Hello all !
I am currently writing a nursing care plan for a pt of mine that was diagnosed with a Malignant Brain Neoplasm. She undergoes radiation treatment daily. The pt is bed bound and aphasic but is still ANO x2 (PnP). She has right sided weakness and contractures. Pt is also incontinent with a foley cath in place. Upon skin assessment i noticed some reddened areas over the left buttocks as well. Ive come up with a couple nursing diagnosis that i would like to get some input on for this particular pt. Any help would be greatly appreciated !
Impaired verbal communication r/t impaired cognitive ability as manifested by lack of speaking
Fatigue r/t radiation therapy as manifested by constant sleepiness and weakness of body
Risk for impaired skin integrity r/t impaired mobility as manifested by blanching of skin
Thank you very much for the follow up. Our instructors want us to write our Nursing dx in the format of: Problem -- etiology -- secondary to -- as evidence by. I was a little confused on how i could use my diagnosis of impaired verbal communication as r/t to ? you clarified this greatly to me.
Her chart indicated that the tumor was over the corpus callosum and that the speech impairments only began in the past few months. She has had the tumor resected twice and underwent gamma knife tmt. The contractures are on her right arm and leg and she is completely dependent with ADL. She has limited used of her left arm as it seems very weak and she only uses it to scratch face or hold the rail when turning her. I also forgot to mention that she is on restricted fluid intake of 1500 cc and eats very limited amounts of food. Her urine was a tea color and her skin turgor was reduced ( possible dehydration?) She is both bowel and urinary incontinent as well.
Based on all the great information you gave me i have readjusted a few diagnosis to the best priorities (we are required 3 for this particular care plan)
Bowel incontinence r/t decreased functional ability as evidence by involuntary passage of stool ( i wasnt sure if impaired cognitive ability was an appropriate factor here after taking into consideration what you mentioned about mental status)
Impaired Bed Mobility r/t to decreased strength and endurance secondary to brain neoplasm as manifested by inability to move purposefully in bed (I'm not sure exactly how to word this)
Impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin
Any additional comments would be great !
Last edit by Tampanian on Jun 21, '09