I need six nursing diagnosis

[cleo777]

I had a earlier post I needed help, my patient assigned to me, admitted with ALOC, decreased speech and decreased interaction and a temp of 100.2

past hx cva -2002, seizure disorder, CAD HTN depression arthiritis, dementia, CABG, Afib for the last 2 years.

non ambulatory...left side paralysis

bp on admin 113/88 HR 83 Temp 100 o2 sat 97

when I had him for the day...his bp 113/81 HR78 temp 35.3 o2 sat 97

when speaking with him he does respond to you but it takes him a few minutes to formulate what he needs to say, with my short stay with him of a whole four hours he did intake water, the amount i do not know...he told me he was thirsty..most of the labs are good except for BUN 38 creatinie 1.24...

he is on oxygen at 2 litres per min

this is what i have so far and it could be completely incorrect

Ineffective tissue perfusion r/t decreased arterial blood flow (BECAUSE OF PAST STROKe) m/b altered level of consciouness.

Decreased cardic output r/t altered contractility (because he has Afib for past 2 yrs) m/b ???? how am I seeing it in him

Impaired physical mobility r/t muscular skeletal impairment m/b left side paralysis

am I on the right track and how do the tops ones look and I need 3 more and this is all the info i have

pleeeeeeeeaaaaaaaaaasssssssssseeeeeeeeee help

[GipsGrl]

Hi, do you have to do your care plan based on the nine needs? Do you have any other lab results?

One that I can think of is Communication, Impaired: Verbal r/t- the progressive decline in cognitive function (which this is the def of dementia, but can't use the "word" dementia but can define it, because that is a medical diagnosis) AEB: slow response to verbal communication and commands. Hope this helps. Have a great day.

[cleo777]

I pretty much have all of them but i was looking for a goal, because i am using a self care deficit feeding....person cannot feed themselves, so I know need a goal

I was thinking which can be a bad thing!!!

Pt will receive one on one feeding for each meal? does this sound like a half decent goal?????????????

[Valerie Salva, BSN, RN]

Just curious- was a U/A done? Sounds like this pt could have a UTI.

[GipsGrl]

This is great...thank you for posting..I know it wasn't for me..but thank you..b blessed

[cleo777]

no uti, i think this gentlemen has alot of chronic illness, htn cad stroke you name it he has, it could of been the flu!!!!!!!!!! because when i seen him he seemed fine....however i am stumped on one of the nursing diagnosis

he has edema in lower extremties

decreased cardiac output r/t v

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m/b irregular heart rate and lower leg edema

he did not have a irregular hr when he came in he has atrial fibrillation

can i use the diagnosis?

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[cleo777]

can I use this if the person has lower leg edema, and a history atrial fibrillaton, he didn't have a irregular heart rate when admitted on...can i use this nursing diagnosis

decreased cardiac output r/t altered electrical conduction m/b irregular heart rate and LE edema

or am i completely off

[Daytonite, BSN, RN]

self care deficit, this person cannot do nothing, looking for a client goal for this????????????

still, you have to put into words and describe what it is that they cannot do. if they cannot hold a washcloth and wash themselves you must state that. in many ways, care planning is a writing exercise which is why we need to know how to speak and write english. that can be the hardest part sometimes.

go back to what i originally posted for you regarding assessment. what is it that this patient is not able to do. there are 4 self-care deficits. for example, with bathing. . .what specifically, could the patient not do? a goal is just the opposite and needs to be stated in a positive way. . .what would you like the patient to be able to do. examples of goals for bathing self-care deficit (i don't know what this patient's restrictions are): washes face, cleans perineal area or accepts need for physical assistance. please look at my post #15 on this thread where i posted the expanded steps of the nursing process. at step #3 under planning i address goals and tell you that the affect of your nursing interventions on goals is going to be (1) improving the problem or remedy/cure it, (2) stabilizing it, or (3) supporting its deterioration. if this patient cannot, or is not able to, help the nurses in bathing his/her body at all [that is an assessment stated in a negative way], then an appropriate goal which shows stabilization of the problem is for the patient to accept being bathed by the nursing staff [a goal stated in a positive way--and with the focus on the patient] and interventions will be for the nursing staff to perform the bathing. do you see how they are so closely related with each other? the problem has a negative focus; the outcome has a positive vision (its kind of like a frown turned upside down).

