nursing diagnosis - need help!

hello! i'm 3rd year nursing student. i've got an assignment and its about analysing patient's data to come up with nursing diagnosis to deliver appropriate care for the patient. there is a given scenario. i used the gordon's functional health patterns to classify the data, but then i'm not sure whether im doing it right or not. :confused:and also, it is still hard for me to look at the patient's situation in a holistic way.. such as physically, emotionally, financially etc..

can you please help me out to put things on the right track?

here is the case scenario that is given:

susan ryan, 34 year, works part time as a personal assistant. last year, during her pregnancy, she was diagnosed with a meningioma. the tumour was removed and a c-section performed 5 months ago. since then she has been hospitalised on a number of occasions for revision of a cerebral shunt. she is being admitted to hospital this time for revision of the shunt and for a possible gastric ulcer. she has been experiencing increased nauea and vomiting over the last few weeks.

due to her illness, she has been medically retired from the army. her husband's (real estate agent) income and her military disability pension are the family's source of income. susan appears to have a strong spirituality and believes in prayer as being a great support. she appears slightly introverted and quiet. susan verbalises: "fear and guilt" over her illness, the delivery of her baby prematurely at 8 months and the fact that she cannot independently look after her child. the thought of coming into hospital again "makes me sick".

susan understnads she is coming into hospital for a shunt revision. she believes this revision will alleviate the nausea and vomiting.

lab results (si units)

haemaglobin: 11g/dl

haematorit: 0.35

na: 150 mmol/l

k: 3.2 mmol/l

cl 90 mmol/l

glucose: 6 mmol/l

cholesterol: 4.6mmol/l

triglycerides: 1.0

total protein: 88g/l

albumin 53g/l

further assessments are done and here are the information given (ill just write only that i think considerable)

reason for visit: nausea and vomiting, spasticity and weakness of right side

allergy: erythromyacin

childhood illnesses: measles, mumps and chicken pox

family history: mother uterine cancer; both prents have gastric ulcers; two maternal aunts breast cancer

nutritional: not feeling hungry due to increased nausea and vomiting for last 3 weeks following

integumentary: dry sknin and says bruises easily

gastrointestinal: increased episodes of nausea and vomiting; experiencing pain 1-2 hours after meals, burning gaseous pressure

urinary: voids several times per dya, smaller amounts than usual; dark yellow in colour; strong odour

musculoskeletal: feeling clumsy and body is always weak; uses a four-point cane when walking

neurologic: states difficulty in finding words sometimes

affect/ mood: quiet, slightly introverted

mobility/gait: ataxic

obvious deformities: jerking right arm

symmetry of body: right sided hyperreflexia

dry tongue

some altered balance on standing; ataxia; uses 4-point cane to ambulate

so, all the relevant information should be clustered and make nursing diagnoses about that.

and i have to write validations about that and give references as well.

for example: cluster of cues: -hx of falls; dizziness; older age; medicaton; disorientated and confused

nursing diagnoses would be: risk of falls

validation: older age groups are ar high risk of fall injury (nsw department of health, 2005)

this is supported by.....

please help me out with this

it would be very much appreciated!!

many many thanks!:redpinkhe

[cmonkey]

I don't think 34 qualifies as older age wrt falls, frankly. Her HPI does, though. I'd consider that the tumor (recurrence?) might affect her balance. If she uses a cane, impaired physical activity might fit, wouldn't it? Powerlessness, maybe? Imbalanced nutrition. Self-care deficit, if she has problems with ADLs. Spiritual distress.

There's a plan constructor here

Can you tell we just went over doing care plans in my class? lol

[CRIMSON]

Okay, here are a few ideas to get you started:

Possible DI? Voiding often and Hypernatremia, multiple cerebral shunt revisions

Any other info indicating possible stroke/clot? Low PT/INR or PTT?, one sided weakness and spacisticy, expressive aphasia, hypokalemia (MI also can present as burning pain, N&V, weakness)

Gastric Ulcer? Pain after meals, N&V, burning pain

Coping issues? Stress, guilt, ulcers, verbalizations of inadequacy

Possible NSG Diagnoses:

1.Deficient Fluid Volume r/t increased output and decreased intake aeb voiding ____mls daily, hypernatremia and inability to eat/drink

2.Imbalanced Nutrition r/t inability to eat/drink aeb N&V

3.Ineffective Coping r/t chronic illness aeb verbalizations of stress, guilt and inadequacy

4.Impaired mobility r/t chronic illness and fatigue aeb walking with cane, spacisity, dizziness

5.Risk for falls r/t R sided weakness, hypernatremia, impaired mobility aeb walking with cane, dizziness

6.Risk for injury r/t impaired mobility aeb spacisticy, weakness

These are just a few. Cluster your symptoms by system and start with the most severe and usually “risk for diagnoses” are after “actual problems”

[wjddnjs]

thank you very much for your replies!

it was a much help to start with! thanx alot:p

but ive got afew more questions

i still don't know why the patient bruise so easily? what's the reason behind that?

also, she states that menses have not returned since the baby was born.. what does it indicate?

also, as cmonkey stated, i suspect recurrence of meningioma..

but then that is a medical diagnoses isn't it?

is there a nursing diagnoses for that??

thanks again for all your help!

I really appreciate it

[cmonkey]

If she's nursing, then her menses may be suppressed by the hormones. I went 19 months with one kid

Bruising? I'd suspect mets to the liver, but I've got a twitchy dx gland.

I think her hct and hgb are a teensy bit low, but I don't think that would cause bruising. Have you looked at the normal values to see if they point to anything?

I suspect you need to get some fluids into her, though.