I just had a quick question for anyone willing to help! I am trying to come up with a psychosocial diagnosis for my 3 year old pediatric patient and for some reason I feel like I'm hitting a wall. Basically, my patient was hit by a car (the mother was driving) and unfortunately suffered a traumatic brain injury. He does not communicate verbally (mainly nonverbal cues such as moaning, crying out, pushing my hands away when trying to assess his lung sounds), and has digressed in his Erikson stage from Autonomy vs. Shame to Trust vs. Mistrust. He does not follow commands and cannot meet my gaze for a very long period of time. He can get out of bed to his chair, but needs the assistance of PT and must wear a helmet when out of bed.
I felt the best Biophysical diagnosis for my patient would be acute pain r/t skull fracture and craniotomy AEB nonverbal assessment cues (patient restless, crying out during movements, etc.). However, I'm stuck for some reason on a psychosocial nursing diagnosis.
The psychosocial diagnosis has to be for my patient and my professor does not want any risk for diagnoses. Which leads me to the idea of using Impaired Social Interaction r/t communication barriers and impaired physical mobility AEB the patient is nonverbal and uses only nonverbal cues to express wants, needs, or pain and assistance of PT needed to get out of bed.
Thoughts? I feel like my brain is mush from this semester so any help would be fantastic!
Apr 23, '12
that looks pretty darn good to me. you might want to add that he is nonverbal due to brain injury, and consider what effects the brain injury is having on his biophysical assessment, too. you should be able to get some good hints form the pt/ot evals.
my compliments to your faculty, as you are obviously getting the idea of nursing diagnosis.
Apr 23, '12
Thanks, GrnTea, I appreciate your input. I'm a Junior so I definitely should have the hang of it by now but for some reason I just couldn't think anymore and thought I'd go to other nurses