deanikins211

hi everyone. my pt is diagnosed with tetorifice. he is now on a nasogastric tubing. still experiencing with muscle rigidity on the neck leg and abdominal area. He is febrile with temp of 38 degrees. the wound is reddened . pls correct me if im wrong. I'm trying to formulate an appropriate nursing diagnosis. Nursing dx: elevated by temperature related to release of bacterial toxins secondary to tetorifice infection as evidenced by flushed skin and temperature of 38 degrees Fatigue related to prolonged bedrest Impaired skin intergrity related to mechanical trauma(puncture) Disturbed sleep pattern related to recurrent occurence of muscle spasms(not sure with the term spasm im actually referring to the tetany) thanks evryone i need ur answer as soon as possible

hello nurses. This all about making ncps but my problem is i cant state the nursing diagnosis correctly. Correct me if im wrong An infant is having a diaper dermatitis. Problem:Impaired skin integrity Diagnosis: Impaired skin intergrityrelated to infectious lesions, possibly evidenced by disruption of skin surfaces candidiasis and diaper rash the same? because i got the nursing diagnosis from candidiasis case.

okay thanks. Im now starting making my ncps

thank you . Activity intolerance related to pain. What if i'll change it to limited body movement related to pain? and another question, does all nursing diagnosis requires "secondary to" evidenced by? thank you. Lets say secondary to acute pancreatitis is it the same with secondary to disease process?

Hello nurses. I have here some problems with their corresponding nursing diagnosis. I just want you to check it if whether it needs to be change or not or whether it is wrong or not. thank you ! This is DX and problem is for patient with acute pancreatitis. Problem: Severe Pain Dx: Acute pain and discomfort related to edema, distention of the pancreas and periotoneal irritation Problem: Discomfort DX: Discomfort related to nasogastric tube Problem: decreased oral intake DX: Imbalanced nutrition: less than body requirments related to inadequate dietary intake, impaired pancreatic secretions, increased nutritional needs secondary to acute illness and increased body temperature Problem: Difficulty breathing DX: Ineffective breathing pattern related to splinting from severe pain, pulmonary infiltrates, pelural effusion and atelectasis Problem: Vomiting Dx: Risk for deficient fluid volume related to excessive losses: Vomiting, gastric suctioning Problem: Limited Activity Intolerance DX: Activity intolerance related to pain Problem: Risk for altered tissue perfussion Dx: Risk for altered tissue perfusion related to enforced bed rest , poor nutritional status

1)thank you. but why is it that in NANDA books there is Imbalanced nutrition:risk for more than body requirments but there is no Imbalanced nutrition:risk for less than body requirments..sorry if i keep on asking questions. I just want to make things clear. I appreciate you help a lot.... 2) BAck to my patient, he may go home anytime, he still have ocassional cough ,not afebrile , not dyspneic in fact he looks healthier than me. My problem is that I still have to make 1 potential problem (i already done with the risk for fluid volume deficit) . Isnt it hard to find a potential problem for that kind of patient? HOw about RISK FOR IMPAIRED GAS exchange? his impression is pneumonia but it doest show a positive result.

REgarding "risk for" problems. these problems do not have related to. righ? Problem: Loss of appetite Diagnosis: Risk for imbalanced nutrition: less than body requirments is this correctly stated? or should i add something? or should i write Risk for imbalanced nutrition only?

ok thank you thank you. I dont know if you know this but mine is textbook of medical surgical nursing 11th edition by brunner and suddarth's. author is suzanne c smeltzer et al. I;ll try to find the book you told me about...

hmmmp i got no problem with the potential problem related t pneumonia . I was required to make 4 ncps 2 actual and 2 potential...what confused me most is the potential problem because my instructor keeps on discarding my potential problems. my first diagnosis is risk for infection: spread but our c.i told me to find another potential problem. Pt is not on IV, in good general condition, may go home anytime but still with occassional productive cough.

thanks a lot people.......

my instructor told me to revise my ncp. my pt's chief complaint is productive cough and his impression is pneumonia. I already made a potential problem and that is Loss of appetite and my diagnosis is risk for imbalanced nutrition; less than body requirments related to increased amount of mucus secretions. I know my nusing diagnosis is inappropriate but I really need your help guys on how to correct this diagnosis. This is my first time and I'm out of idea....thank you.

thanks daytonite. God Bless

thanks a lot daytonite. Patient is not diabetic but has high blood pressure...his blood pressure is 130/90..

MY identified problem is :Risk for Constipation and my Nursing diagnosis is:Risk for Constipation related to Insufficient physical activity and inadequate fluid intake Pls tell me if whether my problem or diagnosis is properly stated. Need your answer ASAP thank you God bless

tommorrow will be our first ward exposure. I just finished visiting my patient a while ago. Her diagnosis is Chronic Kidney disease T/C(dont know how to read) infected fistula and chief complaint is Fever and pain over the right side of the chest The question is , how should I assess him so that I can make a good Plan of Care and DAR? thank you