I am currently working on a care plan for a patient with chronic otitis media.
We have to come up with one "at risk" diagnosis and one "wellness" diagnosis.
My idea for the wellness diagnosis was effective therapeutic regimen management, as the patient is an avid swimmer and has not worn ear plugs, resulting in repeated infection with Swimmer's ear. She also had been giving ear drops in the past, but occasionally decided to stop taking the medications when her ears stopped hurting without finish the course of treatment. Alternatively, I thought maybe readiness for enhanced home maintenance management... I'm not sure which one would be more appropriate, but I think my first one makes more sense, although they are both pretty similar.
My at risk was going to be risk for injury or falls, because chronic otitis media can result in poor balance because the inner ear cannot drain properly.
This is my first time using an "at risk" or "wellness" diagnosis, so I just wanted to ensure that I'm using them properly... was hoping for a bit of feedback.
Thanks so much!
Mar 17, '13
Your patient has chronic infections. She is not wearing ear plugs. She is not taking her preventative medications. Does that sound like an effective therapeutic regimen?
Do she express a desire to learn more about preventing ear infections? Is she willing to wear ear plugs and take her medicine? Those are signs of readiness for enhanced home maintenance management. But if she's not willing to take the needed measures to prevent infection, that's not an appropriate diagnosis.