I need help! I need to chose 2 priority nursing diagnoses for the case study below. I have been leaning towards RISK FOR FALLS due to his IV therapy, cataracts, dizziness, history of falling, weakness, use of antihypertensives etc and RISK FOR IMPAIRED GAS EXCHANGE due to his avoidance of deep breathing/coughing exercises.
Unfortunately these are both Risk for... diagnoses, which I've read are not good to use as priority problems. There doesn't seem to be enough evidence in the case study to diagnose any of the ABC issues, but I'm worried if I don't focus on ABC I'll get low marks for ignoring them and potentially killing my patient. We haven't properly covered NANDA diagnoses in my course, and I'm a bit lost because so many of them seem to cover the same territory. If anyone would be willing to take a look and let me know if I'm on the right track, I would appreciate it so much.
(for example, would Activity Intolerance be a better diagnosis than Risk for Falls?)
78-year-old male, admitted to ward following a repair of a left inguinal hernia.
As you enter the room he states, "I'm trying to get to the toilet but I'm caught up on this thing" and he points to the IV pole. He states, "I felt dizzy when I stood up off the bed and I feel so weak nurse."
You ask Cecil whether he has been performing his deep breathing and coughing exercises since he returned from surgery he states, "What exercises? I don't want to cough as it hurts too much and I don't want to burst my stitches either!"
Alert and aware of surroundings
Thin and frail appearance Weight: 48 kg; height: 153 cm
Pale skin and mucous membranes
Initial post operative vital signs temperature 37.1oC, pulse 96b/min regular, respiratory rate 24/min (shallow and using accessory muscles), BP120/65mmHg.
Clear adhesive wound dressing is intact with a small amount of fresh blood ooze.
He is breathless and quite unsteady as he mobilizes.
History of an anterior myocardial infarct 8 years ago but follow up cardiac angiography showed minimal residual ischaemic damage.
Meds include: Felodipine 2.5mg daily, Lisinopril 10mg daily, Clopidogrel 75mg daily, Madopar 125mg three times a day.
Intravenous therapy ordered Normal/Saline 0.9% 1000ml, 12 hourly
Recent diagnosis of Parkinson's Disease and history of two recent falls at home. Shuffling gait noted on admission, he uses a rollator and the assistance of one person to mobilize
History of renal calculi now resolved but takes daily Ural sachets
History of cataract development in both eyes but can still read with glasses
Nil previous surgical history
Full blood count taken last week- results include: Hb 110g/L & Hct 0.32
Aug 25, '10
i'm a student too but he is dizzy, breathless and using accessory muscles. i would be concerned about his o2 stats from the info given. although you’re not given o2 stats?
i don’t think i would say risk for falls as a priority at this point in care.
ps i hate doing these.
Aug 27, '10
respiratory rate 24/min (shallow and using accessory muscles), "did you listen to lung sounds?"
ineffective breathing pattern r/t pain or anxiety(not sure) aeb dyspnea, tachypnea and using accessory muscles
he is breathless and quite unsteady as he mobilizes, shuffling gait
impaired walking r/t impaired coordination and balance aeb unsteady, shuffling gait
pale skin and mucous membranes & hb 110g/l & hct 0.32
(13.5 - 18.0 g/dl normal hgb for male and 42 - 52 % hct normal for male ")
'indicates blood loss" may cause weekness and fatigue.
fatigue r/t low hgb and hct aeb reported feeling of weakness
activity intolerance r/t generalised weekness, prolonged bedrest, aeb verbal reports of weekness or fatigue
hope it helps. i can understand because i am a student too and have care plan due this tuesday and already submitted one last monday. its killing me.