Is this a good NSG diag

[finallyhere]

I have a 71 yof pt. She states she is in the rehab hosp. because she had hip surgery and it is not healing correctly. Her past med history is cancer, cirrhosis, cataracts, she has had one digit on each hand amputated (maybe the cancer?) She was a new admit, so I didn't get a lot of information out of her chart.

Her admit diag is UTI, pancytopenia, Hypokalemia, HTN, Functional Decline, Parkinsons had a question mark behind it with a note that she has it, but no history to back it up.

She has had 2 falls in the last month.

The hospital she was transferred from removed her IV and Foley. She arrived about 14:30 and had no drank much since she was going through all the admission hoops. She had not voided since the catheter was removed. I assume this is because of lack of time to have adequate fluid intake. She is able to do most self care with assist. She feeds herself and is on a normal diet and VS are all WNL.

The nursing diagnosis I was planning on using for her is Impaired physical mobility r/t musculoskeletal impairment aeb falls sustained twice in one month.

I picked this because her ABC's are all good. So I moved to pt. safety. My nanda book covers the related factor of musculoskeletal impairment. I pulled the info about the 2 falls from her chart so it is objective data I used to substantiate this diagnosis.

Just wanting to know if I am on the right track. I have done several pt. care plans already but this one is a big deal and we are being graded on it.

Thanks so much!

[vmoh18]

I'm sorry but I disagree about her ABC's being good. She has HTN, Hypokalemia, and pancytopenia (which is a reduction in all formed elements of blood). All of these can be a factor in her falls. I would go back and look at the ABC's again.

[finallyhere]

Yes, but I didn't list her meds she is on. She has a great many. The pancytopenia could be from the cancer. She was a new admit and her chart was not complete so I was unable to find out what type of cancer she has/had. She is also on Potassium. and on meds for the hypertension. She has normal VS. Thats why I didn't go the route of the HTN or Hypokalemia. She has no airway issues, she has no breathing issues, and no circulation issues. Her pedal pulses were present in both feet. Thats why I went the way I did. I can't go back to the location and recheck her completed chart. I know getting the full scoop would be the best way to approach this. heart sounds were strong lungs clear to auscultation bilaterally abdominal sounds were normoactive and stomach was soft to palpation. Also the NANDA book states that a nsg diag of decreased cardiac output needs to be substantiated by vs not being stable, ekg not normal, ABG not normal etc...... they only ordered CBC and urinalysis screenings on her.

[vmoh18]

OK then look at the UTI diagnosis. How was her output? Was she incontinent? If she had not voided since she had left the other hospital she may have Impaired Urinary Elimination. A piece of advise never assume anything when it comes to health care. Even if she had not had any oral intake, she would still have fluids from the IV in her system. I think there needs to be proof that she has impaired physical mobility other than the two falls. There could have been many factors involved in her falls. Did you see her ambulate? Did she really have hip surgery?

If she did then what about Impaired Skin Integrity or Risk for Infection. I am not trying to be hard on you, just trying to get you to see the bigger picture.

[finallyhere]

Thanks but I got a nurse with 20+ years exp to help me. She thinks I am on right track just need to refine it a bit.

[vmoh18]

Actually the advice I gave in the above reply was from an instuctor with more experience, but whatever. Please relize these are the student forums and 99% of advice will come from another student.

[Fig77]

I would also include the hip surgery and functional decline in the AEB part of dx, although during the planning we will need a specific intervention for each one of them.

I also think vmoh18 puts up a good point about the HTN, hypokalemia and uti getting priority. We can't just assume her output was low because of this and that when we have the objective uti dx on hand.