Care Plan with 5 Nursing Diagnosis... Need some help

ADPIE1 · Apr 18, 2012

The reason this client presented to the hospital was abdominal cramping and blood in the stool ... had a polypectomy that the doctors are suspecting as the cause for the bleeding.

So Acute pain would also be a nursing diagnosis that I need to put that one in also...

guest042302019, BSN, RN · Apr 18, 2012

I'm not sure if this is right but I'll give you suggestions of what I would do. Youre off to a good start. I'll help you clarify some things.

1- Ineffective airway clearance related to obstructed airway manifested by COPD... ??? can I use COPD???

Patient is on 2 liters of oxygen via nasal cannula... and has history of COPD.. hx of CAD, CHF, Hypertension ---- respiratory rate is normal at 18... when on 2 liters oxygen

Ineffective Airway Clearance r/t chronic lung diseases AEB (as evidenced by) 2L/ min O2

2- Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood as manifested by a decreased oxygen saturation ...

Patient dropped down under 95% when not on oxygen (2 liters) and hemoglobin was below normal limits but not at an extreme low

You need to specify why type of ineffective tissue perfusion. There is renal, cardiac, cerebral, gastrointestinal, or peripheral. Refer to your nursing diagnosis book. Considering your patient's circumstance, I would venture to say its' going to be Ineffective Peripheral Tissue Perfusion.

However, you need to consider this. I think there is another nursing diagnoses that would be more appropriate. Think nutrition. Also, what was the RBCs and Hematocrit? Also, what was the protein level?

3- At risk for infection related to urinary tract as manifested by having a foley catheter for over 24 hours with low urine output.

(client is on a 2 liter fluid restriction due to CHF)

Your diagnoses is confusing. Not sure why the "urinary tract" only is the r/t factor for risk for infection. Try something like this.

Risk for Infection r/t urinary stasis (Look up Urinary Stasis)

4 - At risk for fall related to mobility issues as manifested by fatigue and weakness in legs

What does "issues" mean? That has a lot of confusing meanings. Try to have objective, clear wording in your diagnoses to facilitate communication among healthcare workers. Keep it simple.

Risk for Falls r/t impaired mobility AEB fatigue and leg weakness

5-At risk for impaired skin integrity related to reduced mobility as manifested by order of bedrest

Risk for impaired skin integrity r/t bedrest order

No need to discuss reduced mobility because its' implied in the bedrest order

Hopes this helps.