I need six nursing diagnosis

  1. 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
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    About cleo777

    Joined: Apr '09; Posts: 51; Likes: 4

    56 Comments

  3. by   travduck
    Try the following link: http://www.efn.org/~nurses/nanda.html
  4. by   cleo777
    I know about that webpage I guess I really don't understand what my plan of action should be to help him
    all his vitals were fine when I seen him...so now what............
  5. by   Daytonite
    I am working on your post and care plan. However, what is ALOC? It is not listed in my book of abbreviations.
  6. by   cleo777
    Thank you so much I am almost in tears that you are helping me........Altered level of consciouness
  7. by   travduck
    Start at his head and work down just like a P.E. and I bet you will note more than enough diagnosis. Body temperature risk? Injury risk? Communication deficits?: Coping? pt and family. Neurosensory deficits? Hygiene? Elimination? Activity? Pain -arthritis or other? etc.
  8. by   Daytonite
    to care plan, follow the steps of the nursing process. . .

    step 1 assessment - assessment consists of:
    • a health history (review of systems) - admitted with aloc, decreased speech and decreased interaction and a temp of 100.2 (this is common in dementia patients who cannot tell us they are ill) these are signs of illness. probably an infection of some sort.
    • performing a physical exam - low grade temp of 95.5- this patient was admitted with aloc, but there is no neuro assessment. because of the patient's heart and atrial fib, the heart should be assessed. no heart or lung sounds were assessed. atrial fibrillation is a rapid, irregular heart rate which can be easily assessed by taking a pulse. ??? it is also the main reason why people have cvas (strokes) that result in one sided paralysis which this patient has. there is a lot of heart related disease going on. is he symptomatic? any sob, cough, edema, skin color changes? speech problems are a safety issue.
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - being non-ambulatory results in a lot of self-care deficits. how does this patient accomplish urination and defecating? are there skin care issues? how does he bathe, brush his teeth and change his clothes? how does he eat? if he has a need, how does he make it known to others?
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - cva, seizure disorder, cad, cabg, htn, arthritis, dementia, atrial fib, this patient also has cad with is a chronic and progressive heart disease. the cabg was done for the cad. his htn is also a complication of the cad. what medications is the patient on for the cad and the htn? his htn seems to be under control. every one of these diseases should be looked up and its pathophysiology and signs and symptoms found. compare them against what you saw in the patient. a good website to do this on is the online merck manual: http://www.merck.com/mrkshared/mmanual/sections.jsp
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - he is on oxygen at 2l/minute. why? did he have a breathing problem? it may be because of his cad--does he get chest pain because of his cad?
    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is the data you listed
    • non ambulatory
    • left side paralysis
    • temp was 35.3 (95.5)
    • responsive, but it took him a few minutes to formulate what he needed to say
    • bun 38 (normal is 10-20)
    • creatinine 1.24 (normal is 0.6 to 1.2)
    step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -
    • decreased cardiac output r/t altered electrical conduction aeb irregular heart rate
    • impaired physical mobility r/t neuromuscular impairment secondary to cva aeb left side paralysis
    • self-care deficits
    • impaired verbal communication r/t decreased circulation to speech center of the brain secondary to dementia and cva aeb difficulty and slowness in expressing thoughts verbally
    • risk for deficient fluid volume r/t physical impairment affecting access to fluid intake
    • risk for impaired skin integrity r/t physical immobility
    step #3 planning (write measurable goals/outcomes and nursing interventions)

