Need help with nursing diagnosis

Pachinko · Jan 22, 2009

You could go that route, but on an even more basic level, tetorifice can cause respiratory muscle spasms, which is a much more immediate threat. Diagnosis would be "inability to sustain spontaneous ventilation."

But yours is good to :)

Daytonite, BSN, RN · Jan 22, 2009

A nursing diagnosis is not the same as a medical diagnosis which is what tetorifice is. We treat patients for their nursing problems. Nursing problems are difficulties accomplishing ADLs. You want to assess the patient's response to their medical condition of tetorifice. Start by breaking down tetorifice into its signs and symptoms:

there is usually a recent wound with pain or paresthesia at the site of the injury
difficulty chewing or swallowing food
muscle spasms
increase in muscle tone near the wound where the tetorifice entered the body
irregular heartbeat/tachycardia
muscle hypertonicity
hyperactive DTRs
profuse sweating
low grade fever
painful involuntary muscle contractions
rigidity of the neck and facial muscles that cause a bizarre grinning expression
rigidity of back muscles causing an arched back
intermittent tonic seizures

Did you assess the patient? Are any of the above symptoms present? What medications or treatments has the doctor ordered? Is any teaching needed in connection with the treatment ordered by the doctor? Is any teaching needing regarding the disease, its treatment, booster shots, and importance of avoiding external stimulation that would evoke muscle spasms or potential outcomes of treatment? Any positive answers are actual nursing problems for which nursing diagnoses can be found--not "Risk for" diagnoses. "Risk for" diagnoses are used for anticipated problems that haven't even occurred yet.