Struggling with nursing diagnosis

[augurey]

I've been going back and forth on which diagnoses fit best. There are some that seem important, but when I relate it back to the patient, it seems weak. The ones that seem to relate back to the patient best, while important, seem less important and that I'm totally off. I'm finishing up my first semester, so I've only done a handful of care plans.

Pt was admitted for CVA. Right sided hemiparesis, aphasia and dysphagia. Pt can say some words such as "yeah" and "okay", but corresponds inappropriately with the question asked. Pt was also dx with paroxysmal atrial fibrillation.

Pt also has prostate cancer with mets to the spine and is currently doing chemotherapy (chemotherapy temporarily stopped after call placed to oncologist). Patient has been placed on neutropenic precautions (chemotherapy induced neutropenia). High risk for falls.

Pt is NPO - PEG tube was inserted. Pt hasn't appeared to be in pain, but is showing frustration at his inability to communicate effectively. Diet is continuous PEG tube feeding, high fiber.

Most recent I&O showed a net of 2,080.

The possible nursing dx I've come up with:

*Impaired physical mobility

*Impaired verbal communication

*Risk for impaired skin integrity

*Activity intolerance

*Risk for ineffective cerebral tissue perfusion (ineffective cerebral tissue perfusion isn't in the nursing dx handbook - only risk for - otherwise I would've considered this as priority)

*Constipation

*Imbalanced nutrition: less than body requirements (thinking b/c of NPO w/ PEG tube, but the pt's BMI is in the overweight range, so I don't know if this would be appropriate)

*Decreased cardiac output (atrial fibrillation)

*Risk for infection

*Risk for falls

*Risk for injury

*Excess fluid volume

This is everything I can pick out based on all of the information. We were advised that a "risk for" shouldn't be priority - though I almost wonder if "risk for infection" should be because of the neutropenia. I know that the ABCs trump as those are the things that can kill the patient first.

I considered decreased cardiac as priority, but I can't really relate it back to the patient's assessment other than altered heart rhythm and, furthermore, can't really think of what it would be as evidenced by (other than EKG and telemetry monitor).

We were advised that we should have 2 r/t and 3 aeb.

The different ways I've thought about prioritizing are:

1. Risk for infection (not sure if this would be an exception due to the neutropenia)

2. Decreased cardiac output

3. Risk for ineffective cerebral tissue perfusion

4. Impaired physical mobility

(or cardiac first, risk for infection second)

1. Decreased cardiac output

2. Risk for infection

3. Excess fluid volume

4. Impaired physical mobility

Am I really far off the mark? I've been going over this for a few hours now, and I just really do not know where to go with this.

[203bravo, MSN, APRN]

You have a lot of medical diagnosis here but little assessment data... for decreased cardiac output you would need stronger evidence other than just the periods of A-Fib.. there are many patients that have A-Fib with no decrease in cardiac output.. were their other signs? low BP, fatigue, syncope or dizziness, change in mental status? just some examples --

Even a patient that is overweight can have Impaired Nutrition: less than body requirements -- but this should be resolved with the PEG feedings.

And you are on the right track that a "Risk for" diagnosis can have a higher priority over an actual diagnosis if the risk is high enough to cause loss to life or limb... and you should always consider ABCs and Maslow when thinking priority.

[augurey]

There was a change in mental status at one point. A head CT was done to see if there were any changes from the initial head/brain CT (no changes).

Blood pressure has ranged from normal (lowest systolic of 107 and lowest diastolic of 60 - highest was 138/88). Pt is on labetalol and metoproplol. BNP results were elevated (2,633).

Hb and hct were slightly low. ALT and AST slightly elevated.

A significant different in I&O (positive net) with a 6 pound weight gain (from 11/15 until today).

I did forget about Maslows in this as I was more focused on ABC. Thank you for the input!