Create NANDA nursing diagnoses for the following assessments:
1a.) GI: Leopold’s maneuvers performed. The fetus is in the longitudinal lie, in vertex presentation. There is normal elasticity of the skin. Her skin is cool, and she is very sweaty.
1b.) GU: Proteinuria. Foley catheter inserted (less than 1 mL of clear urine). Protein dipstick +4. Negative ketones. Negative glucose.
1c.) Integument: Moderate to severe pitting edema graded to +3. Normal elasticity of the skin. Patient’s skin is cool and sweaty. Facial puffiness present.
1d.) Respiratory: Crackles present at both bases. No sign of airway obstruction. 22 breaths/min. Chest moving equally on both sides. O2 via a nonrebreather mask to maintain greater than 92% SpO2.
NANDA DIAGNOSIS
1. Ineffective tissue perfusion related to diminished venous return as evidence by cold and clammy skin.
2. Fluid volume excess related to decrease kidney function as evidence by less then 1 ml clear urine and proteinuria.
3. Fluid volume overload related to decrease cardiac output as evidence by 3+ pitting edema and facial puffiness
4. Impaired gas exchange related to altered oxygen supply as evidence by crackles sound in lungs and on O2 therapy
Create NANDA nursing diagnoses for the following assessments: 1a.) GI: Leopold’s maneuvers performed. The fetus is...
Create nursing diagnoses for the following head-to-toe assessments 1a.) GI: Leopold’s maneuvers performed. The fetus is in the longitudinal lie, in vertex presentation. There is normal elasticity of the skin. Her skin is cool, and she is very sweaty. 1b.) GU: Proteinuria. Foley catheter inserted. Protein dipstick +4. Negative ketones. Negative glucose. 1c.) Integument: Moderate to severe pitting edema graded to +3. Normal elasticity of the skin. Patient’s skin is cool and sweaty. Facial puffiness present.