Nursing Diagnosis For Spinal Cord Injury Complete Nursing School Care Plan!

Most nursing students really struggle to write a nursing diagnosis for their care plans in nursing school because they miss the eight critical steps of writing perfect care plans. So in this video, I'm going to give you the exact step by step process that I used in nursing school to ace my care plans and we'll write a nursing diagnosis and care plan together for a patient with a spinal cord injury. I've also got some really important NCLEX key points that are super likely to show up on your exams. So hit that subscribe button and click the notification bell and let's dive in. All of these steps in my eight step care plan system are super important, but there's a few of them here that will really set you apart and show your nursing instructors just how awesome you are. So these are key, my friend. And your care planes are really going to ride or die on this one principle. You need to pick the nursing diagnosis that's the most pertinent to your patient. Your nursing instructor will be grading you on how well you prioritize your nursing diagnoses. So always, always, always make sure to choose the ones that apply to your patient the most. Now here's my spinal mnemonic to help you remember some of the top nursing diagnoses. Priorities for for spinal cord injury patients so S for skin integrity, P for physical mobility, I for infection risk, N for neurogenic bladder or bowel, which could be a diagnosis like impaired urinary elimination or urinary retention, A for autonomic dysreflexia and L for life adaptation. These could include things like ineffective coping and disturbed body image. So keep these in mind as we go through the steps and you'll have everything you need to rock your care plans in nursing school. We're going to cover a lot of ground in this video, so be sure to snag my ultimate care plan checklist that walks you through how to write perfect care plans. I'm going to put the link to that in the description below for you to snag it. The first step is to get a jumpstart on your care plans and assess your patient super well at clinical. This is absolutely crucial because here's the thing, my friend, your nursing instructor most likely talked with your patients. Did you know this? And trust me, they will know if you're making things up on your care plan. I promise you, the best thing to do is to take notes for your care plan while you're at clinical. Write out your patient assessments. Jot down some possible nursing interventions or patient goals for your Patient, do as much at clinical as you can so that you can spend less time writing your care plans later at home. And you won't forget everything about your patients by the time that you get home. Right? Happens all the time. And of course, always follow HIPAA guidelines when you're bringing home any information about your patients. Now, as you're assessing your spinal cord injury patients at clinical, here's a memory trick to help. Can't touch lower spine. Think cervical, thoracic, lumbar and sacral. Now here's the critical thinking part that the NCLEX loves to test you on. So cervical injury C1 through C8 think can't do crazy amounts. These patients have the most limitations. C1 through C4 affects breathing. Think can't catch their breath. C5 through C8 affects the arms and the hands too. For thoracic injuries, T1 through T12 think trunk and thighs affected. The arms work, the legs don't. These patients can often transfer independently with training. Then lumbar, sacral, L1 through S5 think lower limitations. These mainly affect the legs, the bowel and bladder control. And a majorly NCLEX critical thinking point here. The higher the injury, the more body systems are affected. Always think about what's below the level of injury. That's what's impacted. Now we move to step two. Select the best NANDA nursing diagnosis for for your patient. Now here's the best news. You don't write the nursing diagnosis by yourself. You simply need to just select from the list of NANDA nursing diagnoses from your textbook. That's it. It really is that simple. Nursing diagnoses are standardized. You don't make them up. So you just need to select from that list. Remember our spinal mnemonic here? Think about skill, skin integrity, physical mobility, infection, neurogenic bladder or bowel, autonomic dysreflexia, and life adaptation. Now, there are three parts of a complete nursing diagnosis. We call this the PES model problem, etiology and symptoms. The problem is that first NANDA label the etiology, which is the related, two factors or the why and the symptoms, which are the as evidenced by part of the nursing diagnosis. It's the proof, it's the evidence for that diagnosis. Now step number three is another one that will make your care plans really stand out from your classmates. This is where you write the related to or the RT section of the nursing diagnosis. And there's one thing I want you to be thinking about when you write this. And this is what's really going to make you stand out. Think about the pathophysiology of what is actually going on with your patient. This is where you'll write why the problem is happening, what's causing it. It's important that this cause, the etiology, gets to the root cause of the problem, the pathophysiology, because the rest of your care plan will be trying to solve for this really underlying problem. So when you write this related to section, think through the pathophysiology of what's actually happening inside the patient' body. So for spinal cord injury patients, you might write things like related to neuromuscular impairment or