Care Plan HELP please!! =)

  1. I am currently in my 1st semester of nursing school and I am having some trouble with care plans!Pt medical diagnosis is Neuropathy. I am thinking about using Activity Intolerance or chronic pain for my nursing diagnosis. He is constantly c/o pain, risk for falls due to balance issues because of the numbness and pain, high B/P etc.

    This is what I have so far, and I'm not even sure if I am doing these right.. Please help and thanks in advance!

    Activity Intolerance R/T pain secondary to Neuropathy AMB increased B/P, facial grimicing, and verbalization of pain.
    Chronic Pain R/T Neuropathy AMB facial grimicing and verbalization of pain. I don't think I am actually allowed to use Neuropathy in my nursing diagnosis since it is medical but I am LOST!!!!!!
  2. Visit britt0625 profile page

    About britt0625

    Joined: Mar '10; Posts: 2


  3. by   pkellogg_6970
    Both are great nursing dx...but I think the first one is going to be the easiest to take care of. Just remember, you don't have to pick something complicated. Most new nursing students are under pressure to pick the hard stuff. I would go with safety. If he cannot ambulate safely, then that is your biggest problem. Just a question of priority. Now that you have your dx...figure out what you want to do with it. Remember to make your goals measurable. It is all good and fine to say 'patient will ambulate safely'..but how? Patient will ambulate 20 feet with SBAx1 with gait belt by discharge....patient will report pain on at <2/10 by discharge. It will help you keep it anchored in your care plan. Believe me I struggle with them, too.
  4. by   L8RRN
    You are not supposed to use neuropathy in your dx (unless used how you did it in your first dx with "secondary to"). We were told we could basically reword the medical diagnosis, altered nerve sensation or disease process affecting nerve conduction or something like that. Best to check with your instructor to see how they view it, though. Some of our instructors were "pickier" than others and wanted it certain ways.

    Good luck. It does get easier.
  5. by   traumaRUs
    Let me move this to the general nursing assistance forum.
  6. by   pkellogg_6970
    You can use Neuropathy as part of your nursing dx because it is stated....secondary to...Neuopathy is a secondary medical diagnosis, so you can use it in your nursing diagnosis. Wording it differently is okay, too Don't worry, you will get the hang of it.
  7. by   K.P.A.
    Uses standardized diagnoses. NANDA seems to be the standard.
    1. Because the work required depends on the diagnosis and one day you may be billing for it!
    2. Other nurses will understand.
    3. Lawyers will understand.
    4. They apply, somewhat uniformly, to the nursing role!
    5. Surely there are more reasons...

    What will the nurse be dealing with? I'm only in my 2nd clinical semester but safety is always number one, followed by pain management. To my mind, safety has two aspects. Physical and physiological. Consider the patient's risk for self harm. With psych or nursing home patients you may have to consider risk for harm at the hand of other patients. Physiologic safety is your vital signs, focused assessments, and medication administration. Some consider pain a vital sign so it all fits together.

    1. The patient may be lacking in strength because the pain has limited their mobility. Think safety here. Are they at risk for falling?

    2. With neuropathy, the patient is in Pain so pain management is a major concern for the nurse.

    3. There is a long list of psychosocial stuff to consider. Is the patient married? Is the neuropathy limiting consort? Are there children? Does it affect care giver role? You can write a book on every patient here :-)