a care plan is about determining a patient's nursing needs and developing interventions to help them. a nursing diagnosis is merely a label that describes in shorthand what a nursing problem is. its definition gives a more specific description of what it is. all actual
nursing problems (nursing diagnoses) are based upon signs and symptoms that the patient has that are found during the assessment of the patient. this is very similar to what detectives do in looking for clues to the crimes that people commit except we don't always know what diagnosis we are looking for. there is a method to doing this called the nursing process. what a care plan book does for you is eliminate having to go through the nursing process. however, care plan books only cover the common medical diseases and conditions. when less common problems arise, the nursing process needs to be used in solving these nursing problems. follow the steps of the nursing process to do this. i demonstrate how this is done all the time in this thread: http://allnurses.com/general-nursing...ns-286986.html
- help with care plans.
nursing diagnoses that begin with the words "risk for" are potential nursing problems that do not exist yet and, therefore, do not have any signs or symptoms.
step #1 assessment
- collect as much information as you can before you even begin thinking about what the nursing problems (nursing diagnoses) are. assessment consists of:
- a health history (review of systems) - this is historical information about the patient. there is a history of physical abuse and a concussion and the patient is stating she now has headaches since the concussion.
- performing a physical exam - you really have provided none. since the patient states she is having headaches a neuro exam should have been done. the degree of the headaches should have been assessed since a headache is pain and pain is a symptom. the body should have been inspected for evidence of bruising and any other injuries. rom of the extremities should have been done to assess for fractures, sprains and dislocations.
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - after a beating there is tissue damage and pain making the ability to perform adls difficult. this should be assessed. there are basic adls and instrumental adls. if the patient contemplates leaving the situation, instrumental adls may be a problem for her to accomplish. (see post #4 at Health Assessment Resources, Techniques, and Forms for information about adl assessments).
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - websites that have information about domestic violence and injuries include:
for the area you live in you should do a survey of the services available to battered women because this information would be needed for your nursing interventions.
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - pain medication?
- all diagnoses are based upon abnormal data. now you have a better base of information from which to put a list of symptoms together. up to this point the only abnormal data that you had was:
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
- husband beat her
- started having headaches
- she feels unsafe
- every nursing diagnosis has a definition, set of defining characteristics (signs and symptoms) and includes some related factors (causes or reasons they happen). a nursing diagnosis reference should be consulted to make sure you are using a nursing diagnosis correctly. more recently published care plan books will include this information in them if all the nursing diagnoses have been used. the appendix of current editions of taber's cyclopedic medical dictionary
will have the information, and about 80 of the most commonly used nursing diagnoses are included with that information on these 2 websites:
based on the data you have provided i would diagnose in this priority:
step #3 planning (write measurable goals/outcomes and nursing interventions)
- acute pain r/t trauma aeb headache
- fear r/t stressful domestic relationship aeb patient's report that she feels unsafe
- ineffective coping r/t inadequate social support and low self-esteem aeb inability to appropriately solve current problems with spouse or ask for help in solving these problems
- risk for self-directed violence r/t history of physical abuse (she is harmful to herself by remaining in a proven harmful situation where she will likely get beaten up again)
- nursing interventions are based upon the aeb items for each diagnosis. the goals are what you predict will happen when the nursing interventions are performed. . .
acute pain r/t trauma aeb headache
(this headache needs better description)
- where the pain is located
- how long it lasts
- how often it occurs
- a description of it (sharp, dull, stabbing, aching, burning, throbbing)
- have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain (this is needed for later assessment and goal development)
- what triggers the pain
- what relieves the pain
- observe their physical responses
- behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
- sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
- parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
the patient will report improvement of the headache.
- assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
- assess and document where on the head the pain is located and what, if anything, makes it worse or better
- observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
- assess for any declining level of consciousness and report changes to the physician.
- give pain medication as ordered
- provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
- use short, simple relaxation exercises to distract the patient's attention
- dim the lights in the room and keep noise down
- play soft, soothing music
- reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
- teach the patient about prescriptions they will be taking including the dosage, how they should be taken and any side effects
- instruct the patient to report any worsening of the headache to her physician.
- - - - - - - - - - - - - - -
is it risk for violence or just plain violence?
i was thinking perhaps you help her make a plan to escape if (but of course she feels unsafe all the time perhaps have her form a codeword and the number she can reach you and you call 911? but would you give out your number to a client? in class we talked all about having a client that was in a violent situation have a code word but who is she calling? perhaps a family member? i am at a loss for the nursing actions and goals.
these are the official nanda diagnoses and their definitions. they are patient based because the patient is always the focus of the diagnosis:
- risk for other-directed violence: at risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to others.
- risk for self-directed violence: at risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self.
there are several problems here that have to be addressed. she has a physical problem, a headache, and physical problems always take priority over other things. see maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
).then you can get to the safety issues. read the domestic violence articles first. she states she feels unsafe. deal with that. then teach her how to cope with her problem. if she did, she would have done something about it a long time ago (your hypothetical patient). the reason people stay in abusive relationships is because they don't know what they can do about it. she's not going anywhere until her self-esteem is boosted and someone shows her how to help herself. often there is a knowledge deficit as well going on (i didn't include that with the related factor) so teaching nursing interventions can be included. or, you can just add a deficient knowledge
diagnosis which goes to the bottom of the actual diagnoses list. a plan for escape would come under the risk for self-directed violence
because the goal for any potential problem is for that problem not
to occur. your nursing interventions for that are specifically:
- strategies to prevent the problem from happening in the first place
- monitoring for the specific signs and symptoms of this problem
- reporting any symptoms that do occur to the doctor or other concerned professional (in this case the police or social professional)