Jun 6, 201016 yr I am doing a concept map for my clincial day and I just have a couple questions about it. Any response would be great.Here is my information:20 yr old femaleMedical DX: Right Midshaft Femur FractureRod placement.Abrasions on right abdomenContusion on chestHead LacerationNo past medical HXon telemetryFatty EmboliEdema to legeating poorly50% weight bearingHigh Fall RiskStaples to left scalpexperiences tachycardia when upHypoxia, weaning her off of 02I'm just having problems with my Nursing DX i'm going to use 4 nursing dx's.Possible nursing DX's: Acute Pain r/t edema, trauma Impaired Physical Mobility (but she can walk to the bathroom now and out in the hallway with therapy) Risk for impaired Skin Integrity r/f shearing forces when moved Risk for Injury r/f unsteadiness when ambulating, high risk for falls Anxiety/Fear r/t change in health status, trauma, tachycardia Risk for Peripheral Neurovascular dysfunction r/f tx of the fractureWhat do you think? I'm just having trouble narrowing it down...
Jun 6, 201016 yr Does she have a fat embolism? If so, where?Prioritization of nursing Dx's is important. Look for things that have the potential to end your patient's life first.
Jun 6, 201016 yr How's her breathing? You mentioned contusions to her chest and being on 02. I'm thinking ineffective breathing pattern, or impaired gas exchange r/t ineffective chest wall expansion. Its usually better to use more actual diagnoses vs risk for. It sounds like she may have orthostatic hypotension too. Were you able to take her bp laying sitting and standing? This would also put her at risk for falls. How's her mental status? You also mentioned lacerations to her head. How was your neuro assessment? Of the diagoses you've listed I would use Impaired mobility & acute pain.
I am doing a concept map for my clincial day and I just have a couple questions about it. Any response would be great.
Here is my information:
20 yr old female
Medical DX: Right Midshaft Femur Fracture
Rod placement.
Abrasions on right abdomen
Contusion on chest
Head Laceration
No past medical HX
on telemetry
Fatty Emboli
Edema to leg
eating poorly
50% weight bearing
High Fall Risk
Staples to left scalp
experiences tachycardia when up
Hypoxia, weaning her off of 02
I'm just having problems with my Nursing DX i'm going to use 4 nursing dx's.
Possible nursing DX's: Acute Pain r/t edema, trauma
Impaired Physical Mobility (but she can walk to the bathroom now and out in the hallway with therapy)
Risk for impaired Skin Integrity r/f shearing forces when moved
Risk for Injury r/f unsteadiness when ambulating, high risk for falls
Anxiety/Fear r/t change in health status, trauma, tachycardia
Risk for Peripheral Neurovascular dysfunction r/f tx of the fracture
What do you think? I'm just having trouble narrowing it down...