ok..well im working with a patient who is very lethargic, weak, and fatigue. his respirations are within normal range (18breaths/min), however the patient's O2 sat is 92%..
what im trying to figure out is a nursing dx for this patient, which i came up with "Self-care deficit r/t limited physical mobility as evidenced by lethargic, weaness, fatigue, low o2 sat, and altered mental status" does this sound ok? im trying to figure a nursing dx that relates with his low o2 sat as well as limited mobility. this is a patient who cant do much because of neurological conditions.
should i just do a nursing dx "Failure to thrive" or stick to the one that i have which is the one about self-care deficit?
for me personally we were taught the failure to thrive is not a very good nrsg dx unless the pt has lost a considerable amount of weight (anorexia, cancer). so in my opinion i would stick to the self care deficit. did you look at the pt. labs ? They can really give you some clues also. I had a pt today she was s/p x4 of a perforated bowel. her RR 16, HR 72 crackles at the bases and was coughing up some major phlem. Her sats were only at a 92-95%. She was taking short tiny breaths which kept her RR wnl but unless she started taking some deep breathsthere was no improvement. USE THE INCENTIVE SPIROMETER...... REMIND THEM TO USE IT....they are there all day watching TV. tell them at every commercial break to do it 3x's. The minimum is once every hour. They can do it more. If you had the pt do the IS while she is on the pulse ox you will see it increase. I dont know if this is the reason why your pt's sats were low, there are lots of reasons. dont forget to look in your book for nursing diag. the related to HAS TO MATCH from the book you can not make them up (learned from my own mistake) ..... good luck