nanda issue

Jun 30, 200917 yr

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!

Jun 30, 200917 yr

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. :)

Jun 30, 200917 yr

Experts

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

https://allnurses.com/lpn-lvn-nursing/prioritzing-my-nandas-402325.html

. 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

https://allnurses.com/lpn-lvn-nursing/prioritzing-my-nandas-402325.html

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.

nanda issue

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