Please help with a care plan problem!

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    I am in my last semester of nursing school and my teacher has changed the way we are doing care plans I have the medical diagnosis of NECK PAIN. My pt. had a non-palpable mass in the c3,4,and 5 area of her neck discovered after a MRI and had a CT guided needle biopsy. I received the pt. soon after the procedure and she was in moderate pain which i medicated her for and was ordered neuro and dressing checks q4hrs heat packs q6hrs prn for pain. She also had limited ROM in upper extremities due to the pain and the procedure. I have to put down the top 4 nursing assessments that I need to do and a nursing diagnosis for each assessment. I have: 1- pain 2- neuro 3-Integumentary 4-Musculosketal. For # 1 pain r/t muscle spasm #2 i have no idea of a nursing dx other than risk of injury r/t what??? needle biopsy??? #3 risk of infection r/t invasive diagonostic procedure # 4 imparied mobility r/t pain. I need help with # 2 if anybody has any ideas i would be so thankful.
    Last edit by comalley on Feb 22, '13
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  3. 6 Comments so far...

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    #1 Pain r/t muscle spasm - Is it muscle spasm or is the mass compressing a nerve? (May not be that important)

    #2 Neuro as in CNS which consists of the brain and spinal cord. If there is a mass in the pt's spine this could have all kinds of implications on the health and function of the CNS (and ANS). The mass could interrupt impulses that travel between the brain and spinal cord and to the periphery. I would find out what type of mass this is and what the risk factors are. Have the biopsy results come back? After that go to your Nx Dx handbook and use one of the risks for your nursing diagnosis. You could use the biopsy for potential risks as well. Find out what the potential risks of the biopsy are specifically (google it) and use your Nx Dx handbook to determine a Dx based on those risks. One risk that comes to mind is the potential for CSF leaking out of the meninges if the needle goes in or out the wrong way. This would have a profound affect on ICP. What happens when ICP drops dramatically? What Dx's can you come up with for that? What is the function of CSF? What happens when you lose it? If ICP leaks out how do they treat it? Are there risks involved with that treatment? (HINT pt. will need to be supine for an extended amount of time).

    #3 No. The chances of infection are real but rare and I wouldn't use this either. If your going to use integumentary I would say risk for impaired skin integrity r/t immobility. Is the pt on spinal precautions? If so, this would certainly limit the activity and amount of time OOB.

    Are you addressing any of the psychosocial issues? How is the pt and family coping with this new problem? Is the mass malignant? These are very important as well and an important nursing consideration.
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    Quote from comalley
    I am in my last semester of nursing school and my teacher has changed the way we are doing care plans I have the medical diagnosis of NECK PAIN. My pt. had a non-palpable mass in the c3,4,and 5 area of her neck discovered after a MRI and had a CT guided needle biopsy. I received the pt. soon after the procedure and she was in moderate pain which i medicated her for and was ordered neuro and dressing checks q4hrs heat packs q6hrs prn for pain. She also had limited ROM in upper extremities due to the pain and the procedure. I have to put down the top 4 nursing assessments that I need to do and a nursing diagnosis for each assessment. I have: 1- pain 2- neuro 3-Integumentary 4-Musculosketal. For # 1 pain r/t muscle spasm #2 i have no idea of a nursing dx other than risk of injury r/t what??? needle biopsy??? #3 risk of infection r/t invasive diagonostic procedure # 4 imparied mobility r/t pain. I need help with # 2 if anybody has any ideas i would be so thankful.
    Common problem: You have decided what nursing diagnoses you want, and now you're looking for the evidence to support them. Exactly, completely backwards.

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."


    "Related to" means "caused by," not something else.


    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition).

    You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.


    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.


    Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.


    For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications (and there are more, and many that an individual patient might have independent of his medical diagnosis).. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.


