[x-tremestudent]

This is my 1st case study. My client has urinary incontinence. A 75 yr old lives alone in a continuing care retirement home, w/no family. She has had difficulty with urinary leaking when sneezing,coughing. She gets up @ night 4-5 times a night afraid of wetting bed. Each time at night she has fallen when getting up. She drinks 4 glasses of fluid a day, and never after 5 pm. Also I need a nursing diagnosis with goals, and three interventions. I need to address:

1. what assesment questions do i need to ask regarding incontinence risk factors.
2.formulate nursing diagnosis and goals.
3.what type of incontinence dos she have
4. write a nursing diagnosis,a goal,& interventions
5.what questions do u ask to determine fall risks

Here is my nursing diagnoses - Am I right?
1. incontinence urge
2 risk for injury r/t falls
3. sleep disturbance
4. fear risk for loneliness r/t living by self in retirement home.

My assessment: assess gait, balance, eyes, medications, tests for UTI, parkinsons.

Should I consider alcohol use? why/why not?
Also I need to make a diagram illustrating age related changes in urinary system. Any help will greatly be appreciated. Thank you so much!

[Suesquatch]

Don't forget impaired skin integrity r/t incontinence.

[JohnBearPA]

how about something like poor body image r/t incontinence? maybe something on the psychological issue of continued incont? Been a while since I did a care plan, but I kinda' remember some diagnoses like that.

[Daytonite]

I have read both the threads you have posted on this case scenario. Based on what you've posted to both threads this is my reply.

With regard to the incontinence. . .
It sounds like the scenario is describing stress incontinence which is the inability to prevent urination during the stress of such activities as coughing, sneezing, lifting or laughing. It is normally due to muscle weakness and is common in women who have had a history of vaginal deliveries of children. Assessment questions you want to ask with regard to incontinence are things such as:

• When does it occur?
• Is the incontinence related to any activity such as coughing, sneezing, lifting or laughing? (YES)
• Does the incontinence occur at any other times?
• How long has this been happening?
• Did it start suddenly? Or did develop gradually over time?
• What was the normal pattern of urination during the day? During the night?
• Has the urine changed color?
• Has the urine developed a change in odor?
• Is there any urgency?
• Is there any starting and stopping of the urinary stream?
• What kind of fluid and how much is being drunk during the day? Is the fluid restriction being followed?
• Is the patient on any medication that could be affecting urination?

With regard to the problem of falling. . .
The elderly frequently fall due to gait and balance problems. This is a link to 3 gait and balance assessment tools that are used for elderly patients that will give you an idea of what is assessed in patients who might be at risk for falling and the questions you should ask.
http://www.medicine.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=3
Assessment questions you want to ask with regard to falling might be such things such as:

• Are there any physical deformities of the lower extremities?
• How much range of motion does the patient have in each of the joints of the lower extremity?
• How much muscle strength is present in the muscles of the lower leg?
• Does the patient have any weakness in one or both legs?
• Is the patient unable to move one or both legs?
• Does the patient stumble or trip when walking?
• Does the patient have difficulty getting out of the bed?
• Is the patient having any muscle spasms or cramps in one or both legs upon standing? If so, what makes it worse? What makes it better? Is the patient on any diuretics?
• Does the patient have any pain or stiffness in the joints of the hip, knee or ankle? Describe the pain. Is it radiating, burning, sharp, dull or aching in nature?
• Does anything make the pain worse? Does anything make the pain better?
• Is there any swelling or pain anywhere in the lower extremities that might be interfering with movement?
• Is there any stiffness in the joints upon attempting to arise from the bed or a sitting position?
• Is the patient overweight?
• Can you palpate pulses?
• Is the skin warm to touch? Or, cool?
• What did the last set of electrolytes look like?
• When did this falling during the night begin?
• Has it happened before? Or, is it a new problem?

I am curious as to why you ask if you should consider if the patient is using ETOH (alcohol). Unless this question was asked as part of the scenario, I wouldn't even consider that the patient might be abusing alcohol. How would ETOH figure in with a patient who was on a fluid restriction, getting up to the bathroom 4 to 5 times a night and falling when getting up? Although alcoholics are prone to falls, they are also prone to a number of other problems as a result of long term usage:

• peripheral neuropathy
• brain damage
• seizures
• hallucinations
• severe memory problems
• confusion
• a number of personality disorders
• major depression
• anxiety
• cirrhosis
• vitamin deficiencies

This article from the American Family Physician includes a list of the symptoms of alcoholism in the elderly. You can use it as a guideline to develop a list of questions to develop for an assessment of alcoholism in your case scenario patient: http://www.aafp.org/afp/20000315/1710.html - Alcoholism in the Elderly. From my knowledge of working with alcoholics in detox I would say you don't have enough evidence to suggest that this patient has an alcoholic problem unless there are other symptoms that you have not listed in your posts.

Based on the information you supplied, I believe there are only two good nursing diagnoses that you can come up with. I only have one online link to a nursing diagnosis where you can get outcomes and nursing interventions. Also, for the stress incontinence you really don't have enough information to determine the etiology (related factor) of the incontinence although we know it is most likely due to muscle weakness. One of the interventions for stress incontinence is to instruct the patient in Kegel exercises.

1. Stress Urinary Incontinence R/T weak pelvic muscles AEB dribbling of urine when sneezing and coughing http://www.nlm.nih.gov/medlineplus/ency/article/003975.htm - Kegel exercises Urinary Incontinence in Women -- Topic Overview - Urinary Incontinence in Women Urinary Incontinence in Men -- Topic Overview - Urinary Incontinence in Men
2. Risk for Falls R/T history of falls http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_026.php

I would not use Disturbed Sleep Pattern as one of my nursing diagnoses because the cause of the interrupted sleep pattern is related to urinating. The reason for the frequent urination is not clear to me as to whether the patient is self-waking to go to the bathroom or there is some other factor, either physical or pathological that needs to be determined. There may not be a sleep problem at all.

