nanda issue

  1. Hello... Anyone want to help me with these NANDAs? No matter how many times I do them in school I can't seem to get any better at them!!!!

    I wanted to know if these are ok

    Excess fluid volume r/t compromised regulatory mechanism secondary to CHF aeb +2 pedal edema

    Risk for constipation r/t medication regiment and insufficient physical mobility

    Functional urinary incontinence r/t altered physical mobility, lack of ability to detect urge to urinate

    Impaired skin integrity r/t trauma, pressure, aeb ulcers on sacrum, buttox, L heel and L calf, and R heel

    Impaired physical mobility r/t generalized pain and weakness aeb no WB L leg, pain 8/10, and dependence with transfers

    risk for impaired gas exchange r/t alveolar - capillary membrane changes secondary to disease process (COPD)
    _ she has no exacerbations or symptoms at present which is why i put the risk for. shes not even on O2...

    she also has a HA with pain 8/10 and Leg pain 8/10.. i wanted to do acute pain but I dont know how to put the r/t

    and her neuro was fine shes a&o X3 and sometimes her responses are delayed but I'm not able to come up with a neuro nanda or a psychosocial. I spent about 3 hours with this woman and I have to come up with a nanda for every body system. not having such an easy time with this!! I'd appreciate anyones help right now!! ) Thanks so much!
  2. Visit ConniePN profile page

    About ConniePN

    Joined: Jun '09; Posts: 4
    from US

    2 Comments

  3. by   NamasteNurse
    Daytonite will probably answer you perfectly and you can also search the site here..but

    You list the nanda diagnosis then the r/t as you did. lets take for example, Activity intolerance. then you look at symptoms and state what may be causing or contributing to the nursing diagnosis commonly referred to as the etiology. Ideally its something that can be treated BY A NURSE WITHOUT A DOCTORS ORDER.

    "A carefully written individualized r/t statement enables the nurse to plan nursing interventions that will assist the client in accomplishing goals and return to optimum state of health" (nursing diagnosis handbook Ackley , and Ladwig)

    So, you have the problem (nursing diagnosis), the etiology ( r/t phrase) Signs and symptoms (defining characteristics)

    Activity intolerance related to deconditioned status and inexperience with activity m/b shortness of breath on exertion.

    Interventions, help pt to ambulate 5 minutes a day as tolerated until sob returns.

    Then you have your outcomes. Pt will ambulate "X" amount without experiencing sob in one week.

    Get a good Nursing diagnosis handbook from a library and read up. Once you get it, it's actually fun, LOL to me anyway.
  4. by   Daytonite
    excess fluid volume r/t compromised regulatory mechanism secondary to chf aeb +2 pedal edema (use instead: excess fluid volume r/t arterial hydrostatic pressure exerting greater control than venous oncotic pressure over water movement into interstitial tissues secondary to chf aeb 2+ pitting edema.)
    this is the same diagnosis you used before and i know i mentioned this compromised regulatory mechanism business with you then on Prioritzing my NANDAS!! HELP!!!!. what is happening in chf that causes pedal edema to occur? that's the compromised regulatory mechanism you are talking about. you need to put it into as few words as possible and put them in place of compromised regulatory mechanism. i actually know what it is, but do you? write this down somewhere so you don't forget it because it is a mouthful (i have it penned into my copy of my nanda taxonomy): excess fluid volume r/t arterial hydrostatic pressure exerting greater control than venous oncotic pressure over water movement into interstitial tissues secondary to chf aeb 2+ pitting edema. the arterial hydrostatic pressure exerting greater control than venous oncotic pressure over water movement into interstitial tissues is the compromised (messed up) regulatory mechanism that is going on. it is a biochemical principle.

    risk for constipation r/t medication regiment and insufficient physical mobility (use instead: risk for constipation r/t side effect of _______ and insufficient physical mobility)

    medication regiment is a misstatement. i understand that you want to impress your instructors, but be careful with the words you use. regiment is a military term that means "a large number". a regimen is a system of diet or health designed to achieve a specific effect. we know you are specifically referring to the side effects of specific medications that produce constipation. so, say side effects of ____ and name the specific medications.
    functional urinary incontinence r/t altered physical mobility, lack of ability to detect urge to urinate (use instead: impaired urinary elimination r/t lack of ability to detect urge to urinate aeb incontinence)

    this is another diagnosis that i went over very specifically on Prioritzing my NANDAS!! HELP!!!!. functional urinary incontinence has to do with the action of urination that is impeded by the inability of the person to get to the toilet on time. so, altered physical mobility would be a related factor (cause), but the lack of ability to detect urge to urinate would not. lack of ability to detect urge to urinate is a sensory motor impairment so your diagnosis and related factor would be impaired urinary elimination r/t lack of ability to detect urge to urinate aeb incontinence.
    impaired skin integrity r/t trauma, pressure, aeb ulcers on sacrum, buttocks, l heel and l calf, and r heel (use instead: impaired skin integrity r/t trauma and pressure aeb open areas on sacrum, buttocks, left and right heels and right calf.)

    there really should be a better description of the ulcers (length, width, depth, presence of drainage and amount and any odor, appearance of wound edges). depth of wound is necessary to determine if this is skin or tissue integrity that is violated.
    impaired physical mobility r/t generalized pain and weakness aeb no wb l leg, pain 8/10, and dependence with transfers (use instead: impaired physical mobility r/t generalized pain and weakness aeb unable to bear any weight on left leg, slow movements and unable to maintain balance when transferring)

    pain 8/10 is an assessment and measurement of the pain that the patient has, does not describe any physical immobility and does not belong with this diagnosis. you do not need to assess their level of pain in describing their mobility problem. how does pain affect their mobility? as a related factor generalized pain is there because it causes the patient to slow their movements, right?

    no wb l leg sounds like a doctor's order and that is an order for treatment. aeb items need to be signs and symptoms of a problem. a treatment order is not a symptom of a problem. if this were stated as a symptom that you observed it would be written as unable to bear any weight on left leg. weakness in the patient might be observed by you as slow movements. dependence with transfers really needs to be more specific. why do they need help (dependence) with transfers? are they weak? can they not keep their balance? state what was observed by you.
    risk for impaired gas exchange r/t alveolar - capillary membrane changes secondary to disease process (copd)
    _ she has no exacerbations or symptoms at present which is why i put the risk for. shes not even on o2...

    she also has a ha with pain 8/10 and leg pain 8/10.. i wanted to do acute pain but i dont know how to put the r/t (use instead: acute pain r/t ??? aeb patient complaints of headache of 8/10 and pain in __ leg of 8/10)
    what were her medical diagnoses? in arthritis and osteoarthritis the joint pain is due to inflammation. if there are electrolyte imbalances there can be leg pains. headaches are caused by stress.
    it is hard to help when you don't give the medical diseases other than copd and chf. when a patient has a lot of medications there is a lot going on. medications are clues as well. ask yourself why each medication is being given.

close