Help w/ head injury pt - page 2

Can someone help me figure out what exactly was wrong with my patient? I waited until 2 days before I go back to school to do my maxi map/care plan and now I'm kicking myself big time. I'll tell... Read More

  1. by   luv2shopp85
    I don't think I could use Risk For Injury R/t inability to control movement during seizures because we can't use a medical diagnosis in the r/t. Also.. we have to list one potential complication of the main medical diagnosis that patient has and then list interventions we did to prevent that potential complication from occuring. I was going to use Seizures as a potential complication so I Dont think i could use it twice it might look like I'm repeating myself. So far I have.

    Disturbed Thought Processes R/T Neurophysical Changes Secondary To Head Trauma AMB Disorientation To Place, Altered Behavioral Patterns, Impaired Ability To Perform ADLs, Memory Impairment, Inaccurate Interpretation of the Environment, Distractability, Difficulty With Speaking and Forming Words, Slowed Responses to Stimuli, Difficulty Concentrating, Difficulty With Comprehension




    Impaired Physical Mobility R/T Musculoskeletal Impairment, Neuromuscular Impairment, And Limited Strength AEB Inability To Move Purposely Within Physical Environment, Limited ROM Of Right Extremities, Decreased Muscle Endurance, Decreased Muscle Control, Decreased Muscle Strength, Inability To Perform Actions As Instructed, Dragging Of Right Foot With Ambulation, Limited Ability To Perform Gross And Fine Motor Skills, Decreased Walking Speed, Difficulty Initiating Gait, Small Steps When Walking, Shuffling Of Feet.
  2. by   luv2shopp85
    Also... I almost forgot about this but i was looking through my notes and I realized the day before I had her that she had tried to get out of bed to get up and go to the bathroom and fell. So maybe I should use Fall risk instead of Risk for Injury. I kind of thought they were the same thing. And that Risk for Injury would account for fall risk as well but im not really sure. Can anyone help me on this?
  3. by   srg4784
    Yeah, this is what I was talking about.....safety is an issue b/c of right sided weakness...and Hx of falls so.. Risk for fall r/t hx of fall, right sided weakness........... risk for injury is alittle bit different......eg. Risk for injury:fall r/t right sided weakness ......and I think you said the pt. mentioned the weakness and if so you could change it to Risk for injury:fall r/t pt. statement "right sided weakness" or Risk for fall ..." "

    and your other dx that you mentioned were awesome as well as daytonites (shes the best source ever btw!!!) but as a priority .... I think safety should be first, that's just what has been drilled into my head since day one. When I actually look at pt's charting though under nursing dx, safety is usually number 2 or 3 which I never understood why it wasn't number 1.
    Last edit by srg4784 on Jan 3, '07
  4. by   Daytonite
    luv2shopp85. . .i think you're good to go with using disturbed thought processes r/t neurophysical changes secondary to head trauma amb disorientation to place, altered behavioral patterns, impaired ability to perform adls, memory impairment, inaccurate interpretation of the environment, distractability, difficulty with speaking and forming words, slowed responses to stimuli, difficulty concentrating, difficulty with comprehension and impaired physical mobility r/t musculoskeletal impairment, neuromuscular impairment, and limited strength aeb inability to move purposely within physical environment, limited rom of right extremities, decreased muscle endurance, decreased muscle control, decreased muscle strength, inability to perform actions as instructed, dragging of right foot with ambulation, limited ability to perform gross and fine motor skills, decreased walking speed, difficulty initiating gait, small steps when walking, shuffling of feet.

    how about risk for injury r/t history of falls and loss of consciousness? then, your nursing inventions would include all the steps you need to take protect the patient from seizure activity--as well as from falling.

    other ideas in wording the r/t part of risk for injury. . .ackley and ladwig list the wording for this with seizure disorder as risk for injury r/t uncontrolled movements during seizure (page 126, nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig). doenges, moorhouse and murr list the risk factors for this nursing diagnosis as altered consciousness, weakness, balancing difficulties, cognitive limitations, loss of large or small muscle coordination and/or emotional difficulties (page 211, nursing care plans: guidelines for individualizing client care across the life span, 7th edition).

