I'm confused I need help with Diagnosis

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It might seem small to everyone but I'm having a problem either finding a diagnosis or it already is...i dunno..

Ok so I have a pt who has a hip fracture undergoing ORIF sooo the medical diagnosis would be Hip fracture or Open Reduction Internal Fixation. The after that said and done the Nusring Diagnosis can be what?

Symptoms are normal. Having trouble eating, pt is at risk for fall which she fell at her ALF if that helps a little

Past Medical History: COPD, anemia, schizophrenia, CVA, ASHD, dementia

-Activity intolerance?

-chronic confusion?

-Risk for falls?

-impaired memory?

-impaired physical mobility?

-risk for OR actual impaired skin integrity?

Which sounds better or any more suggestionS? Interventions? goals? Sorry this is my 1st semester in the RN program..

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i would go with impaired physical mobility

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i would go with impaired physical mobility

ok thank you but I have a Question is ORIF a Medical diagnosis? or would the medical Diagnosis be "fracture hip" then the interventions would be Open Reduction Internal Fixation??? Do you know what i mean?

If you do know what I mean, any ideas for Nursing interventions?

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here is how to narrow you focus for nsg Dx

your first priorities are always airway, breathing, circulation

then it goes to maslows needs with physiological needs then safety ect.

(In my opinion) Your client two main Dx are risk for impaired skin integrity and risk for falls

both are relevant but risk for skin integrity is more important because it harms the patient physiological need and falls has to do with safety.

their are some key things her your client has decreased mental status, decrease mobility, impaired nutrition, and anemia and CVA that lead me to the conclusion that skin integrity is the main Nsg Dx.

here is a link to a good website for making care plans, it will help with interventions and stuff.

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_063.php

This is just my thought process :twocents:

hope that helps ... It get easyer with practice ... I remember my posting when I needed help with my first Nsg Dx.

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:down:Oh I have this book.. I don't like it at all ... it is to random and hard to fallow it took me most almost 2 years to figure out how to navigate it.

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Specializes in LTC, Hospital, Mental Health.
ok thank you but I have a Question is ORIF a Medical diagnosis? or would the medical Diagnosis be "fracture hip" then the interventions would be Open Reduction Internal Fixation??? Do you know what i mean?

If you do know what I mean, any ideas for Nursing interventions?

First off- your nursing diagnosis and interventions include nothing from the medical side of the house. So, take anything that has to do with that out. The fractured hip is a medical diagnosis, and the ORIF is a medical intervention. You still have to think about the medical diagnosis when you are coming up with a care plan. Ask yourself "What do I need to be concerned about when I am caring for someone who has a broken hip?"

Your interventions are going to depend on which nursing diagnosis you choose. With a hip fracture, your nursing diagnoses and interventions are going to be concerned with circulation, pain, infection and skin integrity. Your interventions can include positioning, checking distal pulse of affected leg, administering pain meds, assessing drainage of dressings, etc, etc. The intervention will depend on the diagnosis.

I hope that this helps and hasn't confused you further.

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Don't forget about the patients pain! I garauntee that is the highest priority on your patient's list!

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