Nursing Diagnoses

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Specializes in Emergency!.

So, I'm sure that I will be able to figure out some on my own but I just thought I'd ask for your thoughts on nursing diagnoses for a patient who is 65 years old, with a recent tracheostomy and PEG tube. He was has bibasilar atelectasis and had a barium swallow study and was shown to silently aspirate on honey thick liquids. He also has diabetes, hypertension, and his BUN/Cr were slightly elevated.

Let me know your thoughts, Thanks!

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

a tracheostomy and peg tube are medical treatments ordered by a physician. it would be a good idea for you to find out why these treatment modalities were ordered. the barium swallow study was part of the doctor's investigation of the patient in order to come to some kind of decision about their medical diagnoses. bibasilar atelectasis, diabetes and hypertension are medical diagnoses that the doctor would have based upon doing a ros (review of systems) and physical exam of the patient in order to come to those decisions.

nursing diagnosis isn't that much different. we follow the nursing process. you must first thoroughly assess your patient before you can diagnose any nursing problems that they have. the only evidence you provided of potential nursing problems was:

  • bun/cr were slightly elevated
  • they aspirate on honey thick liquids

nursing assessment (step #1 of the nursing process) consists of:

  • a health history (review of systems)
  • performing a physical exam
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

determining the patient nursing problems, or nursing diagnoses, (step #2 of the nursing process) consists of pulling out the abnormal data you have collected from the assessment data you collected. we are primarily interested in how the patient responds to their medical diseases and other stressors in their lives. you already know 2 of those,

  • bun/cr were slightly elevated
  • they aspirate on honey thick liquids

but i am sure there must be others if you go back through the data.

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