Daytonite

I receive 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. I would clean up the wording a little bit as follows:
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. This could be improved. 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. 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:
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.

I am surprised that there were two IV sites, but the nurse chose the hand to run the vanco.

If I have a choice, I always run in a larger vein. On our ped floor, we have to check IV sites every hour, and IV fluid amounts every two hours.

It's frustrating to wake a sleeping kid if you can't visualize his IV site in the dark, but you've seen a great example of why you need to do it anyway, regardless of what the kid or parent says.
We frequently placed second IV lines when vanco was being infused because vanco was being run over an hour and a half. The second line was needed so other IV medications and fluids could be given.
Impaired Tissue Integrity
Definition: damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
Related factors (causes): fluid excesses, chemical irritants including medications
Vancomycin is one of the most irritating antibiotics that can be given into a peripheral vein. When I was an IV therapist we encouraged docs to give this IV antibiotic through some type of central IV line when possible because of the phlebitis it caused to peripheral veins. If it infiltrated in this patient, then there would be tissue damage and the diagnosis of impaired tissue integrity would be appropriate.
I have seen severe infiltrations where entire hands and forearms were swollen with IV fluid because the nurses were not performing regular checks of the patient. Infiltrations can be slow leaks of fluid going into the tissues while the majority of the IV fluid is still infusing into the vein so that it can take some time for the swelling to manifest itself. I saw it happen a lot.
This is why the IV site needs to be compared to the opposite limb as well as touched and assessed for tenderness.

EHBSO WITH PFC ID BLND - Endoscopic Hysterectectomy and Bilateral Salpingoophorectomy with Planned Functional Class Identification and Bilateral Lymph Node Dissection
PHACO - Phacoemulsification
LA WITH MAC - Local Anesthesia with Monitored Anesthesia Care

Diagnosing is based upon the symptoms the patient has that will support a diagnosis. (A diagnosis is a label for a problem and the symptoms are evidence of the problem.) Expressive aphasia, only responding to loud auditory stimuli and the inability of client to express himself are evidence of a communication problem which is generally considered a safety issue although nanda places communication in a psychosocial category. That does not mean your instructors agree with that.
In order to diagnose a psychosocial problem you need evidence of what might be considered abnormal behavior. Look at the defining characteristics for powerlessness. It has to do with self-perception and a physical inability to speak is not exactly the kind of symptom that defines what powerlessness means. Since this diagnosis is about a psychological problem your symptoms need to be of a psychological nature. The assessment data you collected in a head to toes assessment isn't going to work here. How does he behave as a result of being unable to express himself?
A long time ago, I listed the Nanda breakdown of the psychosocial diagnoses from the taxonomy and posted them at Desperately Need Help With Care Plans.
Class: Behavior
ineffective health maintenance health-seeking behaviors noncompliance effective therapeutic regimen management ineffective therapeutic regimen management ineffective community therapeutic regimen management ineffective family therapeutic regimen management readiness for enhanced therapeutic regimen management Class: Communication
impaired verbal communication readiness for enhanced communication Class: Coping
risk-prone health behavior decisional conflict ineffective coping ineffective community coping readiness for enhanced community coping defensive coping compromised family coping disabled family coping readiness for enhanced family coping ineffective denial grieving complicated grieving risk for complicated grieving post-trauma syndrome risk for post-trauma syndrome rape-trauma syndrome rape-trauma syndrome: compound reaction rape-trauma syndrome: silent reaction relocation stress syndrome risk for relocation stress syndrome self-mutilation risk for self-mutilation risk for suicide risk for self-directed violence readiness for enhanced coping stress overload readiness for enhanced decision making Class: Emotional
anxiety death anxiety fear hopelessness chronic sorrow readiness for enhanced hope Class: Knowledge
deficient knowledge (specify) readiness for enhanced knowledge (specify) Class: Roles/Relationships
risk for impaired parent/child attachment caregiver role strain risk for caregiver role strain parental role conflict dysfunctional family processes: alcoholism interrupted family processes impaired parenting risk for impaired parenting ineffective role performance impaired social interaction social isolation risk for other-directed violence readiness for enhanced family processes readiness for enhanced parenting Class: Self-Perception
disturbed body image disturbed personal identity risk for loneliness powerlessness risk for powerlessness chronic low self-esteem situational low self-esteem risk for situational low self-esteem readiness for enhanced self-concept readiness for enhanced power risk for compromised human dignity If you have a copy of Taber's Medical Dictionary all the diagnoses, their taxonomy information and a medical diagnosis cross reference is included in its appendix.
Use the defining characteristics that are listed under some of these diagnoses as a guideline for what you need to look for in this patient.