related to physical immobilization and decreased sensation below that level of injury. So here in step number three is where you can really show your nursing instructor that you know really what you're talking about, my friend, which will really help you get an awesome grade on your care plans. And step number four is, I would say, one of the most common places that I see nursing students getting tripped up with. And I'll explain why in just a second. This is really where you will write that as evidenced by the AEB section of the nursing care plan and the nursing diagnosis, all this is is where you list out the signs and symptoms that your patient had that relate to their problem. These will need to provide really evidence for your nursing diagnosis that Nanda label and justify to your instructor why you chose that nursing diagnosis in the first place. So think back to your assessment of your patient and then their nursing diagnosis you chose and why you chose it, and list out your assessment findings here in this as evidence by the AEB section to show support for why you chose that nursing diagnosis that you did. So, for example, if you chose impaired physical mobility, your AEB section might include inability to move lower extremities, Requires assistance of 2 for transfers, and patient states, I can't move my legs. But here's where a lot of nursing students get stuck. They try to make it way more complicated than it needs to be and include symptoms that don't apply to that nursing diagnosis that they chose. So you've got to look back at your nursing diagnosis and say, okay, which of these symptoms that my patient had actually apply to this particular nursing diagnosis? Because a lot of them just won't. And if you write ones that don't, your instructor is going to see that and you'll lose points on your care plan. And that's exactly what we don't want. And here's another big, big, big NCLEX key point. If it's a Risk for nursing diagnosis there's no to or really as evidenced by sections, there's no symptoms of it because it hasn't happened yet. Instead, you'll list out risk factors that the patient has. So for risk for nursing diagnoses, these have only two parts, the NANDA label and the risk factors. They don't have any etiology or technically any symptoms yet because it hasn't actually happened. So don't fall for that trap question on the NCLEX or any of your exams. Now, I have this all written out in inside my Ultimate Care Plan Checklist for you to help guide you as you write your care plans. So be sure to click the link in the description and snag that. Now let's walk through a couple of complete nursing diagnoses to really help this all come together for you. So number one impaired physical mobility related to neuromuscular impairment secondary to C6 spinal cord injury as evidenced by inability to move lower extremities requires assistance of two for transfers and the patient states I can't move my legs. Now this secondary two part is optional. That's the medical diagnosis and you can include it if you want. Some nursing schools want you to and some don't care. So you can check with your instructor on that one and see what they prefer. And another NCLEX tip for you is to look for words like paralysis, weakness can't move requires assistance. These scream impaired mobility so that nursing diagnosis of impaired physical mobility is perfect for these symptoms. Now, number two Risk for impaired skin integrity Here's a critical thinking point for all of your nursing school exams. Definitely remember this one. Okay? No sensation plus can't move equals pressure injuries. So here for a spinal cord injury risk for impaired skin integrity Risk factors physical immobilization, decreased sensation below the level of injury and moisture from incontinence. So here's a memory trick for you. Think PIM. PIM pressure, immobility moisture. These are your three big risk factors. Now nursing diagnosis example 3 ineffective breathing pattern this is mainly for cervical injuries because that's really where we see those really breathing problems like we talked about earlier. So here's what this nursing diagnosis could look like. Could look something like ineffective breathing pattern related to neuromuscular impairment of the respiratory muscles secondary to a C4 spinal cord injury as evidenced by shallow respirations, a respiratory rate of 28, use of accessory muscles and O2 saturation at 89% on room air. So remember that one for the NCLEX and your nursing exams, my friend. Any cervical injury above C4, think respiratory compromise. This is high priority. And now step number five is another big one that you can't get wrong. This is where you'll list out the patient goals, but there's some really key things that you'll need to include and we'll go over all of those. Your nursing instructor will tell you how many patient goals that you should have on your care plan. So don't miss that. Typically they want between three to five goals. Now the patient goal section of the care plan is where you will write out the appropriate goals for your patient to really help them make progress overcoming their nursing diagnosis. Your goals need to be smart specific. Exactly what will they do? Measurable? Can you count it or observe it? Achievable? Is it realistic for their level of spinal cord injury? Is it relevant? Does it match the diagnosis? Is it time bound? When will this happen and when do you want them to achieve that goal? So an example short term goal for impaired physical mobility might be something like the patient will demonstrate safe transfer technique with minimal assist using sliding board within one