Is this a correct diagnosis for my care plan?


I am doing a care plan for the first time and I wanted to make sure I was doing it correctly.

admitting diagnosis: total knee arthroplasty

patient underwent a r/t total knee re-arthroplasty surgery on 3/27/11.

history of present illness: pt had right tka 2008, cabgx3 2010, mrsa spine 9/2010; r/t knee became infected and had to have r/t knee prosthesis removed, was treated with 6 weeks vancomycin. needs revision of r/t tka

tokmom, BSN, RN

4,568 Posts

Specializes in Certified Med/Surg tele, and other stuff. Has 30 years experience.

Thats a diagnosis and history. Do you need history? Unless things have changed that was never addresed in the care plan.

I'm assuming the plan of care is next?

Specializes in L&D, PACU.

For our care plans we always had to have a nursing diagnosis. A nursing diagnosis would address the patients functional condition. So, it would be something like ...impaired mobility. The impaired mobility can be related to the arthroscopy, but the arthroscopy cannot be the principle dx. Are you using a book that gives nanda approved nursing diagnoses? LOL , I've forgotten how to do them, I remember there were three parts to a diagnosis.


25 Posts

Impaired mobility r/t intentional tissue trauma seconadary to rt. tka aeb inability to support weight on right leg

Specializes in Cardiology and ER Nursing. Has 10 years experience.

That's not even close.

It's NANDA diagnosis related to something a NURSE can do something about and if you must secondary to a MEDICAL diagnosis then you put your as evidenced by the cluster of data that supports your nursing diagnosis.

A proper NANDA would look like

Impaired skin integrity r/t complete bed rest and poor nutritional status AEB a stage 2 sacral pressure ulcer.

Keep in mind you can have more than one r/t and more than 1 AEB.

Then you set your CLIENT centered goals, both short term and long term. Then you set your nursing interventions to try to meet those goals. Finally you reevaluate your patient to see if they have met those goals and then either establish a new nursing diagnosis, or modify the goals.

I came up with 3 probable NANDA diagnosis the r/t and the AEB just from the little bit of data you presented for your patient, but it's not my job to do your homework.

Specializes in Med Surge, Tele, Oncology, Wound Care. Has 11 years experience.

What is your nursing diagnosis?

I don't see one here.

You have a medical diagnosis- or what the patient was admitted for.

Nursing is a separate entity with our own diagnosis, used to separate us from the MD diagnosis.

You will use your related to factors (subjective and objective data)

netglow, ASN, RN

4,412 Posts

OP, you have to really take a look at your readings and study how to nurse DX. Yes it is silly. But if you want to graduate it's a must. Go back and work it out, we might guide you but if you don't figure this out so you know it you will fail your class as you will be doing this nursing DX garbage over, and over (rinse and reapeat). We simply won't be there to help you.