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nursing diagnosis help plz!?!

Posted

Hi, i have never wrote a care plan or nursing diagnosis before but have to now. The person this care plan is about is a 76 yo male who came to the er with history of seziures (2) and complaints of fainting, diarrhea and vomiting. His medical diagnosis was syncope. While at the hospital he had no vomiting or diarrhea. He does have a trach and when ordering his lunch ordered food like cake with nuts and salad. In other words not soft foods. I have to have 3 diagnosis. i was thinking something like decreased mobility because he does need help getting out of bed to chair and a walker to walk. Maybe fall risk? and something along the lines of education because he tried to eat the wrong food. He did have, while in the hospital, urine retention and was straight cathed twice but idk if thats really something i can write on. =( plz help i dont know where to start with this. thanks!

KeeperMom

Specializes in ED. Has 10 years experience.

Look through the Care Plan / Nursing Diagnosis sticky at the top of the forums.

Make sure you are prioritizing your nursing diagnoses and keep ABCs and Maslow in mind while prioritizing.

We won't do your homework for you but we are usually very willing to help once you post what you have so far and show some effort and attempt.

Make sure you have all the SBAR info and have the subjective and objective data and go from there.

Risk for infection due to urinary retention, aspiration risk from wrong food,

Boog'sCRRN246, RN

Specializes in Utilization Management. Has 10 years experience.

Risk for infection due to urinary retention, aspiration risk from wrong food,

I've had patients with trachs who eat hamburgers, salad, rice, etc. As long as the cuff was deflated, there was no problem. Not saying aspiration wasn't a risk, just saying that not all patients with trachs require special diets.