Care plan help!

[springchick1, ADN, RN]

I need some help. I have a patient who had a seizure two days ago while at the doctors office. He was transported to the hospital where he has been seizure free since then. His BP is 86/50 and HR 58. He is on BP meds (which we held) and other pain medication. When coming up with a nursing diagnosis to develop into a care plan, I came up with Risk for Injury. He is a fall risk because of his meds and his BP being so low and he is at risk for having another seizure which could cause injury. My clinical instructor said that he wouldn't be at risk for injury since he has already had a seizure and said that I should do Ineffective Health Maintenance. My questions are:

1. Isn't the nursing diagnosis supposed to be based off of what is happening right now with the patient, not what happened to days ago?

2. I am understanding Ineffective Health Maintenance to be someone who isn't taking care of themselves, isn't keeping doctors appointments, and is ignoring signs that they should seek medical treatment. Am I understanding this correctly? I emailed my instructor to ask her these questions but I haven't heard back. Thanks for the help!

[jmilkah]

I think the care plan is based on what you can do as a nurse to lead the patient to recovery. There are measures you can implement independently to ensure this event doesn't recur, like monitor v/s/ labs/med admin etc..events leading to situation might guide you..see chart on page 207 of Berman/Snyder 9th edition, on what can be developed into a care plan. Apply the process to your situation and determine what aspects of the event you could independently resolve to conclusion, without collaboration...

[nurseprnRN, BSN, RN]

There are approximately one bajillion threads about learning how to plan your patient's nursing care here, so I hesitate to repeat myself in another one. The A#1 thing you must do to make a diagnosis, which is what you are doing, NOT selecting one off a list, is to have the data you need to support your making one. If this patient has data indicating that he has a real problem with ineffective health maintenance, by all means, you can make that diagnosis and plan to give care that will help him.

Do not pass GO without getting the NANDA-I 2012-2014 from Amazon, because it is the ONLY definitive book on how to make a nursing diagnosis. It includes all approved nursing diagnoses, with their causes and defining characteristics. You cannot make them up, nobody can. Nobody. You can only, only, only make a diagnosis if you have the defining characteristic(s and cause(s) in that book for it, and that's the end of it.

No other book has these as comprehensively or as currently, because NANDA-I owns the work and doesn't grant everyone else who wants to write a "care planning handbook" unlimited permission to copy all of it. Also if your other work is from before 2012, it may very well include diagnoses that have been removed from the approved list because of lack of support, or miss including new ones. $29 and free 2-day delivery, or $25 and instant delivery to your Kindle or iPad. Do it.

A given nursing diagnosis could be based on what came before today; assessing history is part of your diagnostic process. When you consider that your patient is here in your care today, but will be discharged sooner or later, you have to consider where he came from and where he'll be going.