    --------------------------------------

    ineffective tissue perfusion r/t decreased arterial blood flow (because of past stroke) m/b altered level of consciouness.
    ineffective tissue perfusion should not be used unless the cva is new and happening right now.
    decreased cardic output r/t altered contractility (because he has afib for past 2 yrs) m/b ???? how am i seeing it in him
    atrial fibrillation is a problem caused by an error in the electrical conduction, not the contractility of the heart. it is manifested by a rapid, irregular heart rate. read about the signs and symptoms of atrial fibrillation.
    impaired physical mobility r/t muscular skeletal impairment m/b left side paralysis
    the related factor (cause) of the impaired physical mobility is neuromuscular impairment caused by the cva.
  9. by   cleo777
    Thank you very much and I really appreciate this, just when I think I have a handle of nursing diagnosis, I don't. Do you know of any good nursing diagnosis books?
    So what you are saying is pull out all you find in a abnormal assessment, or labs, and match this assessment possible problems that the pt may have or may develop due to these abnormal findings? Okay another question...can you explain to me, in a simplier form then my book...exactly the importance of BUN and creatinine, this is my understanding, when it is increased the body is holding on to urine? Is this correct?
    the
    Last edit by cleo777 on Apr 16, '09
  10. by   cleo777
    Thank you very much and I really appreciate this, just when I think I have a handle of nursing diagnosis, I don't. Do you know of any good nursing diagnosis books?
    So what you are saying is pull out all you find in a abnormal assessment, or labs, and match this assessment possible problems that the pt may have or may develop due to these abnormal findings? Okay another question...can you explain to me, in a simplier form then my book...exactly the importance of BUN and creatinine, this is my understanding, when it is increased the body is holding on to urine? Is this correct?
    I am sitting here amazed, that you could actually come up with what you did!!!!
    I see you have nursed for a very long time, will my thinking be anything like you
    with experience?
  11. by   Daytonite
    just when i think i have a handle of nursing diagnosis, i don't. do you know of any good nursing diagnosis books?
    were you a championship driver after a few weeks of driving? it takes time to learn to do this. it took me 6 months to learn to start an iv. it took me years to become a master at it. you can't expect to be perfect at this. the whole idea is to not only learn about nursing diagnoses, but to also learn about assessing patients and how to solve problems.
    so what you are saying is pull out all you find in a abnormal assessment, or labs, and match this assessment possible problems that the pt may have or may develop due to these abnormal findings?
    that's what i'm saying. that's what a care plan is all about.
    okay another question...can you explain to me, in a simplier form then my book...exactly the importance of bun and creatinine, this is my understanding, when it is increased the body is holding on to urine? is this correct?
    yes, i was looking at those results. the creatinine really wasn't elevated. it was at the borderline. the bun was elevated. when there is renal disease they will both be elevated significantly. however, my first thought was that this man is probably mildly dehydrated. the bun will fluctuate very rapidly hour to hour. the creatinine, however, takes days and days to change. with a normal creatinine level, his kidneys are ok. urea, which is the bun measurement, is an end product of protein metabolism and is formed in the liver. so, look at other labs of liver function to make sure this man does not have a liver problem. in elderly people it is not unusual to have slightly elevated buns.

    i never heard of "the body holding onto urine". what is that in medical terminology?

    if you do not have a lab reference use these online websites:
  12. by   cleo777
    Another question I know there is a concern of his immobilty and DVT's does this need to be addressed? I have to use Erickson's developmental stages..in one of my nursing diagnosis....age related....Integrity vs Despair
    Powerlessness r/t left side paralysis m/b patient's inability to perform ADL's
    is powerlessness suitable ?
  13. by   cleo777
    I really meant to say the kidney's holding on to water, not the body...thank you for the web pages....the thing with nursing school is they have you going night and day and you don't even have time to absorb what you are learning!!!
    Is this what it is like at all schools, non stop, with no sleep?
  14. by   Daytonite
    another question i know there is a concern of his immobilty and dvt's does this need to be addressed?
    after reading up on all his diseases and conditions and what you know after taking care of him, what do you think? a dvt is usually a problem when there is poor circulation in the lower extremities or a history of having had them before.
    i have to use erickson's developmental stages..in one of my nursing diagnosis....age related....integrity vs despair,
    did you look at this stage and what it means? see http://www.haverford.edu/psych/ddavi...on.stages.html. ego integrity is the ego's accumulated assurance of its capacity for order and meaning. despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends.
    powerlessness r/t left side paralysis m/b patient's inability to perform adl's. is powerlessness suitable?
    while this diagnostic statement works with someone who is depressed, it lacks depth. powerlessness is a psychosocial diagnosis. its definition is perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening (page 190, nanda international nursing diagnoses: definitions and classifications 2009-2011). while a long term physical condition may be the cause of this, the inability to perform adls is not a specific descriptor of an outcome. i would describe the most important activities that have been lost. what about the patient's roles in life? his job? what about his control over decisions of his care? answers to this would reflect a more in depth conversation with the patient, his relatives or care givers who know him.

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