So, my patient was admitted for TDRF following a subarachnoid hemorrhage. He was found unconscious in his home after a fall. He has a medical history of schizophrenia, bipolar disorder, chronic kidney disease, seizure, diabetes insipidus, subdural hematoma.
Although he was admitted for TDRF, he is now on a ventilator with full support. He obviously still has a trach collar. He has a sacral wound and wounds on both heels, 1+ pitting edema in both feet, zero movement in both legs and right arm; left arm is the only one that moves, although it's very limited due to its contraction. He doesn't communicate, but can sometimes track you with his gaze. He was incontinent of bowel and had a condom cath. He also had a temp of 94.5 degrees. Hopefully, I didn't forget anything.
We are to come up with 6 diagnoses, one being deficient knowledge r/t ----. Here'es what I've come up with so far:
Ineffective airway clearance r/t presence of secretions AEB diminished breath sounds, inability to cough, dysphagia, purulent secretions on and around trach collar.
Impaired verbal communication r/t decreased cognitive function AEB disorientation to person, place, time, inability to follow verbal commands, dysphagia, muscle weakness, schizophrenia, bipolar disorder.
I need one more diagnosis + the deficient knowledge (which I will figure out after reviewing my notes from the day). Here are my potentials:
Ineffective Thermoregulation r/t decreased amount of subcutaneous fat OR decreased hypothalamic function secondary to brain injury?? AEB low temp of 94.5.
Impaired physical mobility r/t decreased LOC AEB brain trauma, passive ROM, inability to bear weight.
What do you guys think thus far and what would you suggest? Any help is appreciated!
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So, my patient was admitted for TDRF following a subarachnoid hemorrhage. He was found unconscious in his home after a fall. He has a medical history of schizophrenia, bipolar disorder, chronic kidney disease, seizure, diabetes insipidus, subdural hematoma.
Although he was admitted for TDRF, he is now on a ventilator with full support. He obviously still has a trach collar. He has a sacral wound and wounds on both heels, 1+ pitting edema in both feet, zero movement in both legs and right arm; left arm is the only one that moves, although it's very limited due to its contraction. He doesn't communicate, but can sometimes track you with his gaze. He was incontinent of bowel and had a condom cath. He also had a temp of 94.5 degrees. Hopefully, I didn't forget anything.
We are to come up with 6 diagnoses, one being deficient knowledge r/t ----. Here'es what I've come up with so far:
Ineffective airway clearance r/t presence of secretions AEB diminished breath sounds, inability to cough, dysphagia, purulent secretions on and around trach collar.
Risk for aspiration r/t impaired swallowing, depressed cough, decreased LOC, weakened muscles.
Impaired verbal communication r/t decreased cognitive function AEB disorientation to person, place, time, inability to follow verbal commands, dysphagia, muscle weakness, schizophrenia, bipolar disorder.
Impaired skin integrity r/t prolonged bed rest AEB sacral wound, heel wounds, Z-Flo boots, Dolphin bed, Z-Flo positioner.
I need one more diagnosis + the deficient knowledge (which I will figure out after reviewing my notes from the day). Here are my potentials:
Ineffective Thermoregulation r/t decreased amount of subcutaneous fat OR decreased hypothalamic function secondary to brain injury?? AEB low temp of 94.5.
Impaired physical mobility r/t decreased LOC AEB brain trauma, passive ROM, inability to bear weight.
What do you guys think thus far and what would you suggest? Any help is appreciated!