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

[cleo777]

I have no idea why the extra numbers or letters came up on my post No 47 but I will put it in again

I am looking for a Integrity vs Despair, without having very little conversation on speaking with the patient or spending anytime with the patient...apprx 6 hr

depression r/t chronic illness m/b immobilty and inability to do ADL's

I know that is a stretch, and does it even work??????

[Daytonite, BSN, RN]

depression r/t chronic illness m/b immobilty and inability to do adl's

• depression is a medical diagnosis so you can't use this
  
• immobilty and inability to do adl's even as a medical diagnosis are not symptoms of depression. "physical symptoms include changes in weight or appetite, loss of energy, fatigue, psychomotor retardation or agitation, and sleep disorders (insomnia, hypersomnia, early morning awakening). patients may appear miserable, with tearful eyes, furrowed brows, down-turned corners of the mouth, slumped posture, poor eye contact, lack of facial expression, little body movement, and speech changes (eg, soft voice, lack of prosody, use of monosyllabic words)." (http://www.merck.com/mmpe/sec15/ch200/ch200b.html#sec15-ch200-ch200b-460)
  
• i addressed integrity vs despair back on post #12. if you are saying that this man is in despair, look up the word despair. it means hopeless, sad, despondent. there is a nursing diagnosis for this: hopelessness r/t deteriorating physical condition aeb . . .
  
• here is a website with information about this diagnosis: hopelessness
  

[cleo777]

Okay I am looking up info this diagnosis under

fluid volume excess

Compromised regulatory mechanism exactly what is exactly mean by "regulatory system"

thanks

[Daytonite, BSN, RN]

It's generic language for any body process that will affect fluid retention. We have to supply the process involved to explain the symptoms.

One compromised regulatory mechanism I have written into my NANDA diagnosis book for this diagnosis is "arterial hydrostatic pressure exerting greater control than venous oncotic pressure over water movement into interstitial tissues" [AEB peripheral edema].

Another is renal dysfunction.

[cleo777]

I spoke with one of my teacher's about careplan with this patient from orginal post from a very long time ago.........

patient has LLE and you sent be a diagnosis.. on cardiac output, teacher says it should be addressed with fluid volume excess r/t cardiac disease m/b LLedema -nonpitting

I don' think I can use cardiac disease it is a medical diagnosis???????

[cleo777]

since you have done telemetry what does "patient bottomed out mean"

[Daytonite, BSN, RN]

I spoke with one of my teacher's about careplan with this patient from orginal post from a very long time ago.........

patient has LLE and you sent be a diagnosis.. on cardiac output, teacher says it should be addressed with fluid volume excess r/t cardiac disease m/b LLedema -nonpitting

I don' think I can use cardiac disease it is a medical diagnosis???????

Do what your instructor tells you.

since you have done telemetry what does "patient bottomed out mean" ?

Don't know. Never used that terminology.

[leqwedz]

I'm going to start doing my care plans in class in two months.i can't say enough thanks to the members of this nursing thingy..lol.i have come to learn a lot mote than i thought i could learn from one place.now i know where to clip my problematic cares plans to...thank you old nurses naturing us in new students and nurses...thank you again gays.this's really really helpfull to me.

[lauraburke]

Consider also Risk for falls, risk for fall related injury, risk for delirium, risk for pressure ulcers (depending on his activity and mobility issues), activity intolerance (cardiovascular/respiratory intolerance to activity), risk for venous thromboembolism.