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Nursing diagnosis for exam

hi, i'm a 3rd semester student, my exam in in 2 weeks, i need help!!please :crying2:

we are given some scenarios and asked to find 2 high priority nd..

here's scenario 1:

roz is a 53-year-old woman who recently started working for the xxx after a period of unemployment. she was diagnosed with metastatic pancreatic cancer approximately six weeks ago and she has been admitted to a medical ward with uncontrolled pain. roz's family says that she has become thinner over the past few weeks and they are worried about her lack of appetite.

assessment data

  • roz states that she has upper abdominal pain that is usually controlled with opioids but is currently not well controlled
  • she describes feeling weak and being easily fatiguedshe appears cachexic
  • her haemoglobin is 73 g/dl
  • she has a family history of cancer. her brother is currently undergoing treatment for bowel cancer and her cousin died 18 months ago from the same disease.

1st nd: acute pain rt pressure 2o metastatic pancreatic cancer amb patient uncontrolled upper abdominal pain

2nd nd: imbalanced nutrition: less than body requirements rt anorexia, cachexia and fatigue 2o to cancer aeb patient's unwillingness to eat.

2 scenario:

sid is a 38-year-old man who has been feeling stressed at work and "not 100% well". he saw his general practitioner (gp) a month ago for a health check and his blood pressure was found to be elevated. at a follow-up visit, his blood pressure was 180/110 mmhg and he was diagnosed with hypertension. he was prescribed bendrofluazide(thiazide diuretic) and the practice nurse discusses with him the risks associated with uncontrolled blood pressure, medication adherence and lifestyle modifications.

two weeks later sid experiences an episode of chest pain and is admitted to the inpatient setting.

assessment data

- his mother has hypertension and his father died of stroke at age 60 years

- sid smokes one pack of cigarettes daily and he has been trying to cut down in the last month

- he drinks a few glasses of whisky each night

- he has heard that blood pressure medication interferes with sexual functioning.

1nd : inadequate health maintenance rt inability to take responsibility in meeting basic health practices aeb current lifestyle i.e smoking, drinking.

2nd: it has to be something to do with his risks of develping stroke (rt his family history aeb pt episode of chest pain) but can't find it on nanda list..

3rd scenario:

luke is a 19-year-old male admitted to the inpatient setting via the emergency department. last week he crashed his motorcycle into a pole at high speed and he sustained a traumatic amputation of his left leg and a fractured right radius and ulna.

luke has arrived on your ward following an open reduction internal fixation (orif) of his fracture and surgical intervention to the site of his amputation, under a general anaesthetic. he has an intravenous infusion of 0.9% normal saline in situ, a low vacuum suction drain in place and a patient controlled analgesia infusion containing morphine (1mg/ml).

luke has been recruited to be involved in a fracture research trial.

assessment data

- luke is drowsy but rouses to voice

- there is slight wound exudate visible through the dressing on his left leg

- there is 80mls of blood in the suction drainage bottle

- he states he has a lot of pain and tenderness at the site of amputation

- vital sign recordings are: blood pressure 102/66mmhg, heart rate 120/min respiration rate 20 breaths per minute, temperature 37.6 degrees celsius and oxygen saturation is 94% on 2l/min of oxygen.

1nd: acute pain rt tissue damage 2o surgical intervention to the site of his l)leg amputation aeb patient stating he isin a lot of pain

2nd: deficient fluid volume rt active fluid volume loss 2o trauma aeb high heart rate, hypotension and amb patient's feeling drowsy.

last scenario 4:

anne is a 53 year old, self-employed woman who has her own cleaning business. her partner works fulltime. anne is interested in all sports and plays tennis socially every saturday. she also enjoys watching her 12 year old daughter play netball. anne gets up early in the morning and often has just sultana bran for breakfast. depending on the number of houses she has to clean, she eats lunch around 13:00. lunch is usually a filled roll and a soft drink which she buys from the bakery. three months ago anne cut her left ankle while she was working. she is now in a surgical ward with a non-healing wound.

assessment data

- anne has lived with type 2 diabetes mellitus for 10 years

- blood glucose levels are normally between 9 and 14 mmol/l

- hba1c was 9% when she was last tested 6 months ago

- anne takes metformin 850mg tds

- wound swab results indicate a multi-resistant organism (mro) growing in the wound.

1nd: ineffective therapeutic regimen management rt inadequate knowledge of diabetes mellitus type 2 (t2dm)aeb continued hypoglycaemia and non healing wound.

2nd: impaired skin integrity rt chemical irritants 2o the inflammatory response produced by a positive mro infection aeb infected wound and delayed healing.

thanks in advance, i appreciate all the help that i can get ..:):)


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