    by the way, you've got a spelling error. i've red bolded it above.
    distractability should be spelled distractibility according to my spell checker.
  5. by   jov
    Quote from rn/writer
    The original post shows that this poster has put plenty of thought and effort into working on her care plans for this patient. Needing help to understand is not the same as asking us to do the work for her.
    Since it is allowed, I am going to disagree here. The poster has written a lot of DATA in the original "care plan" but the very fundamental bones of nursing is using nursing diagnoses instead of trying to find a medical diagnosis. Whilst there may be a lot of typing, energy etc. going into the care plan, it appears evident that unfortunately the OP does not grasp the essential bottom line. Hence, "see your instructor ASAP."
  6. by   luv2shopp85
    Well I've finished my maxi map and will be handing it in tomorrow. SO theres no need to discuss this any more and say that I was asking for you guys to do it for me because obviously I wanted to do it myself and make sure I was doing it right so i was actually learning something. And yes I did learn something. UKnurse, you helped me by what you wrote! It helped me understand better. And daytonite you helped a lot too! Thanks people. But the majority of the maxi map was done by me.
  7. by   Daytonite
    Quote from jov
    um...i could be wrong but it appears you are asking us to do your care plan?

    the best i could recommend is to see your instructor asap
    i am always curious as to how people make a determination that others might be asking forum members to do their homework. so, please, tell me, how do you determine this? i really want to know.

    i maintain a list of people that i question might be doing this. before i would even think of publicly chastising them, i do some assessment and investigation of my own first. sometimes that involves answering their first question or two. but often by a third question, and in the frequency they post, their motives become pretty obvious. i have a list taped to my computer of those who i believe are looking for forum members to do their homework for them and i eventually stop replying to their posts. and, you know what? so do the other regular members. and, they fade away.
  8. by   rn/writer
    Quote from daytonite
    i am always curious as to how people make a determination that others might be asking forum members to do their homework. so, please, tell me, how do you determine this? i really want to know.

    i maintain a list of people that i question might be doing this. before i would even think of publicly chastising them, i do some assessment and investigation of my own first. sometimes that involves answering their first question or two. but often by a third question, and in the frequency they post, their motives become pretty obvious. i have a list taped to my computer of those who i believe are looking for forum members to do their homework for them and i eventually stop replying to their posts. and, you know what? so do the other regular members. and, they fade away.
    thank you, daytonite! i, too, have noticed certain things about those who are looking for an easy out. it doesn't usually take too much to smoke them out. for one thing, when we ask in depth questions, they don't have much to say. it becomes apparent that they don't want help, they want a total rescue.

    i didn't ever get that impression with this poster. she had put forth a great amount of effort. perhaps some of it was "barking up the wrong tree," so to speak, but that is often part of the education process. learning what an appropriate care plan is can begin by learning what it is not.

    the op appeared to have acted in good faith and asked her questions with an open mind. besides supplying a large amount of data, she seemed teachable and eager to use our input as a supplement to her own thoughts, not as a substitute for them.

    the kinds of members who invite negative responses are those who post things like, "what should i do my term paper/research project/thesis on," and don't supply an ounce of information beyond that or demonstrate that they've given their assignment any thought whatsoever. or they post questions that sound like they're lifted right from the classroom and don't discuss their possible answers and rationale.

    i don't have any problems with the ones who at least try. if they don't quite get it, they've come to the right place. but the ones who expect easy answers are a different story.

    as daytonite said, they don't usually last very long.

    lovetoshop85, please follow up with us and let us know how you did.

    i wish you well.
    Last edit by rn/writer on Jan 4, '07
  9. by   ukstudent
    I am glad that I was able to help in a small way. I gave you the same advice that I was given, by a wonderful clinical instructor when I was having problems. The best advice as always comes from daytonite.
  10. by   jov
    Quote from daytonite
    i am always curious as to how people make a determination that others might be asking forum members to do their homework. so, please, tell me, how do you determine this? i really want to know.
    good question, daytonite!
    the first tip off is:
    "i waited until 2 days before i go back to school to do my maxi map/care plan and now i'm kicking myself big time." nuff said.

