Nursing Care plan on patient with a gunshot wound to the head

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    Hi I need some help on my very last care plan in nursing school since I graduate in May! My patient has a gunshot wound to the head, only 48 hours out of surgery and still in critical condition. I need 5 prioritized nursing diagnosis or potential complications. I can come up with 5 just by following my ABC's, but since it is my last one I would like to be creative with it. If anyone has any ideas I would appreciate them. Even a start to some would help I can come up with the R/T, AEB, or secondary to. (Patient info: self inflicted, intubated, ICP line, possible left side paralysis, no response to verbal or painful stimuli, + drug screen,male)
  2. 2 Comments so far...

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    Where are your 5 diagnoses? I am curious to see how you can be creative with them.
    psalm likes this.
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    I can come up with my normal nursing diagnosis just from following my ABCs(airway, breathing, & circulation just to clarify) such as:


    Ineffective airway clearance r/t increased pulmonary secretions secondary to decreased level of consciousness;


    Ineffective tissue perfusion: Peripheral and cardiopulmonary r/t interrupted blood flow with corresponding risk for thrombophlebitis and PE secondary to immobility and decreased vasomotor tone;


    Risk for infection r/t inadequate primary defenses secondary to ventilator intubation in patient with a traumatic brain injury;


    Impaired verbal communication r/t neurological deficit and intubation.


    And I can come up with a bunch more but they are the same one’s I use every time I have written the goals and intervention 100 times. I wasn’t trying to get anyone to do my care plan. I was just trying to see if anyone else had a different outlook on the situation. Some others I can do just to prove my point are as follows (not listed in any specific order):
    Constipation
    Decreased intracranial adaptive capacity
    Impaired physical mobility
    Risk for impaired skin integrity
    Impaired oral mucous membrane
    Pain
    Risk for activity intolerance
    Risk for disuse syndrome
    Ineffective role performance
    Disturbed body image
    Disturbed sensory perception
    Risk for infection r/t a number of things
    Impaired gas exchange
    Risk for aspiration
    Risk for imbalance fluid volume
    Risk for imbalance nutrition
    Risk for imbalance body temperature
    Self care deficit

    For the Family:
    Fear
    Anxiety
    Ineffective coping
    Powerlessness
    Spiritual distress
    Anticipatory grieving/ Risk for dysfunctional grieving
    Deficient knowledge r/t a million different things
    Interrupted family process
    Compromised Family coping

    I could use any of the above I just wants someone else’s input particularly someone with neurological or ICU experience. Thanks
    Last edit by VickyRN on Apr 11, '09 : Reason: Make easier to read


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