help with a care plan

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SOrry i am new here and im not real sure where i should post this but it here it goes...

I am an RN student and am working on a care plan for a child that had a radical left mastoidectomy and a right tympanostomy tube insertion.....ideas for nursing diagnosis???? Also what would be some key assessments that i need to include other than those that i would normally include in any surgery???

Thanks so much

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Specializes in med/surg, telemetry, IV therapy, mgmt.

the choice of any nursing diagnoses is always based upon the assessment information that you have. it follows the steps of the nursing process which are:

  1. assessment (collect data and separate out the abnormal data)
  2. nursing diagnosis (group your abnormal assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

the symptoms that you find in your assessment of the patient are what you use to choose diagnoses. therefore, without any of that information, i cannot help you.

as for assessment, you would probably have wanted (i'm assuming the patient is long gone by now) to have done a little more in depth focus on the head and neck. the best i can suggest is to read through the assessment information on this web page:

these are links to other threads that addressed general surgery patients and some of the general anesthesia problems they have along with some nursing diagnoses involved with those:

once you have your list of the patient's symptoms and you are still having a problem determining the nursing diagnoses, post that list and i will help show you how we find the correct diagnoses.

there are two threads in the nursing student forums to help with writing care plans and picking nursing diagnoses:

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Specializes in ICU.

Diagnosis: Anxiety r/t threat to self : Assess: fatigue, weakness, alteration in sleep paterns, alterations in appetite, observation of irritability, self-focusing behavior

Diagnosis: Anticipatory grieving r/t future change in body shape/structure: Assess: express potential loss, alterations in communication pattern, observation of anger

Diagnosis: Accute Pain r/t surgical interventions: Assess: >5 on pain scale (1-10), observation of guarding, alterations in sleep patterns, observation in facial masking, alteration in activity

Diagnosis Disturbed body image r/t surgery : Assess: refuses to acknowledge site, social repression post-op, denies alternation in body appearance, self-negating statements

Not earth shaking diagnosis but that should do you for the Mastectomy

On the tympanostomy tube insertion think alterations in commnication, pain, facial nerve involvement, balance, cleaning

Hope that helps

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Diagnosis: Anxiety r/t threat to self : Assess: fatigue, weakness, alteration in sleep paterns, alterations in appetite, observation of irritability, self-focusing behavior

Diagnosis: Anticipatory grieving r/t future change in body shape/structure: Assess: express potential loss, alterations in communication pattern, observation of anger

Diagnosis: Accute Pain r/t surgical interventions: Assess: >5 on pain scale (1-10), observation of guarding, alterations in sleep patterns, observation in facial masking, alteration in activity

Diagnosis Disturbed body image r/t surgery : Assess: refuses to acknowledge site, social repression post-op, denies alternation in body appearance, self-negating statements

Not earth shaking diagnosis but that should do you for the Mastectomy

On the tympanostomy tube insertion think alterations in commnication, pain, facial nerve involvement, balance, cleaning

Hope that helps

Read more carefully. The patient had a mastoidectomy, not a mastectomy. This is one reason why you shouldn't be assigning nursing diagnoses to a patient without first assessing their symptoms and then determining the proper diagnosis. With the symptoms in front of you, the issue of changes in the breast wouldn't be presenting themselves.

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Specializes in ICU.

ooops my bad..........sorry about that

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