first nursing diagnosis

Bird2 · Jan 23, 2006

Hi I'm stumped. I have to do my first Diagnosis an a goal on a patient admitted to the hosp following a stroke, which has left him paralyzed on the right side. He is unable to bathe himself or participate in ADLs Our teacher said to use the NANDA reference guide. I just have no clue.

Check the internet for NANDA, your careplan book may list them, or usually in the back of one of your nursing books will have the list of Dx s.

sebring · Jan 23, 2006

thanks for your quick reply I'm looking in my books now

Daytonite, BSN, RN · Jan 23, 2006

When you are forming diagnoses you need to first know what the patient's primary problems are. You have here a stroke patient. Based on the physical deficits that the stroke has left, what are the patient's problems with realation to meeting his activities of daily living? Which ADL's is he now going to need assistance with. If you go with the unilateral paralysis as his major problem, you will want to list out the kind of help he is going to need. He needs help with bathing, eating, dressing, toileting, mobility. From those you pick your nursing diagnoses. Which one do you think will be the most important? You need to prioritize. This is where you might want to base your choice on Mazlow's. Once you have determined that, then you use the NANDA list to help you write the actual diagnostic and goal statements.

DCJ3 · Jan 25, 2006

here are all that might apply... pick the ones that fit your patient's condition and individualize it to your patient:

*anxiety r/t situational crisis, change in physical condition or emotional condition

*chronic confusion r/t neurological changes

*constipation or risk for constipation r/t decreased activity

*disturbed body image r/t chronic illness, paralysis

*distrubed sensory perception: visual, tactile, kinesthetic r/t neurological deficit

*grieving r/t loss of health

*impaired memory r/t neurological disturbances

*impaired physical mobility r/t loss of balance and coordination

*impaired social interaction r/t limited physical mobility, limited ability to communicate

*impaired swallowing r/t neuromuscular dysfunction

*impaired transfer ability r/t limited physical mobility

*impaired verbal communication r/t pressure damage, decreased circulation to brain in speech center informational sources

*impaired walking r/t loss of balance and coordination

*ineffective coping r/t disability

*ineffective health maintenance r/t deficient knowledge regarding self care following CVA

*interrupted family processes r/t illness, disability of family member

*reflex incontinence r/t loss of feeling to void

*risk for aspiration r/t impaired swallowing, loss of gag reflex

*risk for disuse syndrome r/t paralysis

*risk for impaired skin integrity r/t immobility

*riks for injury r/t disturbed sensory perception

*self care deficit:[specify which] bathing/hygiene, dressing/grooming, feedng, toiletting r/t decreased strenght and endurance, paralysis

*total urinary incontinence r/t neurological dysfunction

*unilateral neglect r/t disturbed perception from neurological damage

hope this helps,

B.

cleo777 · Jun 12, 2009

Okay I have CVA patient in rehabillation, and I am looking at the pathophysiology, of the stroke.

As of yesterday, assessing him he cannot stand or at all on his own, he is a two person assist, he can pivot with his legs. He cannot feed himself, but he can move his arms, he has dysphagia, aphasia(speaks very little), dypraxia. So my question as I am looking at different nursing diagnosis, the related to factor

in his immobility...is it really due to muscle weakness, or is it due to neuromuscular involvement. He does have sensation in all four extrememties.

So as I look at my nursing diagnosis the related to factors, how do I determine whether is it muscle weakness, neuromuscular involvement, I can't talk with the client, because of his speech inability. This stroke happen approx 2 weeks ago, this is a big healthy guy, would his muscles start to become that weak that he cannot stand?

Daytonite, BSN, RN · Jun 15, 2009

okay i have cva patient in rehabillation, and i am looking at the pathophysiology, of the stroke.
as of yesterday, assessing him he cannot stand or at all on his own, he is a two person assist, he can pivot with his legs. he cannot feed himself, but he can move his arms, he has dysphagia, aphasia(speaks very little), dypraxia. so my question as i am looking at different nursing diagnosis, the related to factor
in his immobility...is it really due to muscle weakness, or is it due to neuromuscular involvement. he does have sensation in all four extrememties.
so as i look at my nursing diagnosis the related to factors, how do i determine whether is it muscle weakness, neuromuscular involvement, i can't talk with the client, because of his speech inability. this stroke happen approx 2 weeks ago, this is a big healthy guy, would his muscles start to become that weak that he cannot stand?

you say you were "looking" at the pathophysiology of a stroke. what did you learn? is the reason he cannot move his arms, has dysphagia, aphasia and dypraxia because of muscle weakness or neuromuscular impairment as a result of the stroke? taber's cyclopedic medical dictionary defines "weakness" as a subjective term used by a patient to indicate a lack of strength compared with what he or she feels in normal. does "weakness" sound like a scientific term we should be using to base the cause (related factor) of a diagnosis upon? if this patient can't talk how do you know he even has muscle weakness? who determined he had muscle weakness? he certainly didn't (reference: the definition of the term "weakness"). i wouldn't use the term "muscular weakness" as a related factor in a diagnostic statement for the basic reason that (1) the patient didn't determine it and (2) it is subjective.

