Can anyone help with a nursing diagnosis?

  1. Pt. with R/O TIA....complaint of HA and dizziness...what would you consider as some nursing diagnoses?
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  2. 9 Comments

  3. by   KatieBell
    This one I can do even after being out of school:

    Lack of knowledge

    RIsk for injury

    Pain r/t HA

    There are several more if you think about it.
  4. by   Atlanta Kellie
    Thanks Katie. I had posted previously, but I had no responses and time is running out. I have to present my client tomorrow, and we had little time to work on it.
    I had thought maybe...
    1) Impaired physical mobility as evidenced by dizziness and general weakness
    2) Risk for fall/injury for same reason
    3) Activity intolerance as evidenced by dizziness and general weakness as well as orthostatic vital signs (am wording this correctly???)
    4) Caregiver role strain as evidenced by impaired physcial mobility (pt is main bread winner in home, has had to take work off due to this and past history of MI, also expressed concern about not being able to be home for her boys)
    5) Altered tissue perfusion as evidenced by vital signs when standing, or walking (sitting B/P 125/68 standing B/P 99/70)
    I'm not sure about that last one....but she does have a drop in
    B/P when standing, and she is very dizzy when she stands. Also, would this be a cardiopulmonary tissue perfusion?

    I'm really worried about this. This is my first patient and first time trying to come up with a nursing diagnosis. Not sure I'm doing it right. I don't want to stand up in front of my class tomorrow and look like a total idiot! Should I re-think some of these? Am I missing something big?
  5. by   Atlanta Kellie
    oh yeah, I did consider altered thought process or risk for altered thought process, but she seemed very oriented and was not at all confused. Should I still list it, or list it as a risk? HELP ME!!!! I feel thee panic growing everytime I sit down to think about presenting this. Even now, it grows....
  6. by   Simba&NalasMom
    Kellie, it sounds like you have come up with some great ones all on your own. Don't give in to the panic!

    Has she shown signs or verbalized any anxiety r/t her COC? Anxiety is always a good one, i.e "Anxiety r/t altered condition AEB verbalization "I'm worried about my outcome" (don't know if she's verbal)...ditto for depression.

    Iimpaired skin integrity, risk for...r/t immobility, AEB pt. unable to turn self in bed.

    Have you seen any other objective signs of alterted tissue perfusion (cardio) besides the orthostatic blood pressure, such as respiratory rate not WNL, lowered cap refill, arrhythimias, etc? If not, maybe you should change it to "risk for" or reconsider using it, or use peripheral tissue perfusion if she has edema, skin temp changes, weak/absent pulses, etc.

    Is she continent? If not, incontinence (urinary or bowel) may be used: incontinence r/t neuromuscular limitations, AEB bedsheets sat. c urine/BM.

    Self-care deficit (feeding, dressing, grooming, etc.) r/t L or R-sided weakness, AEB limited ROM for affected limb.

    Impaired transfer ability r/t L (R)-sided weakness, AEB inability to bear wt on effected side.

    Risk for constipation, r/t environmental changes, possible abdominal weakness from the stroke, lack of physical activity, use of narcotics, etc. (I'm sure you know by now what causes constipation), AEB pt not having a BM for three days.

    You're gonna be great!!! Go get 'em, Nurse Kellie!!! :spin:
  7. by   Atlanta Kellie
    Thanks so much for replying! She has no problems with communication. Can care for herself, walk, etc. She had orders for bed bath only, but took care of her needs just fine. Feeds herself. Other than her complaint of HA, dizziness, general weakness and numbness in her face, she was okay.
    The only orthostatic signs were with her B/P. Should I not use that altered tissue perfusion? She has no edema, cap refill is fine....just lower B/P with standing.
    She had made some statements regarding worry over missing work, worry about not being able to help her sons, and she did say "What's wrong with me" a couple of times. I didn't feel she was overly anxious. No more than what I would feel in the same situation. She was calm, and communicated with me well regarding her symptoms, feelings and concerns. Then again, as I had never seen her prior to her hospital stay, her talking at all about her feelings could be a sign of anxiety for her.
    Thanks so much. I will be working on this all day and checking this site if you have any other advice. Thanks again for responding.
  8. by   KatieBell
    Actually from what you have said, she easily could have anxiety. A person doesn't have top be having an anxiety attack to have a diagnosis of anxiety. in her positoon- with children at home and a confusing diagnosis of TIA, anxiety is a natural thing to have.
    I'd definitely add in knowledge deficit as she probably has not thought much about TIA before dx'd with it, and will need some education as to what it is etc.
    You are doing fine. just relax- and keep working on it.
  9. by   Simba&NalasMom
    Agree with Katie...you totally have it. I would skip the tissue perfusion as there doesn't seem to be much evidence of it. The only additional advice I can give you is if it ain't broke, don't fix it; i.e. you're given what you're given and if she doesn't have that many problems/needs, go with what you do have--pain, anxiety, and a couple of "risk fors." Hope that makes sense. Keep up the good work!
  10. by   Atlanta Kellie
    Thanks for all your help. I had my presentation today and it went fine. I went with activy intolerance, risk for fall/injury, and anxiety r/t knowledge deficit. I really appreciate all your help and looking up all your suggestions actually taught me a lot.
  11. by   Simba&NalasMom
    Way to go, Kellie!!!! Knew you could do it. :hatparty:

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