It's s slang term for a piggyback of potassium chloride (usually no more than 10meq of kcl in 100 ml of ns). They are given when k+ levels are very low. It must be run on an iv pump. Some facilities do not allow it to be infused without the patient being in icu and on telemetry. I saw them run a lot as an iv therapist and they can be very irritating to peripheral ivs--we had to restart many an iv because of k-riders being given. The patients often complain that the solution burns as it is infusing into peripheral veins. Read your drug information on iv potassium infusions. It should not be infused faster than 10 meq per hour to avoid sending the patient into heart block.
There is an interesting older thread about this:
Patient crashing / k+ rider

Let me try to explain this better. It took me a while to understand this when I was a new manager.
An fte is defined as the total hours worked (and paid) within a fiscal year (52 weeks) to a full-time worker. If a full-time worker does a 40-hour week then 40 hours x 52 weeks = 2080 hours to be worked and paid in a fiscal year. If a full-time worker does a 36-hour week then 36 hours x 52 weeks = 1872 hours to be worked and paid in a fiscal year. You need to know how your facility or unit defines a full-time worker. One unit in a hospital could be having its nurses doing three 12-hour shifts a week and defining this as one fte of 1872 hours (36 hours per week x 52 weeks) based on a 36-hour work week as being a full-time position; another unit could be doing five 8-hour shifts and defining its one fte of 2080 hours (40 hours per week x 52 weeks) based on a 40 hour work week as being a full-time position.
So, as an example, an employee who works a 24-hour week position at your facility that bases its full-time positions on 40-hours of work a week will show on your manager's budget as a 0.6 fte position because the person will only work 1248 hours during the fiscal year (24 hours per week x 52 weeks) divided by 2080 hours (40 hours per week x 52 weeks).
Most managers are given a budget of x ftes for each worker classification (RN, lpn, nursing assistant, unit secretary) that has been approved by the director of nursing and/or the facility accountant or chief financial officer. A distribution of those hours is worked out when the yearly budget requests are due and they are often set in stone and difficult to change. Overtime is not calculated into this, is considered an expense above and beyond the budget allowance and a cause for worry because it will be addressed on your manager's yearly evaluation.

To do this problem you need to know that Pitocin comes in 10 units per 1 mL and that when this 1 mL is added to 500 mL of IV solution it results in the solution containing 20 milliunits per mL of the IV solution (Reference: page 958, 2007 Intravenous Medications, 23rd edition, by Betty L. Gahart and Adrienne R. Nazareno). Therefore. . .a 500 mL solution with 30 units of Pitocin in it will contain 60 milliunits of the Pitocin.
Dose desired: 2 milliunits (mU)/minuteDose on hand: 30 units/500 mL, or 60 mU/500 mL500 mL/60 mU(dose on hand)x 2 mU/minute(dose desired)= 16.666 mL/minute, rounded off to17 mL/minute

Very simply, SpO2 is an indirect measurement of the oxygen content of blood (oximetry) where Sao2 is a direct measurement of the oxygen content of the blood (arterial blood gas sampling). I would ask your instructor to clarify what they meant by "peripheral capillary saturation" at the next class meeting since they were the one to use that terminology. However, just hearing it sounds suspiciously like it is referring to pulse oximetry because pulse oximetry is measured at the fingertips where there are peripheral capillaries.

