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- What care plan/nursing diagnosis book do you have? What about your assessment of the patient stands out to you. What is affected neurologically with a C4 lesion have?
Spinal Cord Injury Levels - Functionality of C4 Spinal Cord InjuryMobility & Movement
Full head and neck movement depending on muscle strength. Limited shoulder movement.
Complete paralysis of body and legs. No finger, wrist or elbow flexion or extension.
Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia.
Electric wheelchair may be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity.
The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety.Complete assistance required during mealtimes.Respiratory System
Able to breathe without a ventilator using diaphragm.Assistance required to clear secretions and assistance in coughing will be required.Personal Care
Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management.Domestic Care
Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.Communication
What does NANDA say about chronic pain? Even thought she has this pain chronically can't some of her pain be acute as well? What does NANDA say about impaired comfort? How are her ADL's affected? What does NANDA say about insomnia?
- She has self care deficit. She has pain. She has insomnia.....saying she sleeps 6 hours your interoretation that she gets enough but the PATIENT complains difficulty sleeping........NANDA defines insomnia as.....
Frequent complaints of disruption in amount and quality of sleep that impairs functioning (noisy roommate counts)
Observed changes in affect; observed lack of energy; increased work/school absenteeism; client reports changes in mood; client reports decreased health status; client reports decreased quality of life; client reports difficulty concentrating; client reports difficulty falling asleep; client reports difficulty staying asleep; client reports dissatisfaction with sleep (current); client reports increased accidents; client reports lack of energy; client reports nonrestorative sleep; client reports sleep disturbances that produce next-day consequences; client reports waking up too early
Related Factors (r/t)
Activity pattern (e.g., timing, amount); anxiety; depression; environmental factors (e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting); fear; gender-related hormonal shifts; grief; inadequate sleep hygiene (current); intake of stimulants; intake of alcohol; impairment of normal sleep pattern (e.g., travel, shift work); interrupted sleep; medications; parental responsibilities; physical discomfort (e.g., body temperature, pain, shortness of breath, cough, gastroesophageal reflux, nausea, incontinence/urgency); stress (e.g., ruminative pre-sleep pattern)
Suggested NOC Outcomes
Comfort Level, Pain Level, Personal Well-Being, Psychosocial Adjustment: Life Change, Quality of Life, Rest, Sleep
Example NOC Outcome with Indicators
Sleep as evidenced by the following indicators: Hours of sleep/Sleep pattern/Sleep quality/Sleep efficiency/Feels
- Oct 12, '12 by MatkaThank you!
- You're welcome.....even though I have never assessed this patient fromher complaints I was able to make a nusing diagnosis? The patient drives what THEY NEED to be better.....