laurelwoods94

I need an at risk nursing diagnosis for one of my patients I had in the hospital in medicine. Pt had als still had complete mobility but was unable to swallow (had peg) or talk anymore. I think risk for falls is the best at risk diagnosis for this project I am doing as she has a history of falls, and looking at all of my data from clinical (which j realize I am giving g you the super short version of) it is evident this is the most concerning g at risk diagnosis. I usually do well with nursing diagnosis however this one I am struggling... This pt is primarily at risk for falls because she moves quickly and impulsively and doesn't ring the call bell for help and she really should be. The problem is we use the carpenito textbook for nursing diagnosis and none of the related to factors fit for the client, especially there is nothing g related to falls and impulsive movements, if someone could please help me out with this one it would be greatly appreciated Thanks!

Hi, i'm a second year student nurse. Part of my assignment this week is to create a nursing diagnosis for my pt. They were at end of life, however still ACP-R, so the hospital is still doing everything they can to get him better. I made my diagnosis Inadequate Nutrition:Less than Body Requirements because that is his presenting problem. I've made my goal, and criteria however I'm having a hard time trying to find applicable interventions with Rationale. The reason being that the interventions had to be things that we did ON OUR CLINICAL SHIFT. I know what I did, but the problem is that many of the interventions were for pt's without the use of an enteral feed. Interventions would be like, - "provide a relaxing environment" or "have 6 small meals instead of three" I know the interventions I provided throughout the day, however I cannot find rationales that I will be able to cite. Here are the interventions I instilled: L.W. consulted with Doctor in concerns to low PO4 balance on lab work (Critical Thinking) - R- it is important to monitor and supplement as needed oral, enteral or IV potassium, magnesium and phosphate intake - medscape L.W. consulted with P/T in order in terms of increasing ROM to decrease risk of pressure ulcers (Communication with Staff) (Accountability and Responsiblity) L.W. ensured V.K's HOB was always elevated at least 30degress. (Ethical Practise) R- aided in preventing another bout of aspiration penumonia L.W. anticipated V.K.'s needs and payed attention to his nonverbal communication. R- (Therapeutic Communication) L.W. provided a complete GI assessment (BS, abdominal tenderness, etc.) during the clinical day. R- reduced or hypoactive bowel sounds may be a sign of reduced gastric motility and constipation d/t low fluid intake poor food choices, reduced activity & hypoxemia. (Provision of Care) as you can see, some of them i was able to find rationale, but i cannot find legitimate sources for the other rationales. I use a textbook as well, but the textbook was of little help as the interventions were not relevant. Any help would be so so much appreciated!

I am making a NCP for my pt. he is 88y/o and very HOHx2. I've started it and my nursing Dx is: at risk for falls r/t lack of awareness of environmental hazards secondary to maturational age and hearing impairment, supportive data: age wears hearing aids confusion chronic back pain inability to hear/understand what is being spoken to (pt. name) requires SBA requires 4w walker partial assist self care my goal: relate few to no falls. outcome: this is where i have trouble. i'm not sure how to do the outcomes or what is needed. any help would be appreciated, as well as any feedback or constructive criticism on my cp. thanks!