    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)


    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way
    Esme12 likes this.
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    Thank you for taking the time to reply. I have not explaned myself corectly. Instead of doing my pt. assessment then concluding what my pt. acutual problem is and doing a care plan from that my teacher wants me to take the medical dx. and decide what top 4 nursing assessments i would do for that pt. upon entering the room. That being said the report given was that my pt. had just returned from a CT guided needle bx of the neck for neck pain and an area of concern on an MRI. The orders were neuro checks q4h, dressing checks, pain meds q4h, and bedrest. So the top 4 assessments when i walk into the room was 1-pain 2-neuro 3-skin/dressing and 4-musculoskeletal. now i need a nursing dx for each assessment.
    pain for pain,
    risk for injury neurological r/t invasive cervical procedure for neuro
    I went with impaired skin integrity r/t incision for diagnostic procedure and temp restrictions on mobility for skin/dressing
    imapired mobility r/t pain and h/o joint repair surgery for musculoskeletal

    Nanda did not have a proper fitting dx for the neuro assessment again because I am sure that doing a care plan this way is incorrect. So I need to know if what I put together is fitting for what she wants.

    BTW the pt. real problem was 1-pain 2-decreased mobility from pain 3-constipation 4-distress about driving a car upon discharge (lives alone 85yo)
  7. 0
    thank you
  8. 0
    Quote from comalley
    Thank you for taking the time to reply. I have not explaned myself corectly. Instead of doing my pt. assessment then concluding what my pt. acutual problem is and doing a care plan from that my teacher wants me to take the medical dx. and decide what top 4 nursing assessments i would do for that pt. upon entering the room. That being said the report given was that my pt. had just returned from a CT guided needle bx of the neck for neck pain and an area of concern on an MRI. The orders were neuro checks q4h, dressing checks, pain meds q4h, and bedrest. So the top 4 assessments when i walk into the room was 1-pain 2-neuro 3-skin/dressing and 4-musculoskeletal. now i need a nursing dx for each assessment.
    pain for pain,
    risk for injury neurological r/t invasive cervical procedure for neuro
    I went with impaired skin integrity r/t incision for diagnostic procedure and temp restrictions on mobility for skin/dressing
    imapired mobility r/t pain and h/o joint repair surgery for musculoskeletal

    Nanda did not have a proper fitting dx for the neuro assessment again because I am sure that doing a care plan this way is incorrect. So I need to know if what I put together is fitting for what she wants.

    BTW the pt. real problem was 1-pain 2-decreased mobility from pain 3-constipation 4-distress about driving a car upon discharge (lives alone 85yo)
    Sure the is a diagnosis for neuro......what are you looking for with the neuro check.....a change in sensory perception. numbness, decreased sensation, hypersensitivity, weakness..right?

    NANDA I.........Disturbed Sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)RT the procedure.

    Defining Characteristics
    Change in behavior pattern; change in problem-solving abilities; change in sensory acuity; change in usual response to stimuli; disorientation; hallucinations; impaired communication; irritability; poor concentration; restlessness; sensory distortions


    Related Factors (r/t)
    Altered sensory integration; altered sensory reception; altered sensory transmission; biochemical imbalance; electrolyte imbalance; excessive environmental stimuli; insufficient environmental stimuli; psychological stress
  9. 0
    Quote from comalley

    Nanda did not have a proper fitting dx for the neuro assessment again because I am sure that doing a care plan this way is incorrect. So I need to know if what I put together is fitting for what she wants.

    BTW the pt. real problem was 1-pain 2-decreased mobility from pain 3-constipation 4-distress about driving a car upon discharge (lives alone 85yo)


    Thanks for the clarification. If your faculty wants you to do it backwards, surprise her by doing it properly, and cite NANDA-I as your source. I think those 4 above are perfect.

    Perhaps the concern about driving would be a self-care deficit, or ... ? I am not in my office, so you'll have to look it up yourself. Much better idea than making something up that doesn't exist in NANDA-I. We can't do that. Good thinking here.


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