Need Help for Nanda

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My patient is 91 y/o. alert / has a 2 wheel walker/ minimal assistance to turn/ he had diarrhea

complaint of urinary/

diagnosis: renal insufficiency

past med hist: anemia, uti, hypertension, cad, colon cancer

1.Nursing diagnosis: impaired bed mobility related to dislocation of hip bones and muscle weakness

2. Nursing diagnosis: risk for fall related to prolonged bed rest and weakness

3. Activity intolerance related to: ???

4. Ineffective health maintenance related to: ??

please help me ..i hope i did the first 2 right. Any suggestion will be accepted.

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Specializes in Trauma/Burn ICU, Neuro ICU.
My patient is 91 y/o. alert / has a 2 wheel walker/ minimal assistance to turn/ he had diarrhea

complaint of urinary/

diagnosis: renal insufficiency

past med hist: anemia, uti, hypertension, cad, colon cancer

1.Nursing diagnosis: impaired bed mobility related to dislocation of hip bones and muscle weakness

2. Nursing diagnosis: risk for fall related to prolonged bed rest and weakness

3. Activity intolerance related to: ???

4. Ineffective health maintenance related to: ??

please help me ..i hope i did the first 2 right. Any suggestion will be accepted.

3. Activity Intolerance r/t bed rest; generalized weakness;imbalance betw. oxygen supply/demand;immobility, sedentary lifestyle

4. diminished fine motor skill; diminished gross motor skills; insufficient resources

Right out of Ackley. You need this book to do care plans.

THis stuff is also available online. Google it! Go to the Elsevier site.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

care planning is accomplished through critical thinking and use of the nursing process which is a 5-step method. determination of the nursing diagnoses is accomplished in step #2 after you have assessed the patient. you need to do a more thorough assessment.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - just looking at this list of medical diseases tells me this patient probably has a lot of nursing problems. what urinary problem does the patient have? you didn't specify. a medical diagnosis is not the same as a nursing diagnosis. however, the symptoms of a medical diagnosis can be used as part of our assessment of the patient's nursing problems. so, break the medical diagnosis down into its symptoms. what symptoms of these medical problems does the patient have?

  • renal insufficiency
  • anemia
  • uti
  • urinary what ???
  • hypertension
  • cad
  • colon cancer
  • dislocation of hip bones

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - these were the only symptoms that i could pull out of the information that you posted. we can only diagnose from symptoms or abnormal assessment data collected from the patient.

  • minimal assistance to turn
  • diarrhea
  • muscle weakness

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - every nanda diagnosis has a set of defining characteristics (symptoms) and related factors (etiologies). this information can be found:

  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
  • based on the information provided, diagnoses for this patient might be:
    • deficient fluid volume r/t active fluid volume loss aeb diarrhea and weakness
    • impaired physical mobility r/t musculoskeletal impairment secondary to dislocation of hip bones aeb minimal assistance to turn

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Specializes in Operating Room Nursing.

I remember doing NANDA at Uni. I have never seen NANDA used anywhere in real life nursing though. I'm wonder if it's a learning tool for student more than something used in everyday nursing.

Anyway to answer the question if the patient has continence issues might I suggest something to do with potential skin breakdown/integrity?

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What about Risk for Impaired Skin Integrity. He has diarrhea and immobility issues.

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I remember doing NANDA at Uni. I have never seen NANDA used anywhere in real life nursing though. I'm wonder if it's a learning tool for student more than something used in everyday nursing.

Anyway to answer the question if the patient has continence issues might I suggest something to do with potential skin breakdown/integrity?

That's exactly what it is.

Doing so many careplans in school helped me to think like a nurse. Now, When I get a pt w/ any DX, I automatically pretty much know what interventions to take, what to watch for and what to act to prevent right off the top of my head. I'm sure it works this way for most nurses.

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