Question

Please! I need help creating nursing diagnoses for the following:

Vital Signs: BP 137/50, P 82, R 15, Temp 36.5 C, PO2 99% on 100% room air (Would this have a nursing diagnosis???)

Neurological: A & O x 4, pain 0/10. H/O CVA with mild residual dysarthria. Unsteady gait. (Diagnosis for the CVA/dysarthria and unsteady gait?)

GI: H/O DM. BM 2x/day. The abdomen is soft, tender, and nondistended. Bowel sounds are normoactive in all four quadrants. The patient is on a consistent carb diet. About 50% of meal consumed. Continent of bowel. (Diagnosis for DM?)

GU: Continent of bladder. Has Stage 4 Chronic Kidney Disease. Patient has a creatinine level of 3.8 mg/dL and BUN level of 51 mg/dL. (I have no clue how to set up a nursing diagnosis for CKD)

Integumentary: Diabetic ulcer and dry gangrene on the right foot. Upper extremities warm and dry. Lower extremities cool, dry, and swollen. Primary diagnosis of cellulitis.

Thank you in advance!

Answer 1

nursing diagnosis

1. vitals remain same it may not be needed any nursing diagnosis

2. diagnosis for CVA

Impaired communcation related to dysarthria

Risk for injury related to unsteady gate

Risk for impaired skin integrity related to CVA

3. diagnosis for DM

Risk for infection related to diabetes mellitus

Risk for hypoglycemea related to DM

4. CKD

Fluid volume deficit related to CKD

Anxiety related to CKD

5. Cellulitis

Impaired skin integrity related to cellulitis