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  1. Step 1 Assessment dark yellow, odorous urine pale dry skin poor skin turgor dry mucous membranes refusing liquids minimal appetite 140/98, hr=106 weight 102-usually 115 thin extremities minimal right leg movement unequal palmar grips-right weaker red 2 cm spot on right elbow oriented x2 occasionally confused and disoriented in the past few months incontinent of bowel and urine in the past few weeks confined to bed Step #2 Determination of the Patient's Problem(s)/Nursing Diagnosis Deficient fluid volume r/t loss of fluid AEB dark yellow, odorous urine, pale dry skin, poor skin turgor and dry mucous membranes Imbalanced nutrition: less than body requirements r/t inability to ingest food AEB weight of 102, thin extremities, minimal appetite (whatever that is, you need to be more specific about this) Total incontinence r/t dementia AEB unaware of incontinence of bowel and bladder Impaired physical mobility r/t ??? (need a cause here, probably her dementia) AEB minimal right leg movement, confinement to bed and unequal hand grips Impaired skin integrity r/t pressure and incontinence AEB stage ii ulcer on sacrum that is 2cm in diameter 1cm in depth and tender to touch and 2 cm red spot on the right elbow Acute confusion r/t ??? (probably dementia) AEB disorientation to ??? and confusion to ??? over the past few months step #3 Planning (write measurable goals/outcomes and nursing interventions) Remember that your goals are a reflection and anticipation of what will happen when your nursing interventions are performed. So, think about what nursing interventions you will be doing when putting your goals together. Your nursing interventions target each of the AEB items of your diagnostic statements. Just as a doctor treats signs and symptoms of a disease, we also treat the symptoms of a nursing problem. Nutritional imbalance of less than the body requires related to the refusal of fluids and minimal appetite as reported by the daughter, manifested by dark orderous urine, dry skin, and poor skin turgor This is not an official Nanda diagnosis the way you have written it. i know what you mean, however. This diagnosis has to do with intake of nutrients insufficient to meet metabolic needs (page 74, Nanda international nursing diagnoses: definitions and classifications 2009-2011). dark ordorous urine, dry skin and poor skin turgor do not have anything to do with the intake of nutrients and are inappropriate symptoms to pair with this diagnosis. You also need to be more specific about a minimal appetite. we are scientific. report a percentage of what she is eating. Management of ineffective family care related to the care of skin integrity manifested by stage II pressure ulcer called a blister by caretaker daughter I have no idea what this diagnosis is. it is not Nanda. The related factor has nothing to do with the management of care. The symptoms also have nothing to do with the management of care.
  2. Daytonite

    Nursing DX for postpartum couplet

    for the mother: effective breastfeeding for the baby: effective breastfeeding ineffective thermoregulation r/t immature compensation for changes in environmental temperature risk for infection r/t break in skin integrity at umbilical cord site
  3. Daytonite

    Need for a psychological dx

    Problems with eyesight are Disturbed Sensory Perception, visual.
  4. Daytonite

    chemo care plan assistance

    ineffective protection r/t bone marrow suppression secondary to disease process and chemotherapy, decreased synthesis of immunoglobulin by plasma cells secondary to decrease in normal circulating antibodies, and immunosuppression secondary to chemotherapy side effects aeb decreased hgb, decreased hct, decreased platelet count, and recent removal from neutropenic isolation. too much information in the etiology. bone marrow suppression secondary to disease process and chemotherapy is good enough. recent removal from neutropenic isolation is not a symptom of a decrease in the ability to guard self from internal or external threats such as illness or injury (the definition of ineffective protection page 219, nanda international nursing diagnoses: definitions and classifications 2009-2011), but a treatment.
  5. Daytonite

    Care planning help

    They already told you in the admitting information. It is sepsis. You can tell from the vital signs.
  6. Daytonite

