.

What is his nutrition like? Under/over weight?

How is his mental status? Depression? Sleep disturbances? Insomnia? Does he seem eager to learn or does he blow you off? There's a lot to look at here.

Does the pt use any assistive devices while ambulating?

What kind of support does the pt have? Family? Children? Spouse?

He is not risk for decreased cardiac output, the official NDx would be Decreased cardiac output secondary to his afib (look up the patho for afib and it will jump out at you)

Impaired sensory perception (hard of hearing)

When WAS the last BM if he didn't have one they day you cared for him?

There are more that stick out.

[mistiffy]

Just curious-You said white frothy sputum was collected but his lungs were clear? I also was unsure where you were getting the fluid volume overload from? I'm not sure if you have to do ur NDX in order of priority or not, but a Risk for should almost never be number one. And I also agree with the above poster that he's not a risk for decreeased CO, but he has it as an actual problem. I would also look at Impaired tissue perfusion, Impaired skin integrity...focus on actual problems before the risks =) Good luck!