Help with Nursing Diagnoses

[Matka]

For our first care plan, we need to utilize 3 nursing diagnoses (2 priority and one of our choice). My patient is a 72 year old female with a non-malignant tumor at C4, which is causing immobility and neuropathy.

Priority Diagnoses:

1) Chronic pain in lower limbs R/T peripheral nerve injury secondary to non-malignant tumor at C4 AEB patient report of constant pain of 6/10 and burning in both legs.

For my second priority diagnosis, I'm torn between two, and would love some opinions.

Option A) Impaired mobility R/T neuromuscular impairment secondary to paraplegia from non-malignant tumor at C4 AEB (still need my evidence, but she can't move herself)

Option B) Disturbed sleep pattern R/T noise level produced by roommate AEB patient awakening frequently through the night, patient statements of being tired, and unintentional naps during the day.

I like the idea of option B, but can't decide if it is a priority over option A, particularly because my patient is sleeping at least 6 hours.

Non-Priority Diagnosis:

Risk for urinary tract infection R/T indwelling Foley catheter.

Any feedback about the diagnoses themselves, especially the priority ones would be most appreciated.

[Clovery]

I agree pain is the first priority.

I think impaired mobility would be the next priority since that puts her at risk for pressure ulcers, DVTs, constipation, powerlessness, etc. However, if she's truly paralyzed and there's nothing that you (as a nurse) can do about it, then another diagnosis would probably be more appropriate. If it's realistic to have a goal of increased mobility (as a result of nursing interventions) then use that diagnosis. If that's not realistic, then go with another dx. Not sure of your patient's exact condition & limitations.

Option B looks okay, but if she's sleeping 6 hours, that's actually pretty good for an older woman in the hospital. Maybe the unintentional naps are due to the side effects of pain meds? I can think of a lot of interventions for this one like ask the doctor about/administer a sleeping pill, promote relaxation with a massage/warm blanket, teach relaxation techniques, reduce stimuli in the environment, etc. But these interventions are pretty similar to ones I'd use for a pain dx, so maybe you want to think of a different diagnosis.

How is her skin? Is she having any breakdown due to being unable to change her position? Look up risk for impaired skin integrity in your care plan book and see if that would fit. Some other ones to take a look at: powerlessness, ineffective peripheral tissue perfusion.

[Matka]

Thank you for your reply.

She's generally, besides the lower limb pain, in fairly good health. I'm actually having a really hard time coming up with nursing Dx for her. Her skin is really good at this point, so risk for impaired skin integrity is an option, but being a "risk for", that is not a priority dx. She doesn't currently complain of constipation, but that is because she is on medication to take care of constipation. However, constipation is a concern, both due to her immobility and the pain medication she is taking. But I don't think I can use that for a priority diagnosis if she is not currently feeling symptomatic, can I?

[Clovery]

How is her circulation in the lower limbs? Is the pain causing an ineffective breathing pattern? What about psychosocial dx?

I think the disturbed sleep is fine, I just personally wouldn't use it (on a careplan) because the interventions are too similar to those for the pain dx and I know my instructor would complain about that. But as a nurse in the hospital I would definitely treat that as a priority.

Impaired Mobility could work, and would be appropriate, if you can improve her mobility in any way. (I'm glancing at a CP book now). There's also "impaired bed mobility". Can you teach her how to use an overhead trapeze to reposition herself? Teach her bed exercises? Do ROM exercises? Have her verbalize the importance of changing position frequently?

[Matka]

Her circulation in her lower limbs is fine. Bilateral pedal pulses present. No edema. No current pressure ulcers. No problems with breathing.

Would impaired bed mobility be a priority diagnosis? I'm thinking that this patient has so few other things wrong with her, that I don't have many options. I actually did have impaired bed mobility on my short list of diagnoses, but changed it out for impaired mobility, because of the broader range. However, given my specific patient, I think I may be able to do more for her with impaired bed mobility, rather than impaired mobility.

Thank you!

[Matka]

So, I've come up with this for a second priority diagnosis:

Impaired bed mobility R/T neuromuscular impairment secondary to pareplegia from non-malignant tumor at C4 AEB impaired ability to turn side to side or reposition self in bed.

How does that sound?

[Esme12, ASN, BSN, RN]

Why is she in the hospital? or is she in LTC. I would think that sleep disturbance is a good one as the patient has that as a complaint.Is she also having trouible sleeping from the pain?

[Matka]

She's in LTC. Sorry I left that part out.

[Esme12, ASN, BSN, RN]

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses 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)
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

[Matka]

Well, I did an assessment, and the only thing she complains of is pain (which I addressed with my first diagnosis) and not being able to sleep because her roommate is noisy. However, she does sleep at least 6 hours a night.

She is not able to reposition herself in bed, and if the CNA's are too busy to help her, she may be sitting in a painful position for an extended period of time.

Her vital signs are normal, and she does not verbalize any other complaints.

[Esme12, ASN, BSN, RN]

What care plan/nursing diagnosis book do you have? What about your assessment of the patient stands out to you. What is affected neurologically with a C4 lesion have?

Spinal Cord Injury Levels - Functionality of C4 Spinal Cord InjuryMobility & Movement

Full head and neck movement depending on muscle strength. Limited shoulder movement.

Complete paralysis of body and legs. No finger, wrist or elbow flexion or extension.

Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia.

Electric wheelchair may be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity.

The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety.

Complete assistance required during mealtimes.Respiratory System

Able to breathe without a ventilator using diaphragm.

Assistance required to clear secretions and assistance in coughing will be required.Personal Care

Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management.Domestic Care

Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.Communication

Spinal Cord Injury Levels - functionality of c4 spinal cord injury

What does NANDA say about chronic pain? Even thought she has this pain chronically can't some of her pain be acute as well? What does NANDA say about impaired comfort? How are her ADL's affected? What does NANDA say about insomnia?

[Esme12, ASN, BSN, RN]

She has self care deficit. She has pain. She has insomnia.....saying she sleeps 6 hours your interoretation that she gets enough but the PATIENT complains difficulty sleeping........NANDA defines insomnia as.....

NANDA-I

Definition

Frequent complaints of disruption in amount and quality of sleep that impairs functioning (noisy roommate counts)

Defining Characteristics

Observed changes in affect; observed lack of energy; increased work/school absenteeism; client reports changes in mood; client reports decreased health status; client reports decreased quality of life; client reports difficulty concentrating; client reports difficulty falling asleep; client reports difficulty staying asleep; client reports dissatisfaction with sleep (current); client reports increased accidents; client reports lack of energy; client reports nonrestorative sleep; client reports sleep disturbances that produce next-day consequences; client reports waking up too early

Related Factors (r/t)

Activity pattern (e.g., timing, amount); anxiety; depression; environmental factors (e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting); fear; gender-related hormonal shifts; grief; inadequate sleep hygiene (current); intake of stimulants; intake of alcohol; impairment of normal sleep pattern (e.g., travel, shift work); interrupted sleep; medications; parental responsibilities; physical discomfort (e.g., body temperature, pain, shortness of breath, cough, gastroesophageal reflux, nausea, incontinence/urgency); stress (e.g., ruminative pre-sleep pattern)

Suggested NOC Outcomes

Comfort Level, Pain Level, Personal Well-Being, Psychosocial Adjustment: Life Change, Quality of Life, Rest, Sleep

Example NOC Outcome with Indicators

Sleep as evidenced by the following indicators: Hours of sleep/Sleep pattern/Sleep quality/Sleep efficiency/Feels