Nursing Diagnosis Please Help

[alegea23]

I am having trouble coming up with 2 potential nursing diagnosis for one of my patients. He does not have a diagnosis and was admitted to the hospital for headache and ear pain. Both of his eyes were red and sensitive to light. They ruled out pink eye. Please help with what he would be at risk for.

Thanks.... I could use the help. 

[Kristi Lee]

Is he on any pain medication, usually the meds have nusing diagnosis listed in the drug guide , try looking there. How about pain?

[Imafloat, BSN, RN]

He is at risk for falls r/t impaired vision. Anyone admitted to the hospital is at risk for infection r/t the hospitalization.

[Kristi Lee]

Sorry, I didn't see that you wanted risk for diagnosis

[CaseManager1947]

alteration in comfort r/t headache manifested by -----

alteration in comfort level r/t photosensitivity manifested by -----

is he immobile??

alteration in vascular system r/t immobility manifested by risk for dvt

nutrition???

sleep????

any abnormal labs, x-rays?????

maybe thats a start,

[Daytonite, BSN, RN]

Choosing nursing diagnoses always starts with the assessment data you gathered. in this case you've provided us with these symptoms: A headache and ear pain. also, that his eyes were red and sensitive to light. Since that's all the information you've given, then those are the only symptoms, or "defining characteristics" I'll have to make a decision on nurses diagnoses.

Here's my suggestions for nursing diagnostic statements (I am using currently accepted nanda nursing diagnoses as of 2005):

• acute pain r/t potential tissue damage (note: it's likely the pain is being caused by edema secondary to some inflammatory process going on in the ear and the sinuses, but you can't say that because it's not in the data) aeb patient report of headache and ear pain.
• disturbed sensory perception r/t changes in visual acuity aeb patient report of sensitivity to light

The patient does not necessarily need to have a medical diagnosis for you to determine nursing diagnoses for him. You start by always following the nursing process. Step #1 is the collection of data. For patients who are hospitalized or residents of facilities this includes gleaning the chart for as much information about the patient as you can find: h&ps, surgical reports, procedure reports, lab results, x-rays, reports and assessments by dietary, physical therapy, respiratory therapy, activities, nursing admission assessments, old nursing notes, physician progress notes and anything else that looks of interest. Add to that your own history, review of systems and physical assessment of the patient (including his ability to perform adls). Only then, do you move on to step #2 which is what you have asked for help with--coming up with nursing diagnoses. From all that data you collected, some of it is going to stand out as not being normal. All that unusual data gets put on a list like the one I made in the very first paragraph of this post. That becomes the "Shopping list" of symptoms, or "Defining characteristics", to put it in nanda terminology, that is going to be the backbone of any nursing diagnoses you choose. These defining characteristics (headache, ear pain, red eyes, sensitivity to light--in this case) are what support the actual nursing diagnosis you choose. The "Related to" part of the nursing diagnostic statement is what is causing the nursing diagnosis. Remove the headache, ear pain, and sensitivity to light and the nursing diagnosis also goes away. Does that make sense? This is relationship between all these items.

Step #3 will be to develop nursing interventions. The nursing interventions will address those items listed after the aeb parts of your nursing diagnoses. So, for acute pain, your nursing interventions will be developed to deal with the headache and the ear pain. For the disturbed sensory perception, your nursing interventions will be specifically aimed at dealing with the sensitivity to light the patient is experiencing. Relationship between all the items--keep that in mind. It all has to flow logically.

I did not address the red eyes because there just isn't enough to go with. It's obviously a conjunctivitis. I would like to stick a diagnosis of "Risk for infection" on this patient, but there isn't enough data to come up with a viable diagnostic statement, so it has to set on a back burner for now.

Hope that helps you. Good luck with your future endeavors with care planning and using the nursing process! It sometimes takes time and doing a number of these before you start to get the hang of it.