    the second tip off is the vast majority of the data came from other healthcare providers and the chart - the ems report, the nurses' report, the x-ray reports, etc. sure it looked impressive, but when you really examined what was there, it was all parroting someone else. the best the op could do was state the patient kind of dragged around when she walked, and then went on to repeat what the other nurse had told her.

    the third tip off was the poster still did not understand the purpose of nursing diagnoses and how they differ from medical diagnoses.

    finally, then she gave 10 nursing diagnoses that would be perfectly appropriate for starting a care plan for the patient but she didn't seem they applied.

    my main concern is that this is a nursing student who apparently has finished at least one semester but still does not understand the most fundamental basics of nursing diagnoses. it seemed she would greatly benefit by sitting down again with her instructor who could walk her through this. also, the instructor would get feedback that a) either this student ain't getting it or b) the instructor ain't getting it across. either way, it's important for the instructor to find out that this student wasn't capable of putting together a care plan on her own.

    i thought some of the other posts were good in the way that they kind of pointed her in the right direction. daytonite, i have great respect for your nursing knowledge but i feel like you handed out the answers on this one. i'm not sure why you felt it would benefit the student to follow your thought process rather than puzzling it out on her own, but there you go. to each his own.
  11. by   Daytonite
    Quote from jov
    good question, daytonite!
    the first tip off is:
    "i waited until 2 days before i go back to school to do my maxi map/care plan and now i'm kicking myself big time." nuff said.

    the second tip off is the vast majority of the data came from other healthcare providers and the chart - the ems report, the nurses' report, the x-ray reports, etc. sure it looked impressive, but when you really examined what was there, it was all parroting someone else. the best the op could do was state the patient kind of dragged around when she walked, and then went on to repeat what the other nurse had told her.

    the third tip off was the poster still did not understand the purpose of nursing diagnoses and how they differ from medical diagnoses.

    finally, then she gave 10 nursing diagnoses that would be perfectly appropriate for starting a care plan for the patient but she didn't seem they applied.

    my main concern is that this is a nursing student who apparently has finished at least one semester but still does not understand the most fundamental basics of nursing diagnoses. it seemed she would greatly benefit by sitting down again with her instructor who could walk her through this. also, the instructor would get feedback that a) either this student ain't getting it or b) the instructor ain't getting it across. either way, it's important for the instructor to find out that this student wasn't capable of putting together a care plan on her own.

    i thought some of the other posts were good in the way that they kind of pointed her in the right direction. daytonite, i have great respect for your nursing knowledge but i feel like you handed out the answers on this one. i'm not sure why you felt it would benefit the student to follow your thought process rather than puzzling it out on her own, but there you go. to each his own.
    i'm sorry, but i don't see any connection between waiting two days before an assignment is due and making a judgment that they are looking for others to do their homework. the op was very simply stating their situation.

    secondly, in both nursing colleges i attended data from other healthcare providers and the chart, including the ems report, the nurses report, the x-ray reports as well as a good many other documentation items were stressed as being inclusive in a nurses data assessment. and my professors weren't the only ones saying this. here's quotations documenting this: "assessment information is obtained first by taking a thorough health and medical history. . .much of this information will be gathered from the physical assessment and diagnostic test results, and possibly from the client's significant others. the information from each of these sources is used to formulate a nursing diagnosis." (page 3, nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig). "client data base. . .includes. . .data that would likely be collected through the history-taking interview, physical assessment, dignostic studies, and review of prior records." (page 9, nursing care plans: guidelines for individualizing client care across the life span, 7th edition, by marilynn e. doenges, mary frances moorhouse and alice c. murr). "assessment data are abundant in any clinical setting. . .methods useful in gathering these diverse data include interview, direct and indirect observation, physical assessment, medical records review, and analysis and synthesis of available laboratory and other diagnostic studies. the sum of all information obtained through any or all of these means allows the nurse to make a nursing diagnosis." (page 3, nursing care plans: nursing diagnosis and intervention, 6th edition, by meg gulanick and judith l. myers)

    when you have a patient, as this one in particular, who is not able to give a satisfactory history you must review the medical record. it is prudent and advisable. i've done it my entire career.

