Help with nursing diagnosis

Published

I am doing my care plan and i am having difficulty figuring out a nursing diagnosis!! It has to be a cardiovascular problem like impaired tissue perfusion, impaired gas exchange, etc. She was in for a laminectomy of vertebrae L3-L5. Her only other past medical history was hyperlipidemia. Any help is greatly appreciated!! Thank you so much!!!

Up Vote Up Vote ×
Specializes in Complex pedi to LTC/SA & now a manager.

Nursing diagnosis is based on patient assessment. So what is your patient assessment?

Up Vote Up Vote ×
Specializes in Emergency.

Curious why it has to be a cardiovascular problem if her CC is postop laminectomy?

Up Vote Up Vote ×

It has to be cardiovascular because that is the area of assessment we just learned in class. As for her assessment, she's a 57yo white American female, she has a midline incision in her lower back, it is 9.5cm long, well approximated with 15 staples. She had no other open areas, vitals were 143/76, 98.1, 57, 20, 96%

Up Vote Up Vote ×
Specializes in Emergency.

Weird way to learn nursing diagnoses. Does she have any cardiovascular problems that you can think of from your assessments (including other assessments aside from basic vitals)?

Up Vote Up Vote ×

It is strange!! And it makes it difficult if they don't have any problem in that specific area! Not that I can think of. Her apical pulse was 66 regular rhythm. Her only other issue besides her spinal stenosis is hyperlipidemia.

Up Vote Up Vote ×
Specializes in Emergency.

Check the patient's notes for any issues surrounding the heart. Any arrhythmias? You may just have to make up a random diagnosis that fits with a cardiovascular issue and not with this specific patient. Weird that they would be making you write out a nursing diagnosis that would not fit with that patient, lol.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What semester are you? I don't understand writing a care plan about a patient that doesn't have that problem? Do they want you to make up a patient? what meds is she on?

Up Vote Up Vote ×

She wasn't on any medications at home, in the hospital she was on:

Ancef

Kefzol

Decadron

Colace

Pepcid

Dilaudid

Morphine

Normodyne

Other than in the hospital she was medication free. I'm in my first semester. We have to go on the patient we had in clinical but it has to be a cardiovascular problem! I am just not seeing one here!!!!!

Up Vote Up Vote ×

She doesn't have any heart issues, no arrhythmias or anything like that!!

Up Vote Up Vote ×
Specializes in Emergency.

OK. You've forgotten to given us important facts such as vitals. Your patient is on Lebatolol. What is this used for? Why is she on this?

Up Vote Up Vote ×
Specializes in Emergency Room, Trauma ICU.
OK. You've forgotten to given us important facts such as vitals. Your patient is on Lebatolol. What is this used for? Why is she on this?

Vitals were given in post #4.

Up Vote Up Vote ×
+ Join the Discussion