Nursing diagnoses and care plan help!! Due tomorrow

[Stoogesfan]

Yes I need help again:(

Anyway, my patient was admitted with pneumonia, hypoxia and hyponatremia. He has a history of copd, seizures, gunshot to head a few years ago, stroke, diabetes, hypertension, anemia, anxiety and depression.

My assessment revealed spo2 95%, pulse 52, RR 14, temp 98.7, BP 150/71 and no pain. He was A&0X2, his speech was delayed and garbled and slightly slurred. PERLA. Pulses were weak 1+ no edema, cap refill less than 3 seconds, respirations regular and unflavored, diminished, and no cough. Abdomen was soft, non tender. Bowel sounds normal in all quadrants. Incontinent of stool. I dwelling catheter, urine was clear and amber colored. Skin pale, turgor fair. He had a stage 1 pressure ulcer on his coccyx and some ecchymosis to his upper extremities.

Ok so I was going to use impaired verbal communication as one of my nursing diagnoses. Does that sound ok? But what would my related to be. I mean I don't know if it was the gunshot or the stroke? Would impaired circulation to the brain work?

Also, since the condition is fairly irreversible I'm having a little trouble with some realistic goals and interventions. I mean would client will use alternative methods of communication be an acceptable goal?

[nurseladybug12]

I would say impaired skin integrity would be an important diagnosis, not only because he has a stage 1 but because he is incontinent and this could make the problem worse. With creating goals, even though he may not actively be participating in his care, an example of a goal could be "patient maintains o2 sat above 95 percent".... if you have the Ackley dx book they have examples of goals in there for each dx. His communication would be related to the stroke most likely, which you could state as "d/t decreased cerebral perfusion during CVA".

[Stoogesfan]

Ya I'm using impaired skin integrity also. I forgot to add that I have to have 2. Im just having trouble with the second one cause my instructor doesn't want us to use ones we've already used so I'm trying to come up with ones I haven't used on other patients before.

I've already used on different patients: impaired physical mobility, acute pain, toileting self care deficit, activity intolerance and excess fluid volume