The op apparently did not have any guidance on this from her nursing instructors so I gave her nanda's stand on this. This particular nursing diagnosis is going to be removed from the official listing anyway next year. You should all classify this diagnosis as your instructors have advised you to do. If it differs from nanda, so be it.
Diagnosing should follow some kind of rules. I am not in school. When I answer questions about care planning and nursing diagnosis I use nanda rules because that is the universally accepted taxonomy that is used throughout most of the u.S. If your instructors are telling you different--OK. Do what your instructors tell you because your grades depend on it. But, you also need to know the nursing process and how to apply the rules your instructors are giving you. What I find from most of the questions that are asked on these forums is that many don't understand the steps of the nursing process and what is supposed to be done in each step, how to put the information together and how it comes to be a care plan (problem solving). People get so-o-o-o hung up on these nursing diagnoses that it stalls them in the whole care plan process. It doesn't have to be that way. I doubt very much that medical students get all frustrated over picking medical diagnoses the way nursing students get frustrated at picking nursing diagnoses. The fact that many who post don't understand that patient signs and symptoms are at the heart of describing each nursing diagnosis is saddening. This is not rocket science. It is very rational thinking. But people see the word "Nursing diagnosis" and rational thinking and what they've been taught about the nursing process seems to go out the window and suddenly chaos reigns.

As a student you must understand that doing a care plan also involves learning about the patient's underlying disease process. This is why I have listed a number of weblinks toward the end of this post for you to explore on subdural hematomas, head injuries, alcoholism and malnutrition. I am not meaning to be mean to you, but I can't believe that your patient doesn't have any abnormal symptoms. What I can believe is that you are just not recognizing them. This may, perhaps, be because you are not familiar with what to look for. Is the subdural hematoma a result of a fall or some kind of head trauma? This is a very common thing with alcoholics. Long term alcoholics often have underlying liver problems which usually means they have some kind of coagulopathy going on which makes the likelihood of hemorrhaging anywhere in the body very easy to occur. Add all that up and alcoholism + a fall = the likelihood of a subdural hematoma. The alcoholism is also going to link you (for your care map) to his low body weight and malnutrition.
I worked on a neuro unit when I first graduated from nursing school and saw all kinds of head trauma. There are always symptoms although they may be very subtle. Did you read the chart? What did the doctor's progress notes and the history and physical have to say? This information can be used in determining his signs and symptoms and in writing your care plan.
A subdural hematoma usually occurs slowly and results from venous bleeding as a result of tearing of the vein(s). Long term alcoholism also contributes to liver problems (coagulopathy) that result in easy bleeding with any trauma. (Do you see these linkages that I'm giving you that you need for your concept map?) You need to make these pathophysiological connections in doing this care plan. A subdural hematoma is the result of an increase in the intracranial pressure in the brain. Increased intracranial pressure obstructs the absorption of cerebrospinal fluid (CSF) and affects the function of the nerve cells which can lead to brainstem compression and death. The signs and symptoms of intracellular pressure include (you will find others in the weblinks I listed for you):
