Readiness for enhance comfort - HELP!!

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Hi all,

I have to write a wellness nursing care plan for a client that the only problem he has is tinnitus (ringing in the ear). He also has 40% of hearing loss on his right ear. I have to write one actual problem, one risk-for, and one wellness diagnosis.

For my actual I am doing:

Disturbed sensory perception: auditory r/t decrease in sensory receptor 2nd to otosclerosis.

Risk-for:

Risk for injury r/t hearing loss 2nd to otosclerosis.

Wellness Dx:

Readiness for enhance comfort level r/t (this is my problem - do I put r/t ringing in the ear?)

Thanks!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You told me what is wrong with him but what does he need? What are his complaints? Is he dizzy? What did your assessment tell you about him and what he NEEDS?

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Hmmm. He complaint that he wishes the ringing could go away. The ringing is so loud that is "driving me crazy".

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

hummmm...impaired coping?

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There are NO nursing diagnoses in the NANDA-I related to "sensory perception." None. Zip. Nada. :no: You can look it up. All of them were removed from the 2012-2014 edition pending separating into individual concepts with defining characteristics and related factors specific to each being clearly identified. So no, you can't use that, even if your older handbook has it in there. Not current.

How is he at risk for injury with this tinnitus? Is he dizzy, does he report that he falls or nearly falls?

I'm with Esme-- what have YOU assessed about HIM?

Has he received any instructions on self-care for this condition? Is he ready to implement a plan of care? Have you looked at "Readiness for enhanced self-health management"? (page 164 of your NANDA-I 2012-2014, which you must have to do nursing diagnosis accurately). This is defined as "A pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae that is sufficient for meeting health-related needs and can be strengthened."

I will leave it to you to find the defining characteristics and see if he meets at least one of them, in your assessment. Hint: One of them is, "Expresses desire to manage the illness (e.g., (which means, "for example"), treatment, prevention of sequelae)" and there are four other possibilities.

(NANDA-I 2012-2014, $29 and free two-day delivery at Amazon or $25 and nearly instant delivery to your Kindle or iPad) :)

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Wow I was not aware that the new NANDA has changed. Thank you!! This is not an actual patient. I had to interview someone I know for my RN-BSN assignment. The only problem this person has is tinnitus which is related to his hearing loss.

The risk for injury is related to the fact that he lost 40% of his hearing. Even his doctor said that he needs to be more caution as he is more prone to injury. And example would be that when crossing the street, because of a decrease in hearing of one ear, his brain has a hard time figuring out where the noise is coming from. And that is why I thought that.

I will take a look at your suggestion. Thanks!

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That would fall under managing or living with his condition...readiness for self-care management. See how that works?:)

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I will take a look. Thanks!

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Specializes in L&D, infusion, urology.

Does your ND have to be related to only the tinnitus, or are you taking the whole patient into account? Generally, you want to look at the whole patient, and sometimes, the ND has nothing to do with a medical diagnosis.

Many nursing students can have a ND of things like Impaired coping, Sedentary lifestyle, Sleep deprivation, Readiness for enhanced sleep, Fatigue, Wandering, Self-neglect, Chronic confusion, Hopelessness, Risk for loneliness, Risk for chronic low self-esteem, Stress overload, Situational low self-esteem, Anxiety, Fear, Grieving, Chronic sorrow, Stress overload, Risk for compromised resilience, Risk for self-directed violence, Social isolation...

:eek: :dead:

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The person I interviewed does not have anything going on except for hearing loss and tinnitus. He is otherwise a health guy. That is why I am having a hard time and thought of doing something related to his hearing loss.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I would have moved on and found someone with more issues. Maybe go to the senior center in your town/city and ask a few questions there.

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It has to be an adolescent or young adult. Since I am not working, I could interview any adolescent or young adult to practice. So I chose my husband. Since I don't know any teenagers. The problem is that he is healthy. Maybe I should think of someone else. Thanks.

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