    chemo care plan assistance

    i get chemotherapy and one of my drugs causes the same problem with my feet as well as my hands. i do have to use a walker on the days that my feet as swollen and sore. your diagnosis impaired tissue integrity r/t chemical insult (?) secondary to chemotherapy side effects or r/t cell lysis secondary to chemotherapy aeb feets bilaterally hot and tender to touch, nonpitting edema tender to touch, protectiveness toward site, thrombocytopenia, and reported local and intermittent pain upon palpation of reddened areas is actually ok although i would clean up the wording a little bit: impaired tissue integrity r/t chemotherapy aeb bilateral feet hot and tender to touch as well as edematous, skin reddened, shiny and taunt over feet and joints, intermittent pain upon palpation of areas of feet and patient protectiveness of the feet. i would not use thrombocytopenia as a symptom of impaired tissue integrity. nutritional deficiency r/t malabsorption and decreased intake secondary to treatment side effects aeb reported loss of the sense of smell and reported loss of the sense of taste. i have runs where i don't feel like eating and then other days where i can eat like a horse. however, nutritional deficiency is not a nanda diagnosis. i would re-write this as imbalanced nutrition: less than body requirements r/t decreased intake secondary to chemotherapy aeb patient report of loss of sense of small and taste. impaired urinary elimination r/t kidney damage secondary to multiple myeloma and chemotherapy aeb reported daily use of diuretics and pt reporting need to rush to bathroom to avoid incontinent episodes. use of daily diuretics is a medical treatment and not a symptom of the nursing problem so you shouldn't be using it as an aeb item. the patient's frequency (rushing to the bathroom) is the symptom of the impaired urinary elimination. i would re-write this as impaired urinary elimination r/t kidney damage secondary to multiple myeloma and chemotherapy aeb patient reports of needing to rush to bathroom to avoid incontinence. social isolation r/t avoidance of crowds secondary to chemotherapy-induced immunosuppression aeb reported avoidance of crowds and h/o neutropenic isolation. well, you have this nursing diagnostic statement all messed up. first of all, avoidance of crowds is not a cause for social isolation. the definition of this diagnosis is aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state (page356, nanda international nursing diagnoses: definitions and classifications 2009-2011). your related factor (r/t), or cause, of the social isolation must explain to the reader why they prefer to experience aloneness and avoidance of crowds secondary to chemotherapy-induced immunosuppression doesn't do that. your one symptom of the isolation, the reported avoidance of crowds, is ok, but a h/o neutropenic isolation makes no sense. that sounds more like something someone would be fearful of. his illness alone and the way he might perceive what he looks like is enough aeb evidence for a social isolation diagnosis. you might try wording the diagnosis this way: social isolation r/t altered state of health aeb refusal to join in any group activities or go out into the public. - - - - - - - - - - - - - - - the construction of the 3-part diagnostic statement follows this format: p (problem) - e (etiology) - s (symptoms) problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information. etiology - also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
  7. Daytonite

    Care Plan Help

    Good diagnoses, but before making any goals, consider what nursing interventions you will order. The reason I recommend this is because your goals are what you expect to happen as a result of the nursing interventions being performed.
  8. Impaired Verbal Communication.
  9. A "risk for" diagnosis almost never is sequenced first because it is not an actual problem. actual problems are always sequenced before potential problems. second, poor tissue perfusion is not an official nanda diagnosis and i have no idea what you mean by it. poor tissue perfusion of what tissues? the diagnosis of decreased cardiac output covers the poor tissue perfusion of the heart. the edema is evidence of that. third, if the patient is actively bleeding and hypovolemic then there is no risk for fluid volume deficit. there is already deficient fluid volume [decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium. (page 84, nanda international nursing diagnoses: definitions and classifications 2009-2011)] if the symptoms are there. the evidence (assessment information) you have of the deficient fluid volume is the tachycardia, decreased urine output and hypotension. someone who has active gi bleeding would be pale and weak. when they try to get up they become diaphoretic and tachycardic and sometimes need help to get back to bed. they have low hemoglobin and hematocrit levels. if this patient had those symptoms then deficient fluid volume would be the diagnosis to use. this would be sequenced after decreased cardiac output. please look at this thread for information on the construction of a care plan using the nursing process and how to determine diagnoses: https://allnurses.com/general-nursing-student/help-care-plans-286986.html- help with care plans
  10. Daytonite

    effective breastfeeding care plan

    Do not mix interventions or goals for the mom with the neonate if the care plan is for the neonate.
  11. Daytonite

    Need chest tube basics

    Because continuous bubbling means there is a leak in the system and therefore the chest tube is not able to do its job. Yes, it is supposed to bubble, but only on expiration when the lung is releasing air from the pleural space.
  12. Daytonite

    effective breastfeeding care plan

    Your goals reflect what your interventions would be, so what are your interventions?
  13. Daytonite

    Confused about this??

    The problem is that the care plan is about the mother. You can't mix up mother and baby problems on one care plan.
  14. Daytonite

    Need some advice on this

    you posted this on the nursing student discussion forum and i just got finished replying to it. you need to go over there to read the answer. https://allnurses.com/general-nursing-student/confused-about-this-457358.html - confused about this??
  15. Daytonite

    Nursing Diagnosis Question

    no. you would know that from knowing the course of the disease. you would know that it created the nerve damage and that is why the patient is having pain. the definition of chronic pain is unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of more than 6 months. (page 355, nanda international nursing diagnoses: definitions and classifications 2009-2011). so placing the kind of damage as the related factor on the nursing diagnostic statement is perfectly acceptable.