how would you create a care plan for someone who has....

CRIMSON · Dec 3, 2009

hematoma on her forehead due to falling.. I mean in the NANDA text there's nothing about hematoma

Ok, just a few questions.

How long since she fell? (pain, acute r/t fall aeb hematoma on forehead), what made her fall? accident or gait impairment? Is she confused? anxious? (risk for acute confusion r/t...., anxiety r/t.....) dehydrated? on meds that made her fall? (fluid volume deficit r/t......) risk for falls r/t medications.....)

Hope this helps with the thought process. Just need more information to really help. Kind of a scenario quick history of current illness type thing. Looking for the time passed, reason for fall, age, mental state will give you a way to go for nursing diagnosis.

NurseKitten, MSN, RN · Dec 3, 2009

Did she fall from a loss of consciousness due to cardiac arrythmias?

Has she started blood pressure meds that made her dizzy and fall?

Knowledge deficit is always a good one - pick a topic regarding her safety (personally, I like the whole orthostatic hypotension and changing positions gradually lesson) and implement that as part of the CP.

Agree with the previous poster - look at the underlying conditions causing.

Also could do something with the potential for a coup/contrecoup injury - read up on it. Good lesson, 'cause I guarantee, it won't be the last time you encounter it in your career. :)

Daytonite, BSN, RN · Dec 4, 2009

hematoma on her forehead due to falling.. i mean in the nanda text there's nothing about hematoma

well, sure there is. it's called impaired skin integrity. look it up in the nanda taxonomy and you will see the signs and symptoms of it there. also include, risk for falls.

diagnosis is based upon the signs and symptoms that a person has, not upon their medical diagnosis.

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans