Help please with nursing diagnosis

  1. I need atleast 5 nursing diagnoses for a pt who has had a R. brain stroke (MCA), L weakenss (CVA). Hx of CAD, HTN, hyperlipidemia, hx of 2 CVAs, cardiomyopathy, lg. ventricular thromobis, heart cath., CHF, RF, and facial drooping. I had too many self care deficits. This pt could do pretty much everything for himself except wash parts of his body (underarms), but I already have a ND for that. HELP, please!!
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    About RNursingStudent

    Joined: Jun '06; Posts: 45
    full time student

    7 Comments

  3. by   RNursingStudent
    I also already have impaired phy mobility and impaired verbal communication.
  4. by   partyof5
    You can use disturbed body image (facial droop)
    also maybe impaired memory because that is an effect of right side stroke
  5. by   RN28MD
    Hi I wish you tell me more of your pt?
  6. by   RN BSN 2009
    Impaired swallowing? Any dysphagia R/T the CVA? Excess fluid volume, or risk for... R/T CHF? Decreased cardiac output R/T CHF? Risk for falls R/T CVA with weakness, Activity intolerance?
  7. by   RN28MD
    There are many out there. Is your pt constipated, incontinent, walking, talking, swallowing. you say he is doing everything does this include these??

    Well, I thought I give you some:

    1. Disturbed Body imaginge r/t chronic illness, patial paralysis ?? maybe
    2. Grieving r/t loss of health (how is he feeling about this again?)
    3. Impaired Social Interaction r/t limited physical mobility, limited ability to communicate ( again is he walking ??)
    4. Impaired swallowing r/t neuromuscular dysfunction (is he swallowing well??)
    5. Impaired communication r/t pressure damage, decreased circulation to brain in speech center informational sources
    6. Risk of aspiration r/t impaired swallowing, loss of gag refles (swallowing ??)
    There are many more but need to know your pt more. Is he moving, walking, being care by home nurse, how is his memory ect
    Good luck I hope this helps
  8. by   RNursingStudent
    Thank you all so much, these were very helpful. End of semester and my brain is fried!
  9. by   Daytonite
    you listed only 2 of your patient's symptoms in your post which were a left sided weakness and facial drooping. the two nursing diagnoses that you have already chosen cover those two symptoms. i looked at your patient's list of medical diagnoses and by my estimation he should be shopping for a cemetary plot. this man is not in any kind of great shape at all. is that rf renal failure or respiratory failure? i wish you guys wouldn't use abbreviations that could mean more than one thing. where's all of the abnormal assessment information you got from your physical assessment and data collection of this patient? that's what drives the nursing diagnoses that you will use. we are nurses, not doctors. we primarily treat adls and help people function within their environments. sometimes all you're going to have is self-care deficits. strokes and debilitating chronic conditions do that to people.

    to begin with his heart sounds like it could be on it's last legs. he's got atherosclerosis (the cad). cad is a chronic condition that gets progressive worse--it never goes away and that is why they did the heart cath on him. they were looking to see if any of his coronary arteries have gotten significantly occluded. that makes me wonder if he had any chest pain at some point because that is usually what triggers the performance of a heart cath. he also has chf, hyperlipidemia, thrombosis and htn. having a stroke is like icing on the cake. was the stroke due to a thrombus or a hemorrhage. my guess is a thrombus based on his history of cad and hyperlipidemia. if they are giving him anticoagulants for this he is at a risk for injury. and, the finding of cardiomyopathy isn't good either. his heart is about ready to peter out. yet you have nothing that really addresses this. it has to be contributing to his activity intolerance.

    here is a list of possible nursing diagnoses that may be applicable to this patient. you still have to determine if any of these nursing diagnoses fit by reviewing and analyzing the assessment data that you collected. my signature now includes a link to a critical thinking flow sheet that you can print out to help you in developing your nursing diagnoses related to a specific medical disease. you can also review the posts on the
    "desperately need help with careplans" thread which is a sticky on this forum for information on developing and choosing nursing diagnoses.

    • activity intolerance (due to the cardiomyopathy, chf, cad)
    • acute pain (if he gets chest pain--due to the cad)
    • decreased cardiac output (due to the cardiomyopathy, chf, cad, renal failure)
    • disturbed thought processes (due to the strokes)
    • excess fluid volume (due to the cardiomyopathy, chf)
    • fatigue (due to the chf, htn, renal failure)
    • impaired gas exchange (due to the cardiomyopathy, chf, cad, stroke)
    • impaired memory (due to the stroke)
    • imbalanced nutrition: less than body requirements (due to renal failure)
    • ineffective breathing pattern (due to the cardiomyopathy, chf)
    • ineffective tissue perfusion: cardiopulmonary (due to the cardiomyopathy, chf, cad, htn)
    • ineffective tissue perfusion: cerebral (due to stroke)
    • ineffective tissue perfusion: renal (due to renal failure)
    • ineffective airway clearance (due to the chf, stroke)
    • impaired urinary elimination (due to renal failure)
    • risk for imbalanced fluid volume (due to renal failure)
    • risk for disuse syndrome (due to stroke)
    • risk for impaired skin integrity (due to stroke)
    • risk for injury (as a result of the effects of the stroke)
    • risk for infection (due to renal failure)

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