Help writing secondary diagnosis for a case study

guest042302019, BSN, RN · Apr 26, 2012

This is what I'm getting from your patient's situation.

Current Problem

MVA

transformaminal lumbar interbody fusion & posterior pedicle screw fixation

Pain: transforaminal region, right leg, right foot

Medical History

DDD, Smoker 30 years, asthma, bronchitis, murmur

Well, this is tough. Your case study has minimal information. I mean, assessment information. Yes, we have medical diagnoses which could imply nursing care. However, without physical assessments and other information, it's difficult to determine how the patient is responding to the his current condition.

So your patient had surgery. What nursing implications are associated with surgery? I mean. What nursing assessments and diagnoses could you think of? While you probably won't find this exact surgery in your nursing diagnosis handbook, you may find a general "spinal surgery" to refer to. Try "spinal fusion." I found it in my nursing diagnosis handbook. See what you can come up with there. Your patient is in pain. How can you address pain?

As far as secondary diagnosis, I'm not sure what that means. Others' thoughts?

What exactly is your assignment guidelines?

Esme12, ASN, BSN, RN · Apr 26, 2012

hi! so yea.. i'm actually doing my first case study ever and i'm kind of confused with what to write for a secondary diagnosis.
a bit of info on the pt i'm doing it on -
the pt is status post back surgery - had a transforaminal lumbar interbody fusion w/ posterior pedicle screw fixation
he had a motor vehicle accident.
chief complaint: pt complains of pain in transforaminal region. he was scheduled for same day surgery but it got cancelled due to insurance problems. he came in to have back surgery. pt also complains of pain in right leg and foot. pt injured back in motor vehicle accident (mva).
primary dx = ddd (degenerative disc disease)
patients hx = smoker - 1 pack per day for 30 yrs.
pmh = back injury (in mva) - hx of asthma as child, bronchitis, and a murmur.
can someone explain to me what it means to write a secondary diagnosis? and if u can try to help me make one using the information that ive provided. thanks a lot !

welcome to the largest online nursing community! we are happy to help you but we don't do the work for you. we will lead you to the place so you can answer it yourself.

you are making the same mistakes all new nursing students makes......you are confusing nursing diagnosis with medical diagnosis. the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

let the patient drive your diagnosis........ 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? how many days post op? is the patient having pain? are they having difficulty with adls? what teaching do they need?. what does the patient say? what are the labs? what does the patient need? what is the most important to them now?

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 them as a recipe to caring for your patient. your plan of how you are going to care for them.

a secondary diagnosis follows the nursing diagnosis. a medical diagnosis in a nursing diagnosis (it can only be used in after "secondary to..."). so if the patient had htn and heart failure. you should say: decreased cardiac output related to increased peripheral vascular resistance secondary to hypertension.

remember: the part following "related to" should define the medical diagnosis but in words that present it on the cellular level. hypertension is "a change in the peripheral vascular resistance"

for example: risk for infection (primary) related to invasive surgical procedure( the tli fusion) due to degenerative disc disease (secondary) as evidenced by pain in the right leg and foot pain.

from a very wise an contributor daytonite.......

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

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.

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:

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)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

a dear an contributor daytonite always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole 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. 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.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

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.

now what information do you have........

"the pt is status post back surgery - had a transforaminal lumbar interbody fusion w/ posterior pedicle screw fixation

he had a motor vehicle accident.

chief complaint: pt complains of pain in transforaminal region. he was scheduled for same day surgery but it got cancelled due to insurance problems. he came in to have back surgery. pt also complains of pain in right leg and foot. pt injured back in motor vehicle accident (mva).

primary dx = ddd (degenerative disc disease)

patients hx = smoker - 1 pack per day for 30 yrs.

pmh = back injury (in mva) - hx of asthma as child, bronchitis, and a murmur. "

not much.....have you actually assessed this patient? it sounds like you copied this off of a h&p in the chart. your information here is very sporifice and it will be difficult to do a care map/plan. what does the patient c/o? how many days post op? what does the physical assessment show? what is the lab work, the vital signs?

do you know what a transforaminal lumbar interbody fusion w/ posterior pedicle screw fixation is? http://lmgtfy.com/?q=transforaminal+lumbar+interbody+fusion+w%2f+posterior+pedicle+screw+fixation+ http://www.bernardrawlinsmd.com/surgical-options8.php

what is the post op care for this patient? what is important to look for? what would be a complication? what do all post op patients need? pain control? vital signs? drsg checks? what nursing care is important in the care of this patient? what would be your priority? what is important for any post op patient......like signs of infection, like fever, color or amount of discharge from incision, increased redness/swelling, or pain. has the patient voided after surgery? what would be important for any spinal surgery......neuro checks how does smoking affect his recovery? can it possibly slow/prevent the fusion from healing?

the patient has pain. what level is his pain? what has he done in the past to relieve the pain? what aggravates his pain? what is being done post op for his pain. this would mean he has an alteration in comfort related to.........other than frustration that his surgery was canceled has no bearing on your care of this patient. since his accident is old....how does this calculate the care you are giving unless it is emotional stress over loss of his job, monetary income that would lead to depression/anger.

http://www.capitalcityneurosurgery.com/wp-content/uploads/lumbar-2009.pdf

you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. .

care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis. some other helpful links.

https://allnurses.com/nursing-student-assistance/priority-nursing-diagnoses-702376.html#post6414084

https://allnurses.com/nursing-student-assistance/care-plan-question-695488.html

https://allnurses.com/nursing-student-assistance/first-care-plan-689164.html#post6283634

https://allnurses.com/lpn-lvn-nursing/prioritizing-according-maslows-684678.html#post6239018

here are some useful care plan sited with examples to follow

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

http://www.scribd.com/doc/10060455/concept-mapping

i hope this helps......come back if you have more info or questions.