62 yo male, paraplegic- need help determining 3 nsg dxs

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Hello all!

I am a 1st semester nsg student. My pt was in a car accident where his T8 was fractured, and he is now a paraplegic. His admitting dx is Acute Respiratory Failure following trauma and surgery.

My instructor wants us to focus our nursing diagnosis on psychosocial and adverse effects of medication if we can.

I have been using Ackley's Nursing Diagnosis Handbook 2011, for my Outcomes/goals and my instructor has marked every one wrong. She said I am supposed to make them up on my own, but I haven't been able to get many of those right. I'm just really struggling with this...

Here are the Cues i have so far:

  1. Pt. Stated "I'm going to be the freak in the wheelchair".
  2. Stated "I am ashamed and embarrassed about not having the use of my legs anymore".
  3. Stated "I have 4 doctors and I only know the name of one and what he's doing. I don't know what the other doctors have diagnosed me with or how they are treating me".
  4. Stated "I don't know what medications I'm taking or what they're for".
  5. Stated "I don't know if I'm even going to make it out of the hospital alive".
  6. Stated "I probably won't live through this".
  7. Stated "My anxiety level is 10/10".
  8. WBC 19 k/uL High (Normal 4.8-10.8)
  9. RBC 3.23 mL/uL Low (Normal 4.70-6.10)
  10. Hemoglobin 9.4 g/dL Low (Normal 14.0-18.0)
  11. Hematocrit 27.7% Low (Normal 42-52)
  12. Enteral feeding via indwelling PEJ tube
  13. Paraplegia; T8 fracture
  14. Stage 4 pressure ulcer; sacrum
  15. tracheostomy
  16. Stated "the pain in my arm is 8/10 any time I move it".
  17. BUN 39 mg/dL High (Normal 7-20)
  18. Creatinine 0.9 mg/dL Normal
  19. Potassium 5.2 mmol/L High (normal 3.6-5.0)
  20. Albumin 2.5 g/dL Low (normal 3.5-5.5)
  21. Tracheal Aspirate Culture indicates presence of yeast species

Here are some possible Nsg Dx I'm thinking of, but I'm not sure if I'm on the right track:

1. Disturbed Body Image r/t loss of leg function, 2. Death Anxiety r/t uncertainty of prognosis

3. Readiness for Enhanced Knowledge r/t medical treatment

4. Anxiety r/t change in health status

5. Risk for adverse effects of medication (high BUN levels may be caused by adverse effects of antibiotic Cefepime...not sure if this is a nsg dx or a medical dx)

6. Pain r/t injury in L arm

I want to use Fatigue r/t anemia and Impaired Skin Integrity, but since I've used them before on other patients my instructor has asked me not to use them again.

I need 3 diagnosis. Will any of these diagnosis work? If so, how do I form measurable outcomes/goals?

Thank you so much for taking the time to read thru this and for responding.

Leslie, S.N.

Ok, thank you! I'm working on the Stress Overload D.P.I.E. right now.

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Oh yeah, this poor guy...I definitely don't envy him.

Ok, so...

Nsg Dx: Stress Overload r/t Inadequate Resources and multiple coexisting stressors.

Goal: Patient will verbalize reduction in stress levels through use of relaxation techniques and other strategies

AEB

  1. Will state implementation of at least one alternative method of reducing stress
  2. Will rate stress level at less than or equal to 4 on a scale of 1-10.

Interventions:

  1. Explore possible therapeutic approaches such as cognitive behavior therapy, biofeedback, neurofeedback, pharmacologic agents, relaxation techniques, breathing techniques, visual imagery, and soothing rituals. . Rationale: Neurofeedback promotes optimum functioning of the central nervous system, induces relaxation, and supports resilience" (Ackley & Ladwig, 2011, p. 806).
  2. Listen actively to descriptions of stressors and the stress response. Rationale: Developing nurse-client partnerships is the best way to obtain valid and reliable information related to stress overload" (Ackley & Ladwig, 2011, p. 806).
  3. Categorize stressors as modifiable or nonmodifiable.
  4. Help patient modify or mitigate stressors identified as modifiable. Rationale: Removing or minimizing some stressors, changing responses to stressors, and modifying the long-term effects of stress are all actions that can assist those with illness and stress" (Ackley & Ladwig, 2011, p. 805).
  5. Assist the client to mobilize social supports for dealing with recent stressors. Rationale: Emotional and social support moderates the impact of recent but not chronic life stress on physical symptom reporting" (Ackley & Ladwig, 2011, p. 806).

How does this one sound?

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I would be very pleased of one of my students submitted this revision, and it seems to meet her desire for your noting how you will know your interventions will be evaluated; this must be what she meant with AEB in the goals. Nice work. I would suggest inserting the patient's actual words in the diagnostic stmt, but if you have them listed in another section above, that would cover it. Be sure you use the NANDA-I for all your r/t and AEB to be confident that you aren't ever making it up.

Get the books, especially the NANDA-I, if only to help you get a really good gut understanding of the process sooner rather than later. The NIC, NOC, NANDA is the best for seeing how to put it all together.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What she said....;)

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Esme12 and GrnTea...THANK YOU!!!!!!

I got a 92 on this care plan! Thank you so very much! And my instructor asked that I pass on her thanks as well :) She said this was by far my best care plan and, because there were no big issues to mark off, the only points I had taken were for small things.

Thank you again!!!!! You two ladies are wonderful!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Congratulations! You did the work we just showed you where to look! I LOVE to hear back from the students!!!! Next care plan please....LOLOLOL

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Hahah! I already posted my next one :geek: under 60 yo female with Osteomyelitis of R great toe :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

LOLOLOL:roflmao:

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Hahah! I already posted my next one :geek: under 60 yo female with Osteomyelitis of R great toe :)

But now you know how to do it properly, right? You got the books? We'll have to go over there and check it out. :)

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