Weakness, altered mental status, pneumonia HELP!

Published Apr 5, 2010

27 Posts

Specializes in Geriatrics, Psychiatric.

I am having a hard time thinking about the appropriate PRIORITY nursing dx for my patient. The thing that ticks me off is her medical diagnosis which is: Weakness, altered mental health, pneumonia. I mean is it even possible to have 3 disorders as a med diagnosis? maybe it is.. but I am really having a hard time because I also need to research about the pathophysiology of the medical diagnosis. Pneumonia is easy but that was resolved already before my interaction. For weakness and altered mental health, i just dont know where to get the patho for both!! arrghh.. anyway here is my assessment:

An 84 yr old woman was admitted on ER 03/25/2010 for altered mental status, lower extremity weakness and pneumonia. She was concerned about her LE stating that all of a sudden she couldn't move it. Radiology tests showed that she mild degenerative pelvic/hip changes, chondrocalcinosis and vascular calcifications. CT scan suggested mild cerebral atrophy & small vessel ischemic changes. Thorax CT showed coronary calcification. CT scan showed a leakage of silicone in her system, which was scheduled to be removed on 04/05/2010. There was no lung infection noted.

History

Medical: CHF, HTN, breast cancer, hypothyroidism, osteoporosis, dementia

Surgical: Appendectomy, R wrist fx, breast implants on both breast

Family: Husband died, daughter -dead - had bipolar disorder, and son is alive.

Allergies: Penicillin - shock

Health assessment data

Vitals are: temp 97.3, pulse 65, resp 18, bp 96/49, pulse ox 96% on RA

Peripheral pulses are palpable, weak.

Apical pulse is weak

Alert and oriented x3

Short term memory impairment noted - patient does not know how long has she been sitting, does not remember what the doctor told her 15-20 minutes ago, forgets about her wrist brace.

Pupils are slowly reactive - patient stated "I should be wearing glasses"

Mucous membranes are pink and moist

Lungs are clear to auscultate, no crackles, wheezing or adventitious breath sounds

When asked to cough, she was able to w/o pain or

No dentition problem

Skin is warm, dry and intact

Bruises noted on her lower abdomen, left brachial arm and left leg - from a previous fall

Muscle mass is diminished - possibly due to old age

Limited ROM

Needs assistance on walking - unsteady gait, fatigue easily

She is using a walker

On a bed rest - bed to chair - chair to bed only

On a cardiac diet

Bowel sounds are present on all quadrants

Patient stated elimination problem - last BM was on 03/30/2010 - compacted - not her usual

Urinary incontinent - on depends

Psychosocial

Patient is interactive

confabulate

On a depressed mood - her best friend died yesterday

Nursing dx

My thoughts are

1. Impaired mobility r/t neuromuscular and cognitive impairment as evidenced by leg weakness, unsteady gait, memory impairment, diminished muscle mass, history of fall.

2. Activity intolerance r/t old age, degenerative disease, neuromuscular impairment as evidenced by early signs of dementia, leg weakness, fatigue

3. Constipation r/t impaired mobility, old age as evidenced by hyperactive bowel sounds, last BM was 03302010

Risks for

Risk for injury

Risk for impaired skin/tissue integrity

Should I also include Impaired memory? I know she is not confused on the moment I was there so I will not put that one in. The thing is, I just need 3 Nursing dx and to prioritize it! risk for is not included at all! PLEASE HELP!!!!