week. And a long term goal might be the patient will independently propel their wheelchair 100ft on a level surface within one month. Now here's a big critical thinking tip. Always consider the patient's level of injury when you're setting goals. Don't expect a C4 complete injury patient to walk right. That's not realistic or achievable for them. And now step number six is another place where you can super duper show off your nursing instructor that you know what you're talking about. This is where you will write out your nursing interventions just like the patient goals. Your nursing instructor will probably want you to write several nursing interventions too. Now in this section you will make a list of the things that you as the nurse would do to help your patient achieve their goal. And your nursing intervention should be written as the nurse will. Here's where you can show off your critical thinking skills. Remember this memory trick. The nurse acted a C T E D Assess what are you monitoring? Care? What hands on care are you providing to your patient? Teach what does the patient or the family need to know? Environmental modifications? What needs to change in their environment and to keep them safe and healthy and then document what did you do and how did they respond for impaired physical mobility? These could be things like assessing their range of motion, muscle strength, skin condition during position changes and then care do passive range of motion exercises every four to six hours, reposition them every two hours and assist with transfers and teach Safe transfer techniques, the importance of movement and regular skin inspections, and then environmental. These could be things like removing clutter, ensure their call light is within reach and that they have the proper bed height. And then document. This could be things like documenting the patient's response to those nursing interventions that you did, documenting the assistance levels that they need, and then documenting any skin issues that they might have. A big nursing intervention for spinal cord injuries is to prevent complications. And we will talk about a huge complication of spinal cord injury in just a second. It's called autonomic dysreflexia and it's a really, really, really big deal. And you will be tested on it a lot. So it's really important that you know about it. So we'll cover that in just a minute. But first, step number seven is to give rationales for those nursing interventions. Most nursing schools, they're going to require you to give a rationale for each nursing intervention that you write. And it will need to be evidence based. I know it sounds tedious to do every time, trust me, I get it. But this is really where you can show your instructor that you know what you're talking about. If you can provide a legitimate, well written and well thought out rationale for each of your nursing interventions, your care plan, my friend, will stand out from your classmates. And this is exactly what you want when your instructor is grading a thousand care plans each week, right? You want yours to stand out. So, for example, if your intervention is to turn the patient every two hours, your rationale might be something like frequent repositioning prevents prolonged pressure on bony prominences, which can lead to tissue ischemia and pressure injury formation in patients with decreased mobility and sensation. You see what I'm saying? Like, that sounds super legit, right? So your nursing instructor will definitely be impressed when you put some really a little bit of thought into your rationales for your care plans. And finally, step eight is evaluate your patient's progress. The last column of your care plan is the evaluation column, and thankfully, it's usually the easiest one. You'll simply write out if your patient met their goal or not. If they did, fantastic. You don't need to do anything else, really. Just move on to the next care plan that you need to write. But if your patient didn't meet their goal, what you'll want to do is you'll write out what adjustments that you're going to make next time to help them reach that goal. Now, here's something huge for the NCLEX that you have to know about. Autonomic dysreflexia. This is a sudden and dramatic rise in blood pressure because there's a noxious stimuli that's triggering that sympathetic nervous system below the level of injury. This usually only happens with injuries at T6 and above, but this is a medical emergency. So here's a memory trick for you to help. Think flush for the symptoms. Flushed face above the level of injury. Low heart rate or bradycardia. Uncontrolled high blood pressure. Severe headache and hot and sweaty above the level of injury. And cold and clammy below the level of injury. And here are your emergency actions. Think sit s I t sit them up in a high Fowler's 90 degrees. Identify and remove the cause. Usually this is a full bladder or bowel and tell the doctor stat. Autonomic dysreflexia is a medical emergency. So we are not messing around here. Sit them up, find the cause and get help. And of course, writing care plans is just one of the key parts of your grade in nursing school. Another huge one that nursing students struggle with a lot is dose calc. But here's the thing. You can absolutely master dosage calculations and walk into your exams with confidence. And in this next video here, I'm going to walk you through my proven six step process for getting every single dose calc question right in nursing school. And as always, my friend, go become the nurse that God created only you to be. And I will see you next time on the Nursing School Show.