slurred speech dilated, nonreactive pupils, often ipsilateral (on the same side) to the location of the hematoma changes in motor function from weakness to hemiplegia with positive Bablinski's reflex (dorsiflexion of the ankle and great toes with fanning of the other toes), decorticate (flexion of one or both arms and stiff extension of the legs) or decerebrate (stiff extension of one or both arms and/or legs) posturing, flaccidity (no motor response at all in any extremity) and seizures hemiparesis (one-sided paralysis) contralateral (on the opposite side) to the hematoma balance problems and impaired gait (if the patient is able to ambulate) dizziness declining levels of consciousness from restlessness to confusion to comaalert wakefulness restlessness drowsiness confusion delirium stupor coma various levels of dementia is usually a specific finding in patients with subdural hematomas headache abnormal respirations a rise in blood pressure with widening pulse pressure slowing of the pulse an elevated temperature vomiting CSF drainage from the ears or nose Any of these signs will lead you to nursing diagnoses of
Acute Pain Ineffective Tissue Perfusion: Cerebral Decreased Intracranial Adaptive Capacity (use this only if the patient is in ICU and ICP pressures are being measured) Risk for Infection Risk for Injury What might be the reasons for the patient's low weight? What does the chart say? Is he eating? Is there an underlying GI problem? Is he so involved with his alcoholism that he focuses on his drinking rather than eating (this is a common problem in long term, diehard alcoholics)?
A big part of doing a care plan is your assessment which includes investigating as much of the patient's background information as you can get your hands on. You have to always be asking yourself "why" questions and seeking to know the underlying pathophysiology of the medical conditions the patient has.
Please go over the signs and symptoms of subdural hematoma and head injury that are listed in these articles and think about what you saw in your patient. Did you miss something when you were observing and assessing your patient? Assessment, when you are new at it, is a difficult skill to learn. We learn from the errors and omissions we make.
Here is a guideline for assessing a patient's mental status:
Sensorium, Mental Grasp and Capacity:
Consciousness: Alert, Clouded, Fluctuating, Stuporous Orientation: Normal, Mild, Moderate, Severe, Disorientation to (time, place, person, situation) Memory: Intact, Mild, Moderate, Severe, Memory Deficits (Immediate, Recent, Remote) Digit Span: Forward (good, poor), Backward (good, poor)Disorders of: Counting, Calculation, Reading, Writing, Attention, Concentration, Comprehension General Knowledge: Good, Poor, Consistent with education, Inconsistent with education, Personalized, Superficial, Pseudoabstraction Intelligence: Normal, Below Normal, Above Normal Insight: Good, Fair, Poor, None Judgment: Good, Fair, Poor, NoneEmotional State/Reaction:
Affect: Unremarkable, Indifferent, Fearful, Angry, Euphoric, Anxious, Sad Range: Normal, Labile, Constricted Depth: Normal, Shallow, Increased Vegetative Symptoms of Depression: Depressed mood, Loss of interest of pleasure, Appetite Disturbance, Sleep Disturbance, Psychomotor Agitation or Retardation, Fatigue of Loss of energy, Decreased concentration, Feelings of worthlessness or guilt, Diurnal mood variation Suicidal/Homicidal: Denies, Ideation, Plan, AttemptGeneral Attitude and Behavior:
Behavior: Cooperative, Passive, Domineering, Withdrawn, Restless, Dramatic, Hostile, Intimidating, Suspicious, Uncooperative, Other __________ Appearance: Unkempt, Disheveled, Clean, Neat, Unusual Attire: Appropriate, Seductive, Loud, Meticulous, Untidy, AtypicalFacial Expression: Unremarkable, Sad, Angry, Perplexed, Fearful, Elated, Immobile, Grimacing, AtypicalGait: Normal, Parkinsonian, Ataxic, Shuffling, Unusual, Other__________Motor Activity: Unremarkable, Agitated, Hypoactive, Tremor, Tic, Hyperactive, Pacing, Handwringing, MannerismsStream of Mental Activity:
Productivity: Spontaneous, Verbose, Pressured, Slow, Soft, Mute, Atypical Progression: Logical, Association, Loose Association Circumstantiality: Perseveration, Halting, Incoherent, Fragmented, Tangential, Flight of Ideas, Ruminations, Confabulation, Neologism Language: Normal, Childlike, Peculiar, StiltedMental Trend and Thought Content:
Perception: Unremarkable, Depersonalization, Derealization, Dissociation Hallucinations: Auditory, Visual, Tactile, Olfactory, Gustatory Cognitive Style: Obsessive, Self Deprecatory, Intellectualized, Autistic, Global (Histrionic), Other__________ Cognitive Content: Obsessions, Phobias, Compulsive Rituals, Religiosity, Ideas of Reference, Bizarre Ideas, Self Depreciations, Delusions, Nihilistic, Somatic, Grandiose, Paranoid, Guilt

