Nursing Diagnosis help

[mark3274]

Hey Everyone I am writing a Process paper and can not seem to find a High priority nursing diagnosis to fit.

Here is the case male 79 year old admitted for CVA X2

Copd 60 year smoker.

K+ 3.3 NA 149 PH 7.28

on lasix 40 mg per J tube

Lanoxin 250 mcg

Albuterol Atrovent

colace senna

robitussin

I already used Ineffective airway clearance for number 1

but MY instuctor wants me to focus on the electrolyte problem I am sure

do you know of any nursing diagnosis that would fit?

I was thinking fluid volume excess.... but does that deal with the fact his electrolytes are all messed up

and yes he is headed to renal failure.. he needs to be striaght cathed to get any urine out of him

no gag reflex TF jevity 1.2 @ 65 cc per hour is only nutrition

The only real water intake he is getting is 250 ml sterile flushes every 4 hours and yet his potassium is always low had to give him a extra 40 mg K+ because his values were so low.

[MagnesiuM]

You can't use a medical diagnosis (the CVA) as a related factor in a nursing diagnostic statement. Read a NANDA reference that tells you what you can use as a related factor for this diagnosis.

I was told that we could not use medical diagnoses either....so why can we use COPD as a R/T? it's confusing, and i don't think our instructors would let us do that....they'd tell us to "explain it out" instead of just putting down COPD or CVA or whatever.

how did he pass with that? man, i'm sitting here flunking for lesser violations than that!!!!!

can i transfer?

[Daytonite, BSN, RN]

i was told that we could not use medical diagnoses either....so why can we use copd as a r/t? it's confusing, and i don't think our instructors would let us do that....they'd tell us to "explain it out" instead of just putting down copd or cva or whatever.

how did he pass with that? man, i'm sitting here flunking for lesser violations than that!!!!!

can i transfer?

so why can we use copd as a r/t?

copd (chronic obstructive pulmonary disease) "is a general term used to describe a variety of conditions that result in obstruction of the airway."

(icd-9-cm coding handbook)

it is not a medical diagnosis. four medical diseases that belong to this condition are:

• emphysema
  
  
• chronic obstructive asthma
  
  
• chronic obstructive bronchitis
  
  
• chronic bronchitis with emphysema

if you look at the nanda taxonomy for ineffective airway clearance you will see that copd is listed by nanda as an acceptable related factor to use with that diagnosis.