Published Jun 21, 2009
Hello all !
I am currently writing a nursing care plan for a pt of mine that was diagnosed with a Malignant Brain Neoplasm. She undergoes radiation treatment daily. The pt is bed bound and aphasic but is still ANO x2 (PnP). She has right sided weakness and contractures. Pt is also incontinent with a foley cath in place. Upon skin assessment i noticed some reddened areas over the left buttocks as well. Ive come up with a couple nursing diagnosis that i would like to get some input on for this particular pt. Any help would be greatly appreciated !
Impaired verbal communication r/t impaired cognitive ability as manifested by lack of speaking
Fatigue r/t radiation therapy as manifested by constant sleepiness and weakness of body
Risk for impaired skin integrity r/t impaired mobility as manifested by blanching of skin
Daytonite, BSN, RN
diagnosis is based upon the abnormal symptoms that the patient has. these are found by assessment of the patient. i went through the data you posted and i have some questions since this patient is confined to bed and doesn't speak. it sounds as if there is a lot of care that needs to be provided for her, but your nursing diagnoses do not seem like they are going to provide that. i shuffled the data and listed it by maslow's hierarchy of needs:
i will address your diagnostic statements next, but possible diagnoses you missed here are bowel incontinence, impaired bed mobility, impaired skin integrity, (acute or chronic) confusion and a number of the self-care deficits based on assessment information that is incomplete. most would come, in priority, before the diagnoses you did come up with:
what you should have done is an assessment that included:
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
my suggestion is that a list of nursing diagnoses in priority order would look something like this:
Thank you very much for the follow up. Our instructors want us to write our Nursing dx in the format of: Problem -- etiology -- secondary to -- as evidence by. I was a little confused on how i could use my diagnosis of impaired verbal communication as r/t to ? you clarified this greatly to me.
Her chart indicated that the tumor was over the corpus callosum and that the speech impairments only began in the past few months. She has had the tumor resected twice and underwent gamma knife tmt. The contractures are on her right arm and leg and she is completely dependent with ADL. She has limited used of her left arm as it seems very weak and she only uses it to scratch face or hold the rail when turning her. I also forgot to mention that she is on restricted fluid intake of 1500 cc and eats very limited amounts of food. Her urine was a tea color and her skin turgor was reduced ( possible dehydration?) She is both bowel and urinary incontinent as well.
Based on all the great information you gave me i have readjusted a few diagnosis to the best priorities (we are required 3 for this particular care plan)
Bowel incontinence r/t decreased functional ability as evidence by involuntary passage of stool ( i wasnt sure if impaired cognitive ability was an appropriate factor here after taking into consideration what you mentioned about mental status)
Impaired Bed Mobility r/t to decreased strength and endurance secondary to brain neoplasm as manifested by inability to move purposefully in bed (I'm not sure exactly how to word this)
Impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin
Any additional comments would be great !
bowel incontinence r/t decreased functional ability as evidence by inability to pass stool ( i wasnt sure if impaired cognitive ability was an appropriate factor here after taking into consideration what you mentioned about mental status)
impaired bed mobility r/t to decreased strength and endurance secondary to brain neoplasm as manifested by inability to move purposefully in bed (i'm not sure exactly how to word this)
impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin
- - - - - - - - - - - - - - -
a nursing diagnostic statement follows this format:
p (problem) - e (etiology) - s (symptoms)
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