Published Oct 17, 2009
crw1026
2 Posts
I AM IN THE MIDDLE OF A NURSING PROCESS PAPER AND WE HAVE TO COME UP WITH AS MANY NURSING DIAGNOSIS AS WE CAN FOR EACH SECTION. I DO NOT REALLY KNOW HOW TO WRITE THEM. PLEASE HELP. I THEN NEED HELP DISTINGUISHING THE TOP 5 MOST THREATENING TO LIFE. THANK YOU
Health Perception/Health Management:
Knowledge deficit r/t poorly explained medical procedures AMB confusion with diagnosis and results of surgery
Readiness for enhanced knowledge r/t medical diagnosis and treatments AMB patient asking numerous questions
Self care deficit r/t weakness, fatigue and decreased mobility AMB poor hygiene and decreased grooming
Effective therapeutic regimen r/t perforated bowel AMB hematocrit and hemoglobin gradually began to stop decreasing and pt subjectively states she is beginning to feel better.
Risk for falls r/t fatigue, weakness, decreased mobility AMB low hematocrit and hemoglobin, previous fall 4 weeks ago sustaining L1 and L2 compression fracture and the need to rely on a walker for stability
Risk for infection r/t the invasive surgical procedure of a colon resection resulting in inadequate primary defense of the skin (4 laparoscopic holes and a 3" opening that was closed using a combination of sutures and staples), inadequate nutrition and knowledge deficit
Nutritional/ Metabolic:
Impaired dentition r/t leaving full set of dentures at home AMB no teeth and only gums
Diarrhea r/t side effects of medications and symptom of certain disease processes AMB watery stools
Imbalanced fluid volume r/t urinary retention AMB 20-25 ml/hr output
Risk for infection r/t the invasive surgical procedure of a colon resection resulting in inadequate primary defense of the skin (4 laprascopic holes and a 3" opening that was closed using a combination of sutures and staples), inadequate nutrition and knowledge deficit
Imbalanced Nutrition: Less than body requirements r/t impaired dentition, nausea, inability to procure adequate amounts of food , knowledge deficit Unwillingness to eat Increased metabolic needs caused by disease process or therapy AMB gradual weight loss, fatigue, weakness, and anemia.
Nausea r/t
Bleeding r/t bowel perforation AMB low HCT and hemoglobin, dark tarry stools and coffee ground emesis
Collaborative Problem: Risk for hypovolemic shock r/t gastrointestinal bleeding
Elimination:
Risk for constipation r/t narcotics, immobility and inadequate fiber intake.
Urinary retention r/t surgical procedure AMB output of 20-25 ml/hr and intake of 75 ml/hr
Activity/Exercise:
Fatigue r/t anemia AMB low hematocrit, hemoglobin and pallor
Risk for falls r/t decreased mobility, weakness and muscle atrophy AMB slow, unsteady gait, and deconditioned muscle strength
Activity intolerance r/t fatigue and weakness AMB increased respiratory rate, tachycardia, and dyspnea on exertion
Acute pain r/t compression fracture of L1 and L2 and surgical intervention of bowels AMB pt complaints of pain at incision site and upper back upon excessive movements.
Bathing/hygiene self care deficit r/t fatigue, weakness and decreased mobility AMB patient complaints of not being bathed how she usually bathes herself
Decreased cardiac output r/t congestive heart failure AMB weakness, fatigue and a decreased ejection fraction.
Dressing/grooming self care deficit r/t fatigue, weakness and decreased mobility AMB patient complaints of not being groomed as she normally is .
Sleep/Rest:
Disturbed sleep pattern r/t IBS and hospital medical workers interrupting sleep (i.e. drawing labs at 0400) AMB daytime sleepiness and pt complaints of being tired and not getting much sleep
Sleep deprivation r/t health care workers interrupting REM sleep throughout the night/day AMB pt complaints of being tired
Cognitive/ Perceptual:
Chronic pain r/t
Disturbed sensory perception r/t decreased visual ability, auditory ability and gustatory senses AMB the need for glasses, hearing aid and extra seasoning
Readiness for enhanced knowledge r/t health promotion and maintenance AMB numerous patient questions
Self Perception/Concept/ Role relationships:
Depression r/t loss of loved ones AMB pt statements of losing her daughter and husband and being alone.
Anxiety r/t surgical procedure AMB patient statements of "am I going to heal ok"
Social isolation r/t death of loved ones AMB subjective verbal patient responses
Situational low self esteem r/t decreased ability to perform ADL's AMB pt statements of gratitude for the help and stating she wishes she could take care of her "old" body herself.
Risk for spiritual distress r/t decreased mobility to attend church AMB
Risk for loneliness r/t loss of loved one, loss of friends, and decreased mobility to get out and interact with society
Risk for impaired social interaction r/t decreased interaction with people Relocation stress syndrome r/t
Ineffective role performances r/t
Sexuality/Reproduction:
Sexual dysfunction r/t
Coping/Stress Management/Values/ Belief Patterns:
Risk for ineffective coping r/t few coping mechanisms
Readiness for enhanced coping strategies r/t