Daytonite, BSN, RN · Jun 15, 2009

okay i have cva patient in rehabillation, and i am looking at the pathophysiology, of the stroke.
as of yesterday, assessing him he cannot stand or at all on his own, he is a two person assist, he can pivot with his legs. he cannot feed himself, but he can move his arms, he has dysphagia, aphasia(speaks very little), dypraxia. so my question as i am looking at different nursing diagnosis, the related to factor
in his immobility...is it really due to muscle weakness, or is it due to neuromuscular involvement. he does have sensation in all four extrememties.
so as i look at my nursing diagnosis the related to factors, how do i determine whether is it muscle weakness, neuromuscular involvement, i can't talk with the client, because of his speech inability. this stroke happen approx 2 weeks ago, this is a big healthy guy, would his muscles start to become that weak that he cannot stand?

you say you were "looking" at the pathophysiology of a stroke. what did you learn? is the reason he cannot move his arms, has dysphagia, aphasia and dypraxia because of muscle weakness or neuromuscular impairment as a result of the stroke? taber's cyclopedic medical dictionary defines "weakness" as a subjective term used by a patient to indicate a lack of strength compared with what he or she feels in normal. does "weakness" sound like a scientific term we should be using to base the cause (related factor) of a diagnosis upon? if this patient can't talk how do you know he even has muscle weakness? who determined he had muscle weakness? he certainly didn't (reference: the definition of the term "weakness"). i wouldn't use the term "muscular weakness" as a related factor in a diagnostic statement for the basic reason that (1) the patient didn't determine it and (2) it is subjective.

cleo777 · Jun 15, 2009

You are absolutely correct, I don't know if it is muscle weakness, but when doing the assessment, and documenting, the nurse I was working with told me to document as Lower extemeties, equally weak? Due to the fact that when we transfer him from the bed to the wheelchair, we can stand with, but need two people to do this, and the only movement he is making is pivoting his feet, it is the only thing we can get him to do? Or is it the fact that he is not processing what we are telling him to do and cannot make that movement, dypraxia?

He has no paralysis, he is a fall risk and has to be watched, one on one, because he gets out of bed in the middle of the night and falls but when we try to interact with him any other time he is almost comatose, and when he decides to speak it is with no no no no or yes yes yes, nothing else other than that..I was not sure whether it really was muscle weakness or not but now I understand what you are saying....He cannot do anything for himself at this point, no feeding, no dressing, no toileting...is this caused by dyspraxia, inability to do a purposeful movement, or is it that he has now some cognitive issues, memory issues, or is it caused by the dyspraxia? What is the underlying issue that he cannot do any of these ADL's for himself?

Daytonite, BSN, RN · Jun 15, 2009

you are absolutely correct, i don't know if it is muscle weakness, but when doing the assessment, and documenting, the nurse i was working with told me to document as lower extemeties, equally weak? due to the fact that when we transfer him from the bed to the wheelchair, we can stand with, but need two people to do this, and the only movement he is making is pivoting his feet, it is the only thing we can get him to do? or is it the fact that he is not processing what we are telling him to do and cannot make that movement, dypraxia?
he has no paralysis, he is a fall risk and has to be watched, one on one, because he gets out of bed in the middle of the night and falls but when we try to interact with him any other time he is almost comatose, and when he decides to speak it is with no no no no or yes yes yes, nothing else other than that..i was not sure whether it really was muscle weakness or not but now i understand what you are saying....he cannot do anything for himself at this point, no feeding, no dressing, no toileting...is this caused by dyspraxia, inability to do a purposeful movement, or is it that he has now some cognitive issues, memory issues, or is it caused by the dyspraxia? what is the underlying issue that he cannot do any of these adl's for himself?

what did your reading about strokes teach you? strokes cause a lot of damage in people and it is not always paralysis. the brain is a neurological organ that gets damaged when a stroke occurs. depending on what area of the brain gets damaged determines what the manifestations (symptoms) are that the patient will have. because we cannot open the skull and look directly inside at the brain it is difficult to assess exactly what the damage is. we have to depend on our observation and assessment skills to figure that out.

see

http://www.strokecenter.org/prof/ems/ - stroke interactive tutorial
http://www.stroke.org/site/pageserver?pagename=las - life after stroke
http://www.nlm.nih.gov/medlineplus/tutorials/strokerehabilitation/htm/index.htm - stroke rehabilitation
http://www.stroke.org/site/pagenavigator/home - national stroke association

J9G2008 · Jun 16, 2009

When I had to my first nursing dx, my instructor said to stick with the simplest things for it. Like: impaired mobility, risk for falls, hygiene, etc. There is enough to learn in doing the first care plan without doing diagnoses that would take you further afield.

Just my two cents.