This is a standard IV solution. I'm thinking that what may be confusing you is the way it is written. It is written a number of different ways:

D5 1/2 NS
D5/0.45 NS
Dextrose 5% in 0.45% Normal Saline
Dextrose 5% in 1/2 Normal Saline
5% Dextrose in 0.45% Normal Saline
5% Dextrose in 1/2 Normal Saline It is a hypertonic solution. A hypertonic solution is one that has an osmolality greater than 340 mOsm/kg. Hypertonic solutions exert more osmotic pressure than the extracellular fluid so when these solutions are infused, fluid gets pulled into the vascular system. You want to monitor patients receiving any hypertonic solutions for fluid overload, particularly if they are being given at a rapid rate of infusion.
The osmolality of 5DW and 1/2 NS is 405 m/Osm/liter and it's pH is about 4.4. It contains 50 grams of dextrose and 77 mEq of sodium and 77 mEq of chloride. The remainder is just sterile water.

Soapie charting is:
S (Subjective data) - chief complaint or other information the patient or family members tell you.

O (Objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values.

A (Assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.

P (Plan) - strategy for relieving the patient's problems, including short- and long-term actions.

I (Interventions) - measures you've taken to achieve expected outcomes.

E (Evaluation) - analysis of the effectiveness of your interventions.

R (Revision) - changes from the original care plan
(This information is from page 676 of Portable RN: The All-In-One Nursing Reference, Third Edition, published by Lippincott, Williams & Wilkins, 2007)
These examples of soap and soapie charting come from page 677 of the same reference...
[nursing diagnosis] #1 nausea related to anesthetic
S: patient states, "I feel nauseated."
O: patient vomited 100ml of clear fluid at 2255.
A: patient is nauseated.
P: monitor nausea and give antiemetic as necessary.
I: patient given compazine 1mg iv at 2300.
E: patient states she's no longer nauseated at 2335.
[nursing diagnosis] #2 risk for infection related to incision sites
[notice there is no "S" charted--no subjective data to chart]
O: incision site in front of left ear extending down and around the ear and into neck--approximately 6" in length--without dressing. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-pratt [jp] drain in left neck below ear with 20ml bloody drainage. Drain remains secured in place with suture.
A: no infection at present.
P: monitor incision sites for redness, drainage, and swelling. Monitor jp drain output. Teach patient s&s [signs and symptoms] of infection prior to discharge. Monitor temperature
[nursing diagnosis] #3 delayed surgical recovery
O: patient oriented x 3 but groggy. Patient attempted to get oob [out of bed] at 2245 to ambulate to bathroom but felt dizzy upon standing. Lungs sound clear bilaterally.
A: patient is dizzy when getting oob. Patient needs post-op education about mobility and coughing and deep-breathing exercises.
P: allowed patient to use bedpan. Assist in getting oob in 1 hour by dangling legs on side of bed for a few minutes before attempting to stand. Monitor blood pressure. Teach patient how to get out of bed slowly to prevent dizziness and to ask for assistance. Teach coughing and deep breathing, turning, use of antiembolism stockings.
I: allowed patient to lie down in bed after feeling dizzy. Patient used bedpan and voided 200ml clear, yellow urine at 2245. Assisted in coughing and deep-breathing exercises and taught about turning, use of antiembolism stockings.
E: lungs remain clear bilaterally.
[nursing diagnosis] #4 acute pain related to surgical incision.
S: 2245 patient states, "no" when asked if she has pain. At 2335 patient states, "it hurts."
O: patient reports incisional pain as 7/10 on scale of 0 to 10.
A: patient is in pain and needs pain medication.
P: give pain meds as ordered.
I: patient given morphine 2mg iv at 2335.
E: patient states pain as 1/10."
There is information on nursing documentation in the student nurses forums on this thread:

DAR is a form of focus charting and the dar stands for data-action-response. It ensures documentation that is based upon the nursing process. Routine nursing tasks and assessment data is documented on flow sheets and checklists.
Your focus is a nursing diagnosis, or in place of a nursing diagnosis you can use a problem, sign or symptom (nausea, pain, etc), behavior, special need, an acute change in the patient's condition or a significant event. Your progress note is written in the DAR form.

D (DATA) - includes subjective and objective information the describes the focus.

A (ACTION) - includes immediate and future nursing actions based on your assessment of the patient's condition and any changes to the care plan you deem necessary based on your evaluation.

R (RESPONSE) - describe the patient's response to nursing or medical care.
Here are four examples of DAR charting:
Focus - nausea related to anesthetic
D - Pt. states she's nauseated. vomited 100ml clear fluid at 2255
A - Given compazine 1mg IV at 2300.
R - Pt. reports no further nausea at 2335. no further vomiting.
Focus: risk for infection related to incision sites
D - Incision site in front of left ear extending down and around the ear and into neck--approximately 6 inches in length--without dressing. jackson-pratt drain in left neck below ear secured in place with suture.
A - Assess site and emptied drain. taught patient s&s of infection.
R - No swelling or bleeding; bluish discoloration below left ear noted. jp drained 20ml bloody drainage. patient states understanding of teaching.
Focus - Delayed surgical recovery
D - Patient reported dizziness after trying to get oob to use the bathroom.
A - Assisted patient back in bed and with use of bedpan. taught patient how to dangle legs and get oob slowly. also taught coughing and deep breathing exercises, turning in bed, and use of entiembolism stockings.
R - Patient voided 200ml in bedpan. did cough and deep breathing appropriately. lungs clear bilaterally. using antiembolism stockings.
Focus - acute pain related to surgical incision
D - Patient reports pain as 7/10 on 0 to 10 scale.
A - Given morphine 1mg IV at 2335.
R - Patient reports pain as 1/10 at 2355.
All of the above is from page 678 of Portable RN: The All-In-One Nursing Reference, Third edition, published by Lippincott, Williams & Wilkins

