case study help

[mani3433]

I have a 95yrs old female patient with cva (only Hemiparlysis with no dysphagia), htn and renal insufficiency. She is urinary and bowel inciontinent because of the immobility. She also has a past medical history of colon resection and pvd.

I have to write 4 nursing diagnoses which i tried but i am not sure -

1. P - fluid volume imbalance

E- renal insufficiency ( because of the patient lab values high BUN - 43 normal range is 8-21 and high Creatinine - 1.5 normal range is 0.6-1.1)

S - Renal failure, monitor for confusion, dryskin.

2. P - fall risk

E- because of poor vision, faitgue, ineffective breathing pattern

S- non ambulatory,complains when she walk,need assistance during ambulation.

3. p - Self care deficit/ bathing and toileting

E- tiredness, inable to transfer ( go to rest room), sit on and rise from toilet, and use proper hygiene.

s- help me?????????/

I am having proble with fourth nursing diagnosis

4.p - Activity intolerance

E- ???????????????

s- ???????????

S- unable to go to

Please give me any suggestions . thanx in advance.

[SFCardiacRN]

Risk for skin breakdown due to incontinence.

[DecafMom]

Risk for skin breakdown due to incontinence.

I agree on this one - especially at her age.

[neneRN, BSN, RN]

For the CVA; Tissue perfusion, altered (related to interruption of blood flow, i.e., occlusion or hemorrhage)/Impaired physical mobility/Risk for unilateral neglect/Knowledge deficit(Learning Need) regarding condition, therapeutic regimen, and potential complications.