most of what you've posted were medical diagnoses. the only signs and symptoms i found in your post was that the patient has pain and numbness, but i don't know where. so, i'm asking again, what were your patient's signs and symptoms? what were the vital signs? what were the lungs sounds? what was the result of the abdominal assessment? was there any peripheral edema? since this patient had a stroke as indicated by the echo are there any neurological deficits? some of the signs and symptoms of a stroke are:
- changes in level of consciousness
- communication difficulty
- problems with mobility
- urinary incontinence
- loss of voluntary muscle control
- hemiparesis or hemiplegia on one side of the body
- decreased deep tendon reflexes
- visual problems
- sensory losses
does your patient have any of these? how does the patient do with her adls? can she eat all by herself? or does she need help opening containers of milk, picking up utensils, getting food into her mouth? can she dress herself? can she get up and take a shower, or does she need help? how does she accomplish urinating and having a bowel movement? does she brush her teeth all by herself? does she comb and brush her hair or does a nurse have to do it?
why is the patient getting tylenol? why is the patient getting asa? why is this patient on heparin? what were the last cholesterol and triglyceride levels? what were the results of some of the labwork that was done on this patient? where is the patient's pain and numbness and why do they have it? what organ has the altered tissue perfusion (i'm assuming that's why they are on heparin)? why are they at a risk for injury. . .what's going on with that?
all this is information that should have been in the chart or you should have collected it during your time with her. it is all assessment information and if it's not normal, it's a symptom. what we nurses call symptoms differ slightly from what a doctor calls a symptom. you and i can get up and go to the bathroom on our own. if this patient can't and needs some kind of nursing assistance to do that--it is a symptom of a nursing problem that you need to address on her care plan
as for your diagnoses. . .
was altered tissue perfusion r/t cardiac (which is incorrect, now that you point it out to me. :-) ) - this needs to be sequenced as the first diagnosis
the diagnosis of ineffective tissue perfusion, (must specify) must be specified as to which organ system of the body is involved. you cannot just say ineffective tissue perfusion and leave the nursing diagnosis at that. the organ system that is having the tissue perfusion problem must be stated. there are several choices: renal, cerebral, cardiopulmonary, gastrointestinal and peripheral) if the tissues perfusion is specifically only the heart, then you must use decreased cardiac output. you cannot use "cardiac" as a related factor.1st diagnosis
is pain & numbness r/t altered tissue perfusion - this needs to be sequenced as the second diagnosis
there is no such nursing diagnosis of pain and numbness
in the nanda taxonomy. don't know where you came up with this. if you are using ineffective tissue perfusion as a diagnosis somewhere else, you can't use it as a r/t item on another nursing diagnosis. anyway, even if you were using acute pain
or chronic pain
altered tissue perfusion is not a valid related factor (r/t item) for these diagnoses. [color=#3366ff]acute pain [color=#3366ff]chronic pain
was knowledge deficit r/t hospitalization - this needs to be sequenced as the third diagnosis
this is another nursing diagnosis that must be specified, so that it is written deficient knowledge (specify). the related factors on this diagnosis have to do with the patient's cognitive limitations, misinterpretation of information, lack of interest in learning and lack of recall. using "hospitalization" as a related factor doesn't mean anything. i ask myself, "how does hospitalization cause the patient to have a knowledge deficit? well, it doesn't. the patient has a knowledge deficit about being hospitalized because of either a general lack of information about being hospitalized, is unfamiliar with how to go about finding the information, is unable to process the information she was given (all hospitals are required to provide each patient with information about the services they offer at the time of admission), or is not interested in learning.3rd diagnosis
was risk for injury r/t numbness - this needs to be sequenced as the fourth and last diagnosis
numbness is a symptom. a related factor cannot be a symptom on a "risk for" diagnosis since this diagnosis anticipates a problem that might occur. the definition of risk for injury
is "at risk of injury as a result of environmental conditions interacting with the individual's adaptive and defensive resources."
(page 125, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international
) when you are using a "risk for" diagnosis you usually have a specific injury in mind although you don't state it. your nursing interventions are aimed at it. your related factor is going to be what will be the direct cause of the injury if it occurs. is numbness going to be the cause of this patient getting some kind of boo-boo? or, will it be because they couldn't feel their skin (due to numbness) and developed a pressure ulcer which is a "sensory dysfunction". [color=#3366ff]risk for injury
you really need to be looking at a nursing diagnosis or care plan book as you work on this.
now, as i've been typing this i kind of get the idea that this lady had a stroke. you need to look at some references about stroke and what happens to patients who have had a stroke. there are three kinds of stroke. which kind did she have? this would have been on one of her x-ray reports. what kind of treatment did the doctors give her for the stroke? were they able to bust the clot? is that why she is on heparin? or is it for something else? you can find online information about strokes on any of the medical information websites listed on this thread of allnurses:
bring me symptoms!!!!!