to review, because i stated the above goals very simply, goal statements have four components. this is the information from post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html on how to construct a goal statement:

1. a behavior
   
   • this is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
     
   • you must be able to observe the behavior
     

[*]it is measurable

• criteria that identifies exactly what you are measuring in terms of
  
  • how much
    
  • how long
    
  • how far
    
  • on what scale you are using
    

[*]sets the conditions under which the behavior should occur

• such conditions as
  
  • when
    
  • how frequently
    

  [*]take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)

  [*]take into account the patient's ability to meet the goals you are recommending

  [*]it is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal

[*]have a realistic time frame for completing the goal

• long-term goals usually take weeks or months
  
• short-term goals can take as little time as a day
  
• it all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.
  

[Daytonite, BSN, RN]

i was looking for a goal, because i am using a self care deficit feeding....person cannot feed themselves, so i know need a goal

i was thinking which can be a bad thing!!!

pt will receive one on one feeding for each meal? does this sound like a half decent goal?????????????

if he/she is not even able to hold utensils/cups and bring food to their mouth, then other appropriate goals are (you need to follow the goal construction guidelines above):

• opens mouth to accept food
  
• chews and swallows food once it has been placed in their mouth
  
• adapts to functional limitations by cooperating and accepting the need for physical assistance with nursing care staff
  
• seeks (or waits for) help to eat each meal
  

to start getting into how many meals the patient eats gets into the realm of the imbalanced nutrition diagnoses and the intake of nutrients. self-care deficits are about the performance of an activity. the difference is important.

in case you are wondering, i am using nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean maas as a reference for these goal ideas. they are not coming off the top of my head.

[Daytonite, BSN, RN]

can i use this if the person has lower leg edema, and a history atrial fibrillaton, he didn't have a irregular heart rate when admitted on...can i use this nursing diagnosis

decreased cardiac output r/t altered electrical conduction m/b irregular heart rate and le edema

or am i completely off

did you look up and read about his heart conditions? he has cad, htn, atrial fib and has had a cabg and a cva. you didn't mention the drugs he was on (did you? i don't remember). anyway, peripheral edema is not surprising. his heart is responding to the effects of all this disease and trauma. to some extent it is also because of his immobility. peripheral edema is a result of (to make this easy) altered contractility of the heart which then affects the fluid pressures in the veins/arteries/tissues of the leg. so, just add this to the related factor of the diagnosis:

• decreased cardiac output r/t altered electrical conduction and altered contractility m/b irregular heart rate and bilateral edema of lower extremities
  

[cleo777]

Let me see if I understand what you are telling me, I have my book med surg sitting in front of me, and I really want to understand this. Blood returns from the veins, into R atrium, fills, then fills R ventricle, low oxygen, going into the lungs for oxgen, we also have oxgenated blood from the pulmonary system entering L artium, then fills L ventricle, pumping out into the body...........so far so good, I think and I have that part down..........if we have increased venous return back to the heart, the ventricles then fill up with more blood then needed causing a higher pressure, increasing the cardiac output. If we have less venous blood returning back to the heart, it is pooling in our lower extemeties, causing peripheral edema. It this some what right???????? Or have I missed the whole point.

Also I have another question, because I have been doing research on this all, it may not sound like it but this stuff is hard, to revisit once its gone. Because this patient is on 2L/min of oxygen does this mean due to his immobilty he could also have Ineffective tissue Perfusion r/t ??????????? I was given a nursing diagnosis book, it is older, but under ineffective tissue perfusion, it has defining characters under peripheral is has edema...then possible related factors, I have looked and searched them all, and nothing seems to fit, because edema basically excess fluid in body tissues, what is the related factor? the blood is not returning back to the venous system? or is there a impaired volume exchange between intercellular spaces of tissues..........Am I making this all to complicated, what am I missing?

You help is greatly appreciated

[cleo777]

I wanted to clarify, that the edema is a non pitting edema, I don't know if that makes a difference or not, on whether I need to address the problem as a diagnosis in my care plan.

[Daytonite, BSN, RN]

His CAD is due to atherosclerosis and is causing his heart to have to work harder to pump his blood which is why he had hypetension. This atherosclerosis is occurring throughout his body. Since the legs are farthest from the heart, by the time the blood reaches his legs the blood has lost some of its pressure and the vessels are smaller. Capillary venous pressures are less as well so fluid is allowed to remain in the tissues. Thus, he has edema.