Need help on nursing diagnoses- I'm stuck!

[SchoolNurseChristine]

I need to develop 5 nursing diagnoses for a patient that I had and I'm really stuck because she was pretty stable and actually on her way to discharge.

The patient is 78 and was admitted to the CVU after having a right carotid endarterectomy d/t carotid stenosis. The only issue I had to deal with that day was a low blood pressure (in the 80's systolic) for which she had a dopamine drip ordered. By the time I got there, her blood pressure was improving and they were beginning to titrate it down. I know there is a nursing diagnosis in there somewhere- decreased cardiac output? Ineffective tissue perfusion? But what is it related too??

I do have risk for falls in there because of the hypotension and she is advanced in age.

Her past medical history is history of TIA, HTN, hypercholesterolemia, and bilateral cataracts.

Is there something I'm missing? I'm trying to think of the main things I had to do for her, but really all I had to do was assist her to the bathroom and monitor her BP frequently.

Any help or guidance would be greatly appreciated!! :)

[Daytonite, BSN, RN]

you are thinking like a doctor instead of nurse. a nursing care plan is about determining a patient's nursing problems, which are given names called nursing diagnoses, and doing something about them. handling their medical problems and doing something about them is the doctor's job and we only assist the doctor in doing that. we nurses address the patient's response to their medical conditions and how they are dealing with them. while some of the nursing problems deal with the patient's response to their physical conditions there are many other that deal with how the patient deal with their adls or cope with the environment around them.

you have a patient that had an endartarectomy. that is a surgical procedure that carries complications and side effects that need to be monitored for which is part of nursing's job. as a post-op patient there are certain complications that need to be monitored and watched for. there are nursing diagnoses connected to them. what about discharge teaching? and, yes, ineffective tissue perfusion of the brain is in there as well. the atherosclerosis going on is the related factor. you need to look at a nursing diagnosis reference which contains suggestions for the related factors. they are based on the pathophysiology of the underlying disease processes going on. assisting someone to the bathroom is helping them with their adls and there is a diagnosis for that. there is also a diagnosis for someone who has visual problems as a result of cataracts.

if you have a recent edition of taber's cyclopedic medical dictionary you will find a nanda taxonomy with all the nursing diagnoses, their definitions, related factors and defining characteristics (signs and symptoms) in the appendix. you need to just sit and thumb through the diagnoses, read about them and learn what is there and available to use.

[ParkerBC,MSN,RN, PhD, RN]

How about risk for infection r/t inadequate primary defense (incision) AEB 3cm by 1cm incision (and where it is located).

Readiness for enhanced nutrition (may have cause her problem to begin with)

Risk for compromised Human Dignity (perhaps because of the surgery, she will not be able to perform her normal activities)