Nursing Diagnosis and Care Plan for Mr. X After a Severe Fall

Your student number:
CNA253 AT3
Scenario:Identify your patient
Mr. X, aged 25 years, admitted after encountering severe fall from horse back and sustaining severe pain and injuries.
Articulate and Prioritise NursingDiagnoses – at least 2 (not included in word count)
1. Ineffective tissue perfusion, that is, disrupted oxygen circulation and gaseous exchange, as evidence by symptoms of
partial paralysis and lower limb loss of sensation.
2. Decreased inter-cranial adaptive capacity as evidenced by loss of spinal reflexes and low blood pressue.
Provide a valid reason for the prioritisation – why is this the most urgent nursing diagnosis? (not included in word
count)
1. Ineffective tissue perfusion is associated with decreased oxygen intake and a resultant hindrance to cells and tissues, via
circulatory mechanism, receiving oxygen and nutrients for sustenance. Hence, a lack of immediate prioritization of the same
will result in undernourishment and inadequate oxygen concentration in the body essential for life, further leading to
aggravations of tissue and organ damage and ultimately death (de Abreu Almeida et al. 2015).
2. Decreased inter-cranial adaptive capacity is associated with loss of compensatory mechanisms underlying maintenance of
equilibrium between hemodynamic and inter-cranial pressures (ICP). Lack of immediate prioritization will result in disruption
of regular cerebral, vascular, neuronal and physiological functioning leading to organ and brain damage and hence, death.
Goals, Actions and Evaluation:(400 words)
Diagnosis 1 Goal/s Related actions Rationale Evaluate outcomes
Ineffective tissue
perfusion
1. Management of
vasoconstriction
2. Improvement of
peripheral blood
circulation
3. Maintenance of
adequate
cerebral
functioning
1. Vasodilatory and
anti-coagulant
medications.
2. Maintenance of
adequate sitting
prior to standing
and flexing of
limbs with
assistance.
3. Vital sign
assessments and
screening of
consciousness
and mental
state, using GCS
1. Vasodilatory
medications
encourages
circulation
through vascular
dilation whereas
anticoagulants
aids in removal
of possible
thrombus or
hematoma based
obstructions.
Nursing
assessment for
hematomas and
Usage of vital sign,
GCS and PERRLA
assessments to
evaluate (Post et al.
2017):
1. Blood pressure,
cardiac output
and rates of
respiration.
2. Motor
movements.
3. Consciousness,
cognition,
speech and eye
movements.

and PERRLA
(Moore and
Fraser 2018).
constriction may
be required
(Carlson and
Fitzsimmons
2019).
2. Management of
orthostatic
hypotension and
associated
occupational
therapy will aid
in alleviation of
patient’s inability
to support body
weight and
encourage blood
circulation hence
alleviating in
effective
perfusion
(Robinson et al.
2018).
3. Adequate
monitoring and
assessment of
cardiac,
respiratory and
cerebral vital
signs using vital
sign and GCS
assessment will
aid in monitoring
of adequacy in
organ perfusion
and presence of
ICP hindrances
(Pettilä et al.