    as far as the op not understanding the purpose of nursing diagnoses and how they differ from medical diagnoses. . .with that i disagree. the op specifically began the thread stating she was trying to figure out what was wrong with her patient. she needed to list a specific medical diagnosis to put on her maxi map. the problem was that the only medical diagnosis she could find on the chart was cerebral injury. that is a very broad term and covers a lot of ground. as a medical coder i can tell you that after discharge this chart would be sent back to the doctor for a more specific medical diagnosis because many of the treatments done on the patient could not be billed nor paid for by third party payers with a diagnosis like that!

    what are the fundamental basics of nursing diagnosis? i repeat them all the time in replies to students. the reason is because this is incredibly difficult stuff for some people to understand. i can tell from the way students pose their questions when they don't understand the process which is why they are stuck. sometimes hearing it from another person helps it click in a person's brain. when other students assist each other by also posting these basics of what make up a nursing diagnosis it also helps reinforce it in their minds as well.

    this is a discussion forum. i don't see anything wrong with someone listing potential nursing diagnoses and asking for help. in discussion you can debate and analyze choices. nothing wrong with that.

    it takes much more effort to post help. were you to post a question for help with an assignment i would extend my same helping efforts to you. i don't understand why you feel i'm giving away answers. care planning is a totally creative process. what i post can be used, or not. there are always choices a student can make in writing their nursing diagnoses. after all, they saw and worked with the patient. i am working from what is written on a page i am reading. i do this not only for the op but for all the others out there who also read these forums. if i am helping only one person understand this material, then i don't feel my time has been wasted. if people posting for help with homework bothers you so much then report it to the moderators and the administrator of the forum--please.

    i wanted to discuss this with you privately, but you have disabled your private messaging.
  12. by   luv2shopp85
    jov,

    It was my Christmas Break... do you want to be doing a maxi map over your christmas Break? I sure don't. The reason I waited till 2 days before was because I was doing nothing those 2 days and knew I would have time to get it done. I also had an exam to study for over Xmas break too so that took up some time. And I was working at the hospital nearly every day to make money to pay off credit card bills. And if you really must know.. my step dad was in the ICU for 3 weeks after Thanksgiving with severe pneumonia and nearly died. From driving back and forth to the hospital and not getting any studying done i was just exhausted and needed some "Me" time. I did not study at all during that time. So i had an exam, step dad to worry about, and then a maxi map. And yes I do understand the difference between nursing and medical diagnosis. Are you kidding me? I was a lil confused because I normally look up a medical diagnosis in my care plan book such as for a stroke and it would give me 7-10 diagnosis and I would use whichever applied to my patient and adjust them to fit my patient specifically.

    Also... I used 10 different nursing diagnosis with one potential complication. Did you see anyone on here list 10 diagnosis for me? NO.. the reason why is I did it myself! After i got some direction I was able to figure thetm out myself and apply it to my patient.

    Did I use some of Daytonite's information? Yes I did.. if i felt it was right and i thought it applied to my patient. Did I use everything she said word for word and all diagnosis? No.. If I didn't like something I will not use it. Its my maxi map and I'm the one with the grade.

    But please this maxi map is done and over with! I will be getting a pretty damn good grade on it because I spent all day doing it and I'm sure its a good one. Thanks for your concern though.. its a little weird but whateverrr
  13. by   jov
    Quote from luv2shopp85
    this maxi map is done and over with! I will be getting a pretty damn good grade on it because I spent all day doing it and I'm sure its a good one.
    FYI, my previous post was a direct response as requested by Daytonite.

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