Nursing Diagnosis help

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Specializes in ICU,PCU,ER, TELE,SNIFF, STEP DOWN PCT.

HI I am trying to figure out a Nursing diagnosis for a patient with CVA, HX HTN and CAD with Left Leg weakness.

I am trying to get a nursing diagnosis for it pliwhat would you put as a outcome and 2 items to do during PCS?

I am getting ready to take a careplan writing class but would appriciate the help.

Any of you in the CPNE have a patient like this?

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

any nursing diagnosis that you choose is based upon the abnormal symptoms you discover during your assessment of the patient. nursing diagnoses are not based upon medical diagnoses. the steps of the nursing process are followed in determining nursing diagnoses. since step #1 is to perform a thorough assessment, you need to do a physical examination and review of the patient's medical record. you make a listing of all the abnormal data you find. this abnormal data forms the foundation of what will become your care plan. nanda (north american nursing diagnosis association) calls this abnormal data defining characteristics. they can also be referred to as symptoms.

to choose a nursing diagnosis you need to have a nursing diagnosis reference of some kind. most students have a care plan book or a nursing diagnosis book. i happen to use nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international because it has the three things about each of the 188 current nursing diagnoses that i need: the definition, defining characteristics and related factors. you choose a nursing diagnosis based upon the symptoms your patient has. you nursing interventions are specifically aimed at those abnormal data items you discovered during your assessment (you're going to "treat" them). your outcomes are what you predict are going to happen as a result of your interventions.

there is information on writing care plans in these two student forum threads of allnurses:

if you are still having trouble determining nursing diagnoses for this patient, post a thread in the nursing student assistance forum where i will see it and i will help you. i need to see your list of the patient's symptoms (abnormal assessment data, defining characteristics) in order to be of more help.

if you are just looking for "possible" nursing diagnoses here to save yourself a lot of time looking for a match, i recommend you get a copy of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig. it has a cross matched index of medical diagnoses and likely nursing diagnoses in the very beginning of the book.

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The above post is correct in the real world but for the CPNE you have to have an actual dx and at risk dx before you can enter the pcs. also the first dx book that they talk about is not accepted by ec. the mosbys book can be used after oct 07 so depends on when you test. but here are a couple of suggestions for pcs careplans for the limited info you have given.

impaired physical mobility r/t neuromuscular impairment aeb: Left lower extremity weakness.

goal: resident will maintain or increase strength to lower extremities during pcs.

interventions: repostion in bed (must do anyway) 2. rom to lower extremities.

at risk for injury r/t lower extremity weakness

goal: resident will have no episodes of injury during pcs.

interventions: 1. assist with ambulation 2. use assistive device ( assure they use one first.)

hope these help

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