help with care maps-LOW BACK PAIN/HTN

[SLOU24]

I am working on my first care map....and it is not going to well! I have a dx of low back pain/HTN....and I have come up with some diagnosis but I am not sure I am getting the right diagnosis can anyone help me with this?

Here is what I have so far...

-PAIN R/T CURVATURE OF SPINE (B/C SHE HAS SCOLIOSIS)

-IMPAIRED PHYSICAL MOBILITY R/T LIMITED RANGE OF MOTION SECONDARY TO SKELETAL CHANGES

-PAIN R/T OSTEOARTHRITIS OF SPINE, AND INTERVERTEBRAL DISK PROBLEM (B/C SHE HAS A WEGDED AND MISPLACED VERTEBRE)

-RISK FOR FALLS R/T RESTRICTED RANGE OF MOTION

-RISK FOR INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT R/T INSUFFICIENT KNOWLEDGE OF CONDITION, DIET RESTRICTIONS, MEDICATIONS, RISK FACTORS, AND FOLLOW-UP CARE (THIS IS FOR HYPERTENSION)

I AM TRYING TO COME UP WITH SOME FOR HYPERTENSION BUT I AM JUST NOT SURE WHAT ELSE I SHOULD PUT....

ALSO IF ANYONE KNOW ANY GOOD WEBSITES TO HELP ME WITH DIAGNOSES/NURSING INTERVENTIONS LET ME KNOW...

THANKS FOR YOUR HELP!!!

[Silk_Daisy]

You need to get a nurses guide to diagnoses. It is called a Nanda. It is the only way to go and very easy to use.

If I am not mistaken, osteoarthritis is not a nursing diagnoses and should not be used in your diagnoses at all.

EX: Instead of: -PAIN R/T OSTEOARTHRITIS OF SPINE, AND INTERVERTEBRAL DISK PROBLEM (B/C SHE HAS A WEGDED AND MISPLACED VERTEBRE)

You could use: Acute pain r/t spine curveature aeb inability to bend forward over 15 degrees.

You have way to many pain diagnoses, try to condense it down to ONE.

Also, you can find some good hypertension diagnoses and interventions in the Nanda, you should invest in one. I hope this helps.

[RedhairedNurse, BSN, RN]

Acute pain - pain that came on suddenly or last less than 6 months.

Chronic pain - this sounds more like it would fit your pt with scoliosis/back pain....that is, if she's had pain for more than 6 months.

Hypertension -

Defient knowledge

Ineffective tissue perfusion

Ineffective therapeutic regimen management