Care plan diagnoses

nurseprnRN, BSN, RN · Nov 1, 2011

"acute pain related to fall as manifested by pain of 7/10

i think the pain is caused by the fracture, and your assessment is supported by his report of pain 7/10

increased cardiac output as related to fall manifested by pain 7/10

increased cardiac output (what is your evidence for this existing?) is not caused by his fall, nor by his pain

activity intolerance related to fall as manifesed by fracture in right hip ( now should i say farcture in right hip?)

i'm thinking less activity intolerance and more "impaired mobility," caused by hip fracture, manifested by inability to bear weight

self-care deficit-(toileting, transfering) as related to fall as manifesed by pain 7/10

i don't think the fall caused his deficit, i think it's the pain and impaired mobility (yes, it's appropriate to refer to a previously-made nursing diagnosis to support another)

falleclipse · Nov 1, 2011

ok I trying to find a nursing dx that had to do with increased BP and pulse...I was at a lost and the closest I could get was increased cardiac output....can you think of another for the increase in Blood pressure...

I started with Assessment BP 165/84...Goal- will have Blood Pressure 110/75-135/85? in idk 2hrs Now I could not come up with a nursing dx for this

nurseprnRN, BSN, RN · Nov 2, 2011

why? what nursing problem is this? nursing assessment would include measuring bp/p as it's data that can tell you about interesting things, such as developing or resolving hypovolemia. however, high blood pressure is a medical diagnosis, and is treated medically.

tell me a little more about what your thinking is for wanting to include something about bp/p in your nursing plan of care, and your desire to decrease it as you describe. what does this relate to, in your mind?

falleclipse · Nov 2, 2011

well my teacher wanted us to address this but I was thinking that it was high because patient was in pain. So I was lost. I thought BP/P high because of the release of adrenaline. Once the pain is treated, these numbers should go down. But she asked us to address it as a separate need.? There was no talk of hypovolemia in the small case study.

KimN · Nov 2, 2011

Well here is my two cents on the BP issue. Based on what is presented here we do not know what is normal for this patient. Yes it is unlikely that her BP is normally that high, however, we cannot assume that she is having increased CO when we really don't know if that is abnormal for her. Also, you can make a nursing diagnosis and interventions related to her pain - within these interventions you can address the BP briefly by stating that pain medication as ordered may decrease anxiety and may lower BP (or something along those lines so it satisfies instructor). Most likely your instructor just wants to see that you can connect increased heart rate and blood pressure to a response to pain. Good luck!

ooomonkeys · Nov 4, 2011

Can't think of a BP/P NANDA for you... But have you considered

Risk for peripheral neurovascular dysfunction (Right Lower Extremity)

Risk for impaired skin integrity

You can figure out the related to's...

falleclipse · Nov 8, 2011

Thanks everyone. A couple good ideas to play with. I will get the hang of this I know it. I just have to get used to a different thought process. All good now :)

xtxrn, ASN, RN · Nov 9, 2011

Can't think of a BP/P NANDA for you... But have you considered
Risk for peripheral neurovascular dysfunction (Right Lower Extremity)
Risk for impaired skin integrity
You can figure out the related to's...

r/t what ? :)

(I think I know where you're going- but it's not simply the fall)