This changes everything. YOu have fallen into the trap that catches all students.......taken your nursing diagnosis from the medical problems instead of from your assessment.
For you next patient or even for this one.....use these information organization sheets to help organize your assessment data and information from a beloved member Daytonite (rip) critical thinking flow sheet for nursing students student clinical report sheet for one patient
So her failed hardware is in her hip? She is a post op? What would be important to a post op? Why would she have edema? What is a low GFR significant of? What effect does major surgery have on the elderly? Could some of her weakness be caused by anemia from surgery? Urinary retention can be a complication of having the foley and old age as the bladder loses tone. If she isn't eating well then she has imbalanced nutrition.
What care plan book do you use? For every diagnosis you use you have to have evidence in your assessment that proves your statement.
For example: #1 decreased cardiac output
NANDA I describes decreased cardiac output as.......Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body
With the Defining Characteristics of.
....or As evidenced by........ Altered Heart Rate/Rhythm
: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia Altered Preload:
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings Altered Contractility:
Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds Behavioral/Emotional
: Anxiety; restlessness Related Factors (r/t)
: Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility
Then you have falls....what evidence do you have for falls...... has she fallen or is she at risk for falls.
She may have a self care deficit but she also has activity intolerance. She has acute pain ....even if medicated she has pain. Anxiety what evidence do you have for anxiety. Knowing that her kidney function tests are high...this means she has renal insufficiency or renal failure.....what impact will this have on her healing? Is she on any anti-psychotics that can affect her recovery process? If she didn't have bradycardia for your assessment...can you have that as a part of your care plan?
Here is what I see from what you have told me.......I use Ackley: Nursing Diagnosis Handbook, 9th Edition care plan book
Excess Fluid volume
Impaired physical Mobility
Bathing Self-Care deficit
Impaired Skin integrity
Delayed Surgical recovery
Impaired Urinary elimination
Risk for unstable blood Glucose level
Risk for Falls