nursing care plan with priority nursing dx
I need a priority nursing diagnosis from the nanda list for this patient. Patient c 92 yr old fell medical dx of C4 fracture and patient has a possible broken arm that patient can not move. Weight 75lbs.has neck immobilizer on, foley cat in, IV in with ns @ 75 cc/hr. on bed rest total care patient. Some demetia. Was npo from time of fall till the next afternoon. Once was allowed to eat patient only ate three bites of her food and refused fluids. The arm that is possibly broken has skin broken at elbow and bruising from elbow up half the back of the arm, edema present, mimimal bleeding.
vital signs all within normal capillary refill was less than 3 sec. toes and feet move with ease.good strength in unaffected arm with barely any strength in affected arm oriented x2. Warm dry pale skin poor skin turgor. I've intake for 7hrs was 469 and urine output was 350 with 2 pasty brown bm's. Urinalysis everything in normal limits
electrolytes all in normal limits cbc= hgb 10.9, hct 32.5, rbc 3.70, wbc 16.6
alert, calm, responsive, speech clear. That's all I have on the patient someone please help me