NUR DX Priority help

meesh2lit · Apr 4, 2011

1- KNOWLEDGE DEFICIT post op diet restrictions

2 -KNOWLEDGE DEFICIT effects of cigarette/canibas smoking w/ asthma

3-KNOWLEDGE DEFICIT effects of drug use

4-HEALTH MAINTENANCE INEFFECTIVE asthma management w/ smoking

5-HEALTH MAINTENANCE INEFFECTIVE poor eating habits & lack of vitamins (or do they need to be seperate?)

6-ACTIVITY INTOLERANCE r/t insufficient knowledge of adaptive techniques needed 2ndry to Asthma

7-SEDENTARY LIFESTYLE low activity

8-READINESS FOR ENHANCED COPING pt quit smoking

9-HEALTH MAINTENANCE INEFFECTIVE inadequate dental hygiene

RISKS are last:

10- Risk for Ineffective Resp Function r/t bleeding of throat

11- Risk for Bleeding r/t surgical incision

12- Risk for Infection r/t surgical incision

13- Electrolyte Imbalance r/t vomiting

14- Risk for Infection r/t excessive use of ear buds (fungal infection of outer ear)

I did not put them in proper PES statements yet.... I need to prioritize my list and use 2 top DX for my care plan to create interventions for. I originally thought of using DELAYED SURGERY RECOVERY or IMPAIRED ORAL MUCOSA and NUTRITION LESS THAN BODY REQUIREMENTS. However, my nur dx book states not to use these and instead use KNOWLEDGE DEFICIT and RISK FOR INFECTION r/t surgery. I know my RISK DX are last and I think I have those in the correct order but Im not sure about the others. Also I have alot of different ones for KNOWLEDGE so I think they have to all be separate PES statements right? Also do I need a nur DX to address the stomach ache pt had b/c of NPO for the 1 day even though he said no pain? Its a little hard using Maslow's Hierarchy for this one so any input would be helpful thanks!!!

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PATIENT INFO:

16 y/o male, 10 day post op tonsillectomy vomiting blood and passed out around 6am. On admission no active bleed, LAB PT high, Toxicology positive for THC

6pm Pt 0/10 pain, no trouble breathing, Vitals w/in range, NPO, no activity restrictions,

Hx: Asthma, smoked cigarettes 1/2 pack/day since 14 states quit 3 months ago, parent in house smokes. pt states 5 mos ago broke hand from fall when trying to jump a certain number of stairs and missed.

Nutrition: 24 Hour diet recall Breakfast-milk & cereal, Dinner-Belgium waffle & ice cream (patient thinks scratched his throat and was the cause of the bleeding the following morning), states does not take daily vitamins and only eats 2 meals a day skipping lunch, says favorite food is cookie cupcakes, weight is within range.

Hygeine: Brushes only 1 x day, no mouthwash, rarely flosses

Low activity: hobbies/likes- listening to music (uses ear buds alot but doesnt clean them, video games and rare occasions plays handball, sits out most gym classes with asthma note.