bgeorge90

I do have a nursing diagnosis book. I have to put 3 medical diagnosis on my care plan so I had a brain fart when I put that! Lol

Sorry Esme, What I meant to put for the first dx was activity intolerance r/t musculoskeletal impairment. This is my first care plan and it is my second semester. Some more assessment data is diminished breath sounds in the left lower lobe, use of accessory muscles, O2 92% on 3L O2, HR 85, BP 136/78, Temp 99.0 F, Pain 0, RR 24, bowel sounds hyperactive x4, foley, wears briefs, radial pulses equal bilaterally, bilateral grips weak, cap refill brisk, good skin turgor, stage 2 pressure ulcer right gluteal fold, several abrasions due to recent fall, 3+ pitting edema right lower leg, pedal pulse absent in R lower limb and thready in Left lower limb. possible DVT right lower extremity. My problem is the patient reports no pain, only responds to pain when we turn him q2h, does not help with ADL's. He is on comfort care, so I don't know how much I should do for him with the nursing dx if that makes sense. Activity Intolerance r/t musculoskeletal impairment and Ineffective breathing patterns r/t fluid accumulation and inflammation aeb RR 24 and diminished breath sounds Left lower lobe. How much do you really perform in your nursing interventions when someone is on comfort care? Obviously q2h turns are important to make the patient comfortable... Thanks for your help

I am having a hard time coming up with 3 nursing dx for my patient(2 physical, 1 psychosocial) and possible interventions. Here is the background information: Patient admitted for R hip fracture due to fall. Patient came from the nursing home and is alert and oriented x1, agitated. Hx of Alzheimer's. When admitted, patient also had pnuemonia, which put a hold on surgery. The patient's pneumonia got worse each day, so they decided to make the patient comfort care and not perform the surgery. Vitals were WNL. Patient on 2 L O2, foley, wears a brief, wearing mitts due to agitation, q2h turn, +3 edema in right lower leg. The problem is that the patient will not tell you if he is having any pain. He just keeps saying "I'm fine". On my last day with this patient, we were also concerned of a DVT in the right lower leg, but didn't look into it any further due to him being on comfort care at the time. The patient's heparin was d/c 2 days prior due to an elevated INR. So far, I am thinking Nursing dx 1: Right Hip Fracture r/t musculoskeletal impairment Interventions: q2h turn, monitor for skin breakdown, not sure about others Nursing dx 2: I am having a hard time coming up for this one related to the pneumonia. The patient's CXR showed a large area of infiltrate in the right upper lobe, left lower lobe consolidation, and bilateral pleural effusion. I am thinking Ineffective breathing pattern r/t fluid accumulation and inflammation? Nursing Interventions: Monitor rate, depth, and ease of respirations, Monitor for signs of hyperventilation, Monitor O2 sats Nursing dx 3: Chronic confusion r/t alzheimer's disease. I don't really like this one but I can't think of a bettter dx for symptoms of alzheimer's, agitation, confusion, etc... Any help is greatly appreciated.