student nurse

  1. hello everyone my name is gissel ? i have a big problem and i need someones help . i need to nursing diagnosis for a person who had CVA and i need a little help finishing them. plz HELP

    1.impaired physical mobility r/t left hemipelgia as secondary to cva AEB
    weakness,............,............. help need 2 more aeb!!!!!!

    2. risk for impaired skin integrity r/t impaired mobility ? is this right?
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    About gissel

    Joined: Nov '06; Posts: 1


  3. by   TheCommuter

    This site has a Nursing Student Assistance forum for people like you who need help or have school-related questions. Click on the link below.
  4. by   Daytonite
    hi, gissel!

    ok, i can tell you are having a major problem here. is this a real patient or a case study? if this is a case study and the patient is someone on a piece of paper then what you need to do is to look at the signs and symptoms of a person with a cva. these will take the place of your assessment data. some of these symptoms in a cva patient are:
    • confusion
    • vertigo
    • deterioration in intellectual function
    • urinary incontinence
    • hemiparesis or hemiplegia
    • sensory impairments
    • hearing loss
    • double vision
    • nystagmus
    • foot drop
    • apraxia (inability to use objects properly)
    • inability to perform purposeful movements properly
    • lack of recognition of a paralyzed extremity
    • intention tremor
    • ataxia
    • aphasia
    • dysphagia
    • inability to make decisions
    do any of these apply to your patient? any abnormal symptoms that your patient (or your imaginary patient) has are going to become the things following the aeb part of your nursing diagnosis statement. so, using the first nursing diagnosis you've posted, you can turn it into this:
    • impaired physical mobility r/t neuromuscular impairment secondary to cva aeb left hemiplegia and weakness.
    the problem i see you having is that the hemiplegia is not the cause of the weakness in the patient. anything following the "r/t" part of the nursing diagnostic statement is the direct cause of the nursing diagnosis, which is impaired physical mobility. the cause of the physical immobility is neurological impairment caused by damage in the brain from the stroke. this is manifested by the hemiplegia, weakness and could also account for such things as hemiparesis, foot drop, or an intention tremor--if your patient has any of those.

    if you are going to use risk for impaired skin integrity you need a potential cause for this. so,
    • risk for impaired skin integrity r/t immobility
    would be the way to word this.

    i would like to suggest that you hop over to the nursing student forums here on allnurses and have a look at these threads which have a lot of information which will help you with putting together care plans:
    here are a couple of websites for the two nursing diagnoses that you want to use that will give you the definition, defining characteristics and related factors for each of them:
    impaired physical mobility
    risks for impaired skin integrity

    here are links to two of the nursing student forums on allnurses:

    see you on the forums! welcome to allnurses!