Published Sep 20, 2009
stormbeige
13 Posts
Hi,
We are tasked to make 3 nursing care plans for a 23-year-old patient who has just delivered via NSVD and has a lower extremity edema. Based on her chest x-ray, she has an impression of pneumonia/pulmonary congestion.
Her abnormal laboratory results were the following:
Hemoglobin - 112
RBC count - 3.9 x 10^12
WBC count - 17.3 x 10^9
Neutrophil count - 0.73
Normal laboratory values for that hospital:
Hemoglobin - 120 - 160
RBC count - 4.20 - 5.4 x 10^12WBC count - 4.50 - 11 x 10^9
Neutrophil count - 0.36 - 0.66
I just need 3 possible nursing diagnoses and its objective cues.
Any help would be very much appreciated. Thank you in advance.
Daytonite, BSN, RN
1 Article; 14,604 Posts
you already listed your some of your objective cues, but some are missing.
if this patient has pneumonia and pulmonary congestion you need to look up the signs and symptoms of these conditions to find the objective cues (symptoms) she would be displaying in order to determine what nursing problems she has connected with the pneumonia and pulmonary congestion before you can go any further with this assignment. once you have that list of respiratory symptoms (cues) add them to the ones above. then, you can start determining what your three nursing diagnoses are going to be. you will match the list of cues you have with a specific nursing problems and give those nursing problems names (nursing diagnoses).
Hello,
Thanks for the quick reply. I forgot to mention that she has undergone episiorrhaphy.
I wanted to use the following nursing diagnoses:
I wanted to use lower extremity edema as one of my cues but i cannot completely state my nursing diagnosis:
can it be like this??
I am not sure if it is correct.. I am having problems stating my nursing diagnoses. Very grateful for your help. Thanks.
i am having problems stating my nursing diagnoses.
- - - - - - - - - - - - - - -
fatigue r/t increased energy requirements of labor.
impaired urinary elimination r/t surgical trauma.
risk for injury r/t invasive procedures and perineal tears with precipitous labor.
impaired physical mobility r/t pain and weakness after labor as evidenced by lower extremity edema
when new at diagnosing use some kind of guide that has the nanda taxonomy until familiar with commonly used diagnoses that you use frequently. the appendix of recent editions of taber's cyclopedic medical dictionary has this information as well as nursing diagnosis reference books. they list the definition, defining characteristics (symptoms) and related factors (causes) for each nursing diagnosis. some of this information can be found on these websites for about 80 commonly used nursing diagnoses:
hello,
thanks for the help... really appreciated it a lot..
i have made some revisions of my nursing diagnoses: kindly make comments about it and if it is wrong, kindly state the correct one.. thanks.
[color=olive]acute pain r/t tissue trauma and birth process, intensified by fatigue
objective cues:
[color=olive]impaired urinary elimination r/t mechanical compression of the bladder and effects of regional anesthesia (we have interviewed the patient 16 hours after delivery and she stated that she has not voided and there is a presence of lady partsl discharge)
[color=olive]deficient fluid volume r/t decreased oral intake, bleeding and diaphoresis
objective cues ( we have not obtained the current weight of the patient)
i realized that i have not gathered a lot of information. next time, i will assess my patient very well. thanks for all the info..
[color=olive]acute pain r/t tissue trauma and birth process, intensified by fatigue [acute pain r/t tissue trauma and birth process]
[color=olive]impaired urinary elimination r/t mechanical compression of the bladder and effects of regional anesthesia (we have interviewed the patient 16 hours after delivery and she stated that she has not voided and there is a presence of lady partsl discharge) - i gave you a hint about the inflammatory response before. the baby coming through the lady partsl canal causes a lot a tissue trauma (see how your body feels after a 5-8 pound baby is pushed through it) which in turn causes all kinds of micro tears of the tissues and sets the healing process in motion which includes the inflammatory response whose steps occur in this order: redness, heat, swelling and then pain as a result of the swelling. depending on the degree of swelling, surrounding structures, such as the bladder can be involved. you have to know this inflammatory response for tissue damage and all infection processes. see https://allnurses.com/general-nursing-student/histamine-effect-244836.html [impaired urinary elimination r/t inflammatory response and effects of regional anesthesia]
[color=olive]deficient fluid volume r/t decreased oral intake, bleeding (body fluids lost during lady partsl delivery) and diaphoresis - the related factor for this diagnosis must explain how fluid was lost from the body. decreased oral intake is not a fluid loss. you haven't explained the pathophysiology of the peripheral edema yet either to account for its existence. [deficient fluid volume r/t loss of body fluids during lady partsl delivery and diuresis]
this peripheral edema is probably a cardiac problem. unless you can figure out how it is a fluid loss, don't use it as a symptom of fluid loss.
[color=sandybrown]thanks a lot! i really learned a lot.. .i can now make my nursing care plan.
if i can finish it early, maybe i can send it to you so that you can make comments about it for my improvement...
donnabade
1 Post
read NANDA!