When you have to come up with some kind of skeleton care plan on a patient you haven't seen yet, all you can work with is the data you have been given. That data, if I understand what you have posted is:
open hip reduction pain on the actual site pain with movement a cast wife has been taught to assist him with movements and how to transfer to and from wheelchair abnormal labs are low rbc,hct,hgb If you have been reading any of the information that I post on care planning and the nursing process then the place to begin is with this data. You should be looking up everything you can find on what is done by a physician during an open hip reduction and what the normal medical treatment and aftercare are. Since the patient has a cast he will need to be given or taught post-discharge instructions on the care and management of the cast. Obviously, mobility is going to be a problem when he goes home. So, are the performance of his activities of daily living. How are his ADLs going to be affected and need assistance at home? You will need to assess and teach on these points. If the patient is anemic due to some blood loss as a result of the surgery what are some nursing actions or teaching you can give him to follow when he gets home? How is the man performing his toileting with a cast on his leg? How is he getting pants on? Have you thought about suggesting adding foods to his diet that would be high in iron and folate? What classification of a nursing diagnosis would that come under?
The way I see this the patient has issues of pain, mobility, nutrition, self-care deficits and healing of the actual surgical trauma to deal with. That covers 5+ nursing diagnoses right there, none of them "Risk fors". When you actually work with the patient you'll be able to streamline the actual care plan.
Impaired Skin Integrity Impaired Mobility Acute Pain Toileting Self-care Deficit Dressing Self-care Deficit Fatigue (this would be a symptom of the anemia) Ineffective Health Maintenance (R/T dietary changes needed to boost his blood system as a result of the blood loss anemia) Risk for Injury (potential for fat or blood embolism, potential for thrombophlebitis) There's your 8 in priority order and only one is an anticipatory diagnosis. You have to think in a very practical and logical way when you are planning care. Picture your own self with the same cast on your leg and imagine the kinds of situations you might have to deal with as you go through your daily life. There's a big part of your care plan right there. I'll let you come up with a goal for each of the first 3 from your care plan book.

