care mapping uuugggg!!! help with diagnoses

salad725 · Feb 25, 2009

A great resource is the Nursing Diagnoses Handbook (8th) edition by Ackley and Ladwig. But I would think Pain (acute) r/t frontal headache secondary to fall amb "patient complains of headache". Maybe Risk for injury r/t confusion (or Hx of falls). Depending if her confusion is chronic or acute, maybe from the recent fall, I may choose Acute confusion. Choosing nursing diagnoses is all about what you are going to do (or did) to care for that patient. Hope I helped! Good Luck!

Daytonite, BSN, RN · Feb 25, 2009

if you are care mapping then you know that your 4 diagnoses must be based upon abnormal data that you collected during assessment since you indicate that you have probably done several of these (i am so tired of these things). assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking

and to determine nursing diagnosis you are specifically looking for the data that is abnormal in the assessment.

there are 3 possible problems already in the information you posted and that is not even based on assessment of the patient! imagine what you can come up with if assessment activities are completed thoroughly.

data:

81 years old - this is a risk factor of risk for falls
headache - this is a symptom of acute pain
small subdural hematoma this is a medical condition and you need to look up its pathophysiology, signs/symptoms (there are others), medical treatment and complications. this acute condition is ineffective tissue perfusion, cerebral.
fall - ask yourself why she may have fallen
memory loss - why might she have a memory loss; is it a result of the hematoma or could it have been pre-existing; what kinds of problems does a memory loss present for a person with regard to performing their adls
confusion - do you think this might present a safety issue? can a confused person remember to follow normal rules of safety as they go through their daily life? can they be expected to think normally and make rational decisions like you and i? there is a nursing diagnosis for this.

also see the sticky thread: https://allnurses.com/nursing-student-assistance/care-maps-225330.html - care maps which has links to examples of nursing concept maps and information on how to construct them.

Reno1978, BSN, RN · Feb 25, 2009

I can't say enough how having a good care plan reference book is. The best one I found was by Gulanick and Myers. ISBN-13: 9780323039543

Check it out if you have a Barnes and Noble nearby, or any bookstore that has nursing reference materials. It was the best $50 I spent in nursing school that made writing care plans a snap.