help with an assignment

[aflac381]

Now, I am not trying to steal anything from anybody. I need help with an assingment. Anyways, yesterday, I had my med-surg clinical. The patient I had was in an motorcyle accident. Diagnosis was Traumatic brain injury (TBI) and hydrocephalus. I have to have 3 nursing diagnoses. I have one. I just need 2 more. Any suggestions. Help is greatly appreciatted. Have a good day.

[itsmejuli]

What is the first one you have?

What were the results of your assessment? Is he on life support? Coma? Other wounds?

[aflac381]

Nursing Diagnosis: Risk for falls r/t the importance of needing walking assistance

Not on life support, patient was not in a coma.

Wound-wise: ecchyomosis (bruising) located on lateral side of the right leg.

[realnursealso/LPN, LPN]

http://www.google.com/search?hl=en&source=hp&q=Nursing+diagnosis+for+tbi&btnG=Google+Search&aq=f&aqi=&oq=

[aflac381]

ok thanks

[Teacher First]

I don't know where you are in regard to level of student experience, however, I can promise that this patient has a number of problems just by virtue of the little you have described. The first thing you need to do is systematically assess this patient from head to toe....if you do not have written information, you will need to try to recall what you can. Assessment is critical in deciding what your nursing diagnoses will be. Think of any deficts this patient has, and how it impacts his/her ability to function (mental, physical, psychological, etc.) That can be a starting place. Do you have a nursing diagnosis book? Go down the list of NANDA diagnoses and see if any of them could apply to this patient, then read about them to confirm that they do indeed apply based on your assessment. This a suggestion for the short term...I bet this is due on Monday. Secondly, please make an appointment to meet with your instructor for help in this area. I find that many students have difficulty initially writing nursing diagnoses, and a lot of the time they need help performing an adequate assessment in the first place.

There is a thread under the student forum about writing care plans that is excellent. Check it out.

[aflac381]

Student level: junior second semester and thanks

[elprup, BSN, RN]

go down to your local bookstore and browse through their Nursing Care Plan books. There are many, and they are a BIG help for assignments like this. I agree your assessment is first. Then, you can take your info from assessment and use the care plan book to give you idea of nursing diagnosis to use. Your medsurg book should have some ideas too, usually at the end of the chapter about pts problems. Good luck.