Nanda has no official nursing diagnosis called "muscle weakness". So, if this is a nursing diagnosis your nursing program approves, you would have to look at it's definition and symptoms to see if they can be related to malnutrition.
However with malnutrition, muscle weakness is a symptom of it, so it would seem to me, to be incorrect to give a symptom its own nursing diagnosis.
With ineffective breathing pattern, the decreased energy is often due to the expended effort required to maintain their breathing. The patients with this diagnosis are often experiencing dyspnea and the effort to keep their breath is what fatigues them along with the oxygen expenditure.
As for the risk for constipation, I think that a more appropriate related factor would be insufficient fiber intake as opposed to nutrient intake. Patients can be on low fiber diets or even tpn, still get adequate nutrient intake and be constipated.
Keep in mind that when you are looking for nursing diagnoses, you are matching patient symptoms with the defining characteristics for each nursing diagnosis. Malnutrition is due to a lack of the required food, inability of the body to absorb and distribute the food substances ingested, deficient diet or deficient breakdown, assimilation or utilization of food. The symptoms of malnourishment can be any of the following and in any degree depending on the seriousness of the malnutrition:
dull, dry thin, fine, straight, easily plucked hair hair loss areas of light or dark spots of hair generalized swelling of the face dark areas on the cheeks and under the eyes lumpy or flaky skin around the nose and mouth enlarged parotid glands their eyes have a dull appearance eye membranes are either pale or reddened there may be triangular, shiny gray spots on the conjunctivae the corners of the eyelids are red with fissures there will be a bloodshot ring around the cornea fatigue of visual accommodation lips will be red and swollen, especially at the corners (cheilosis) the tongue will be swollen, purple and raw-looking there may be sores on the tongue thrush may be missing teeth gums will be spongy and bleeding teeth will be in general disrepair swollen thyroid gland pallor dry, flaky skin rough skin (toad skin) poor skin turgor wrinkling of the skin on light stroking thickening and pigmentation of skin over bony prominences lack of subcutaneous fat spoon-shaped, brittle, ridged fingernails muscle wasting poor muscle tone swollen joints bumps on ribs musculoskeletal hemorrhages tachycardia (heart rate above 100 beats/minute) arrhythmias elevated b/p enlarged liver and spleen amenorrhea irritability confusion paresthesias in hands and feet decreased ankle and knee reflexes inability to maintain posture or just bad posture changes in equilibrium, especially with movement anemia You are likely to see malnutrition states in patients with HIV, hypothyroidism, pernicious anemia, cancer (especially where they are on chemotherapy or radiation therapy), any number of GI diseases (cirrhosis, crohn's, gastritis, hepatitis) alcoholism, hard core drug addiction and just plain old starvation for any reason.
You base your nursing diagnosis on the underlying cause of the symptoms. So, if your patient is malnourished, you must think about why they are malnourished and what is the absolute underlying cause for this condition. In many cases, these become your r/t (related factors) on your nursing diagnosis:
not eating enough of the right food pathophysiological body processes inhibiting the digestion and absorption of the food ingested (ex: imbalanced nutrition: less than body requirements r/t insufficient food intake [or others could be: loss of appetite or inability of body to absorb nutrients because of biological factors or unwillingness to eat or increased metabolic needs caused by disease process ] aeb muscle weakness and decreased energy) The problem with helping you with a nursing diagnosis is that malnutrition is a medical diagnosis that can have a lot of symptoms as well as causes, none of which you have given except for the muscle weakness.
I suspect the patient also has breathing problems since you bring that up with a diagnosis related to it, and constipation which may or may not be related to the malnutrition. You need to take a good look at your patient's symptoms. See if any match the list I've given you and then re-examine possible nursing diagnoses.
Possible ones to use (and this list is by no means comprehensive):
imbalanced nutrition: less than body requirements r/t insufficient food intake aeb muscle weakness and decreased energy deficient fluid volume adult failure to thrive ineffective therapeutic regimen management ineffective protection impaired skin integrity fatigue activity intolerance disturbed sensory perception risk for infection risk for falls risk for injury

Erin (who is trying to get ahead of her studies). . .
Edema is evaluated on it's ability to pit. The examiner's fingers are pressed into a dependent area of the patient's skin for 5 seconds. Areas used to check for pitting are the sacrum if the patient is bedridden, or the lower leg. If pitting edema is present, the fingers will sink into the tissue and leave an impression of the fingers when they are removed. This pitting is graded on a scale of +1 to +4 as follows:
    Definition Grade +1 (Trace) Mild pitting, 2mm indent, slight indentation, rapid return to normal Grade +2 (Mild) Moderate pitting, 4mm indent, rebounds in a few seconds Grade +3 (Moderate) Deep pitting, 6mm indent, 30 seconds Grade +4 (Severe) Very deep pitting, 8mm indent, > 30 seconds to return to normal

"status post" is a Latin expression that means "condition after", so your current pt is being referred to as his/her condition after a tracheostomy.
If you do not already have a medical dictionary, I strongly recommend that you invest in one, preferably Taber's. You would have found this information in Taber's.

I have mostly seen it used to mean "while awake", but it could also mean "with assistance" although the letter "c" with a line over it is usually used to mean the word "with".
In the title to this thread you have "WA with left paresis" which doesn't make sense to me. What does make sense, however, is "s/p CVA with left paresis". CVA means "cerebrovascular accident", or more commonly, a stroke. And, a person having a stroke would get a left paresis. Is it possible that if you look at the handwritting of this phrase that it might be "CVA" and not "WA", that the letters "CV" kind of look like a "W"?
And, yes, s/p, or S/P, means "status post". Do you undertand what status post means?

Solu-Medrol is prednisone. Solu-Cortef is cortisone. Both are immediate acting.
You will find Solu-Medrol being given where reducing swelling is more of a priority than the response to the inflammation. Solu-Cortef is given when reducing the inflammation is more the priority.
However, both do act on either problem.