Please help! Trying to find the best nursing diagnosis for my care plan...

  1. A 22 yr old male hurt his knee and also got a mild concussion. He is getting surgery on his knee. He complains of a THROBBING headache and a pain in his knee. I need to make a care plan for him but it has to be based on which is more important. I came up with a few diagnoses.. but they are all EXTREMELY similiar and don't seem very good...

    Acute Pain r/t physical injury to right knee AEB report of pain, musculoskeletal impairment.

    Acute Pain r/t physical injury to right knee AEB pain report, facial grimacing

    Acute pain r/t trauma to head AEB facial grimacing, pain report, restlessness

    Acute pain r/t head injury AEB expression of pain, communication of pain
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    About shawnakuipery

    Joined: Sep '12; Posts: 1


  3. by   Clovery
    This is off the top of my head, not consulting a book but look into:

    ineffective cerebral tissue perfusion r/t ? head trauma?

    for the surgery I would do:

    risk for infection r/t invasive procedure - focus your interventions on preventing infection from occurring post-surgery

    acute pain r/t physical injury is good... be more specific like: AEB pt states pain is 8 out of 10

    Do you have a care plan book??
  4. by   Esme12 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 assessment. 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 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 (ex:chest pain) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
  5. by   Esme12
    Looking at what you provided it is difficult to come up with a DIAGNOSIS with this plans are based on ptient assessment. What is this patient assessment. Are they alert? What is their neuro assessment.

    A 22 yr old male hurt his knee and also got a mild concussion. He is getting surgery on his knee. He complains of a THROBBING headache and a pain in his knee. I need to make a care plan for him but it has to be based on which is more important. I came up with a few diagnoses.. but they are all EXTREMELY similiar and don't seem very good...
    What is a concussion? What should you be looking for? How can this affect this patient? He is having surgery....what education does he need? What will he need to know about post op? How will his care change post op? How do you control his pain? How does he perfom his ADLS?

    Priority....think Maslows. Think about what can kill them first.......the pain from his hurt knee that is already scheduled to be fixed or a throbbing headache that may be caused by an increase in intercranial pressure.

    What do you think?
    Last edit by Esme12 on Sep 29, '12
  6. by   Esme12
    Look at your nursing diagnosis book What applies to this other than pain?Can his peripheral circulation be disturbed by swelling? What other problems arise from bedrest?

    Ineffective Tissue Perfusion: Peripheral, Cardiopulmonary, Cerebral

    NANDA-I Definition: Decrease in oxygen resulting in failure to nourish the tissues at the capillary level
    Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient, or it can be more acute or protracted with potentially devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. Management is directed at removing vasoconstricting factors, improving peripheral blood flow, and reducing metabolic demands on the body.

    Your patient has cerebral....go to your care plan book and follow that taxonomy.

    What would you look for.....Gulanick: Nursing Care Plans, 7th Edition

    Defining Characteristics—Cerebral
    Altered level of consciousness
    Changes in motor response
    Speech abnormalities
    Changes in pupillary reactions
    Behavioral changes

    Defining Characteristics—Peripheral

    Weak or absent peripheral pulses
    Numbness, pain, ache, claudication in extremities
    Skin temperature changes/cool extremities/clammy skin
    Shiny skin/loss of hair
    Thickened discolored nails
    Difference in blood pressure in opposite extremity
    Skin color pales on elevation/dependent rubor
    Prolonged capillary refill
    Delayed healing
    Altered sensation