Hi! This is my first time posting!
I was given the assignment to put the following nursing diagnosis based on a mock patient they gave us:
Activity Intolerance AEB pt lying very still and rigid position, grimaces anytime someone moves her, And when asked to turn to her side, she states that she is too weak.
Acute confusion AEB slurred speech and gives inappropriate answers to staff and family members related to person/place/time
Deficient Fluid Volume AEB serum osmolality elevated, urine is concentrated and output has been 20 ml/hr for 4 hours, temp 103.4 rectally, pulse 124 and weak, BP 86/38, dry skin, decreased skin turgor, dry and sticky mucous membranes.
Hyperthermia AEB temp of 103.4 rectally
Nausea AEB states she is sick to her stomach, sometimes gags but only brings up small amounts of clear fluid.
Acute pain AEB pt rates her pain as 9- in left leg and entire abd region.
Ineffective protection AEB pt will not cough or deep breathe nor turn or do post-op leg exercises.
Disturbed sleep pattern AEB states she is drowsy, naps about 20 mins at a time, states she can't stay asleep, is restless and irritable.
We only have to list the top 3 priorities. The order I put them in was 1. Deficient fluid volume, 2. Hyperthermia, 3. Acute pain
I have to list the rationale for why these are the most important and I'm coming up blank! Mostly because I'm unsure these are highest priorities!
Thanks in advance for your help