Likewise, I wouldn't use Risk for Loneliness either. Use of this nursing diagnosis presupposes that the patient would experience depression, restlessness, anxiety or unhappiness as a result of some type of isolation or deprivation. However, this patient is living in a retirement community and there is no other evidence of isolation or deprivation to support using this diagnosis.

Your goals or outcomes should reflect what you are trying to accomplish with the nursing interventions you are prescribing and they are the predicted results of your interventions. Remember to make them measurable, patient centered and specific and state a specific deadline by which they should be achieved.

[MASSRN2B]

Bowel incontinence r/t decreased awareness of need to defecate/loss of sphincter control.

Deficient knowledge r/t lack of information on normal bowel elimination.

Disturbed body image r/t inability to control elimination of stool.

Risk for impaired skin integrity r/t prescence of stool.

Situational low self-esteem r/t inability to control elimination of stool.

Tolieting self-care deficit r/t toileting needs.

Functional incontinence r/t altered environment; sensory; cognitive or mobility defects.

Reflex incontinence r/t neuro impairment.

Risk for impaired skin integrity r/t prescence of urine.

Stress urinary incont. r/t degenerative change in pelvic muscles and structural supports.

Urge urinary incontinence r/t decreased bladder capacity (h/o PID, abd sx, indwelling cath).

Hope this helps!

[FutureNurse35]

Risk for falls r/t history of falls
Patient will verbalize understanding of individual risk factors that contribute to posibility of falls and take steps to correct situation

Urinary incontinence r/t weak pelvic muscles and structural supports
Patient will understand condition and interventions for bladder conditioning
Demonstrate behaviors/techniques to strengten pelvic floor musculature
Remain continent even with increase intra-abdomincal pressure.

[Daytonite]

Originally Posted by FutureNurse35

Risk for falls r/t history of falls
Patient will verbalize understanding of individual risk factors that contribute to posibility of falls and take steps to correct situation

Urinary incontinence r/t weak pelvic muscles and structural supports
Patient will understand condition and interventions for bladder conditioning
Demonstrate behaviors/techniques to strengten pelvic floor musculature
Remain continent even with increase intra-abdomincal pressure.

Nice outcomes! However, you also have to put timed deadlines on them. For example:

• In two days the patient will give a return demonstration of pelvic floor strengthening exercises and share an exercise plan with nurse.
• After one week the patient will have no episodes of stress incontinence for one continuous 24 hours period.

[Daytonite]

Originally Posted by x-tremestudent

thank you so much for your help. I am a LVN student and am 43 would u recommend me to go on to RN school considering my age and all

If you want to go on to become an RN, then do it. Your age won't matter. My mother went to LVN school when she was 50+ and worked as a nurse until she was 68. Right now RNs are needed and the largest group of RNs that are presently employed is in their 40s. Go for it!

I hope my reply to your post(s) helped to clear up some of the problems you were having with the case study. Do you have a care plan or nursing diagnosis book to help you with the goals/outcomes and nursing interventions? If so, it is important to review the first chapter(s) on the nursing process and how to write a care plan. Nursing diagnoses are ALWAYS determined by the assessment data that you have. Case scenarios where you don't have a real live patient are always a little edgier because you have to work with the information given to you and sometimes you have to do a little bit of extrapolating and assume some things which you wouldn't normally do with a real patient. Like the question about the patient using alcohol. I think that the idea there was for you to do a little investigation of the use of alcohol by the elderly, or the effects of alcohol abuse in the elderly since two of the actual symptoms you were given (frequent urination and falling) are symptoms of current alcohol use. Problems with balance, which you would have to assume as a possible cause for the falls (can't assume this with a real patient) would be a long term affect of alcohol abuse. Older people who have been heavy alcohol abusers for many, many years have a lot of chronic neurological problems as a result. So even though they many have stopped drinking by the time they reach their 70s and 80s, the brain damage has already been done.

I had an older assessment book that I used to help form some of the assessment questions for you that I bought about 8 years ago called Expert 10-Minute Physical Examinations that was published by Mosby-Year Book in 1997. I don't know that it's even in publication anymore, but the more I use it, the more I realize how simply organized and concise it is. You should explore these three threads on the nursing student forums. The assessment one, in particular, has many links to websites with assessment data on them to help you. I have no quick way to help you be a "question box". This is a skill you have to develop on your own. You have to think about all the possibilities that might be going on and ask questions designed to get you information that will confirm or deny them. That's the best explanation I can think of to tell you at this time. Assessment is not as easy a skill as some would want you to think. You will need to do many assessments of many different types of patients over a long period of time and you still will occasionally forget a question to ask or a subject to explore!

• http://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - Health Assessment Resources, Techniques, and Forms (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)

You can always send me a PM (private message) if you ever have any questions about care planning or assessment. I have extensive files of weblinks that I post all the time to help students out. If I have something that will help you out, I'll get it to you. If I don't I'll let you know that too. Good luck! Hope to see you on the student forums!

[shrgawia]

hi every body..

i'm studend in my first year nursing and i have assignment that i wish any one help me in it .

the assignment is ( give expected nursing diagnosis for male pt of 70yrs old with IHD, CHF , Pulmonary odema , aspiration pnemonia and past history of : MI, poor ejection fraction,, ARF when the pt. is sedative)

plsssss any one help me

[chenoaspirit]

Altered Tissue Perfusion
Impaired Gas Exchange
Fluid Volume Overload

Dont forget to add the "related to" and define why you choose each dx.
example: Altered Nutrition r/t Weight loss and TPN use