Please someone help

Daytonite, BSN, RN · Apr 16, 2009

i can help, but not if you don't post any information! see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans which has instructions and examples on how to put a care plan together and determine nursing diagnoses.

cleo777 · Jun 9, 2009

I have a patient with a TBI and his memory, cognitive abilities, a behavior has changed also, in my assessment he is very forgetful, can't remember if i gave him meds, cant remember the year it is, forget's why he is going to the dining room?

and his wife also said before he was admitted he lost the ability to do simple math, and I understand the occupational therapy is now working with him. His wife told me he became very irritable and moody...

so my question is on nursing diagnosis...of course...

can i use

impaired cognition r/t head trauma m/b memory deficiets

impaired behavior r/t head trauma m/b patient's family states he becomes irritable

Impaired copying r/t head trauma m/b the patient's fear he may may never beab le to return to the only work he knows how to do

Needing some help if you have time

Daytonite, BSN, RN · Jun 9, 2009

did you look at the thread i had suggested above?

step 1 assessment - assessment consists of:

a health history (review of systems) - the patient had a tbi (traumatic brain injury) and his memory, cognitive abilities and behavior has changed.
performing a physical exam - i am not clear on all of the assessment since most of what you have posted seems to be behavioral: he is forgetful, irritable, moody, and has lost the ability to do simple math. he fears he may never be able to return to work. is he in a hospital? why? what physical symptoms does he have since you mention that occupational therapy is working with him? that tells me that they are working with doing things like adls and more finite and purposeful movement of the arms and legs. what's going on there? since this is a brain injury patient, did you do a neuro exam? was there any paralysis or paresthesias as a result of his brain injury? has he had any seizures? is there any depression? what else is going on here that he is unable to work? what kind of work did he used to do?
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what adls does he need help with? can he do all the adls i've listed? can he drive? shop? you mention that he can't do simple math which is a more advanced type of adl. see the adl weblinks on post #4 of this thread: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- http://www.merck.com/mmpe/sec21/ch310/ch310a.html - traumatic brain injury
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what medications is he being given? why is he getting occupational therapy? is he also getting physical therapy and why? what other treatments did the physician order for him? these are clues to the medical plan of care which is important for us to know because we nurses have to help carry it out.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is all you posted:

very forgetful (can't remember if i gave him meds, cant remember the year it is, forgets why he is going to the dining room)
wife also said before he was admitted he lost the ability to do simple math
very irritable and moody...
fears he may never be able to return to the only work he knows how to do

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use:

disturbed thought processes r/t traumatic brain injury aeb irritability and mood changes
chronic confusion r/t traumatic head injury aeb impaired short-term memory (can't remember medications he was given, can't remember the year, can't remember why he is going places) and loss of ability to do simple math calculations.
- this patient has symptoms of both acute and chronic confusion. you did not mention when this injury occurred which has something to do with determination of which diagnosis to use.
[*]anxiety r/t change in health aeb fears he may never be able to return to the only work he knows how to do

- - - - - - - - - - - - - - -

your suggestions for nursing diagnoses. . .

impaired cognition r/t head trauma m/b memory deficiets

this is not a nanda diagnosis, so unless this is something that is allowed by your nursing program i cannot address anything about it.

impaired behavior r/t head trauma m/b patient's family states he becomes irritable

this is not a nanda diagnosis, so unless this is something that is allowed by your nursing program i cannot address anything about it.

impaired coping r/t head trauma m/b the patient's

this is not a nanda diagnosis, so unless this is something that is allowed by your nursing program i cannot address anything about it. also, there are no aebs supporting its use.