Need help with nursing diagnosis please

2 Posts

I AM IN THE MIDDLE OF A NURSING PROCESS PAPER AND WE HAVE TO COME UP WITH AS MANY NURSING DIAGNOSIS AS WE CAN FOR EACH SECTION. I DO NOT REALLY KNOW HOW TO WRITE THEM. PLEASE HELP. I THEN NEED HELP DISTINGUISHING THE TOP 5 MOST THREATENING TO LIFE. THANK YOU

Health Perception/Health Management:

Knowledge deficit r/t poorly explained medical procedures AMB confusion with diagnosis and results of surgery

Readiness for enhanced knowledge r/t medical diagnosis and treatments AMB patient asking numerous questions

Self care deficit r/t weakness, fatigue and decreased mobility AMB poor hygiene and decreased grooming

Effective therapeutic regimen r/t perforated bowel AMB hematocrit and hemoglobin gradually began to stop decreasing and pt subjectively states she is beginning to feel better.

Risk for falls r/t fatigue, weakness, decreased mobility AMB low hematocrit and hemoglobin, previous fall 4 weeks ago sustaining L1 and L2 compression fracture and the need to rely on a walker for stability

Risk for infection r/t the invasive surgical procedure of a colon resection resulting in inadequate primary defense of the skin (4 laparoscopic holes and a 3" opening that was closed using a combination of sutures and staples), inadequate nutrition and knowledge deficit

Nutritional/ Metabolic:

Impaired dentition r/t leaving full set of dentures at home AMB no teeth and only gums

Diarrhea r/t side effects of medications and symptom of certain disease processes AMB watery stools

Imbalanced fluid volume r/t urinary retention AMB 20-25 ml/hr output

Risk for infection r/t the invasive surgical procedure of a colon resection resulting in inadequate primary defense of the skin (4 laprascopic holes and a 3" opening that was closed using a combination of sutures and staples), inadequate nutrition and knowledge deficit

Imbalanced Nutrition: Less than body requirements r/t impaired dentition, nausea, inability to procure adequate amounts of food , knowledge deficit Unwillingness to eat Increased metabolic needs caused by disease process or therapy AMBgradual weight loss, fatigue, weakness, and anemia.

Nausea r/t

Bleeding r/t bowel perforation AMB low HCT and hemoglobin, dark tarry stools and coffee ground emesis

Collaborative Problem: Risk for hypovolemic shock r/t gastrointestinal bleeding

Elimination:

Risk for constipation r/t narcotics, immobility and inadequate fiber intake.

Diarrhea r/t side effects of medications and symptom of certain disease processes AMB watery stools

Urinary retention r/t surgical procedure AMB output of 20-25 ml/hr and intake of 75 ml/hr

Imbalanced fluid volume r/t urinary retention AMB 20-25 ml/hr output

Activity/Exercise:

Fatigue r/t anemia AMB low hematocrit, hemoglobin and pallor

Risk for falls r/t decreased mobility, weakness and muscle atrophy AMB slow, unsteady gait, and deconditioned muscle strength

Activity intolerance r/t fatigue and weakness AMB increased respiratory rate, tachycardia, and dyspnea on exertion

Acute pain r/t compression fracture of L1 and L2 and surgical intervention of bowels AMB pt complaints of pain at incision site and upper back upon excessive movements.

Bathing/hygiene self care deficit r/t fatigue, weakness and decreased mobility AMB patient complaints of not being bathed how she usually bathes herself

Decreased cardiac output r/t congestive heart failure AMB weakness, fatigue and a decreased ejection fraction.

Dressing/grooming self care deficit r/t fatigue, weakness and decreased mobility AMB patient complaints of not being groomed as she normally is .

Sleep/Rest:

Disturbed sleep pattern r/t IBS and hospital medical workers interrupting sleep (I.e. drawing labs at 0400) AMB daytime sleepiness and pt complaints of being tired and not getting much sleep

Sleep deprivation r/t health care workers interrupting REM sleep throughout the night/day AMB pt complaints of being tired

Cognitive/ Perceptual:

Acute pain r/t compression fracture of L1 and L2 and surgical intervention of bowels AMB pt complaints of pain at incision site and upper back upon excessive movements.

Chronic pain r/t

Disturbed sensory perception r/t decreased visual ability, auditory ability and gustatory senses AMB the need for glasses, hearing aid and extra seasoning

Readiness for enhanced knowledge r/t health promotion and maintenance AMB numerous patient questions

Self Perception/Concept/ Role relationships:

Depression r/t loss of loved ones AMB pt statements of losing her daughter and husband and being alone.

Anxiety r/t surgical procedure AMB patient statements of "am I going to heal OK"

Social isolation r/t death of loved ones AMB subjective verbal patient responses

Situational low self esteem r/t decreased ability to perform ADL's AMB pt statements of gratitude for the help and stating she wishes she could take care of her "old" body herself.

Risk for spiritual distress r/t decreased mobility to attend church AMB

Risk for loneliness r/t loss of loved one, loss of friends, and decreased mobility to get out and interact with society

Risk for impaired social interaction r/t decreased interaction with people Relocation stress syndrome r/t

Ineffective role performances r/t

Sexuality/Reproduction:

Sexual dysfunction r/t

Coping/Stress Management/Values/ Belief Patterns:

Risk for ineffective coping r/t few coping mechanisms

Readiness for enhanced coping strategies r/t

Risk for spiritual distress r/t decreased mobility to attend church AMB