[178round]

nursing care plan for a 78yr old patient with no significant medical history that has a large gash to left lower leg following a fall. has had sutures and requires daily dressing. she is living on her own and struggling with adl's what do you think are the actual and potential problems and interventions.

[Tait]

I think most of us don't want to do your homework Especially if you didn't take the time to capitalize, punctuate and actually make the question clear.

[NancyNurse08]

Go to the top of the page. See the tabs? Click on the one that says "Students". That is a more appropriate place to post your question.

[suzy253]

Originally Posted by 178round

nursing care plan for a 78yr old patient with no significant medical history that has a large gash to left lower leg following a fall. has had sutures and requires daily dressing. she is living on her own and struggling with adl's what do you think are the actual and potential problems and interventions.

What have you come up with so far?

[178round]

Originally Posted by suzy253

What have you come up with so far?

A feel that she is a actual falls risk and has potiental of infection and poor wound healing due to inadequate diet and fluid intake. also feel that she is at risk of DVT.

[liv2b]

There is probably a more significant history....ie airway clearance, renal function, etc. How do you think those factors would influence wound healing and progress toward pt / theraputic goals?

[178round]

Originally Posted by liv2b

There is probably a more significant history....ie airway clearance, renal function, etc. How do you think those factors would influence wound healing and progress toward pt / theraputic goals?

Yes i agree but, we have not been giving a significant history. That is what is making it harder to put together care plane.

[Daytonite]

On the sticky thread in the General Nursing Student Discussion Forum http://allnurses.com/forums/f50/help-care-plans-286986.html - Assistance - Help with Care Plans, I give directions on how to write a care plan as well as give links to several other threads with directions. After reading my reply you might also want to read them.

All care planning begins, and is based upon, assessing the patient. It doesn't matter if the patient is real or hypothetical (not real). You work from the information you are given. To care plan, you follow the steps of the nursing process. The nursing process is a fancy name for a method of solving problems which is what we nurses are expected to do on the job. It does, however, have a few special things that need to be done in each of the steps.

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

As you can see. the first step, assessment involves:

• collecting data from medical record - well you can't do that if this is a hypothetical patient. But you can get information from the scenario you are given. 78 years old, has a large gash to left lower leg following a fall, has had sutures and requires daily dressing, she is living on her own and struggling with ADL's.
• doing a physical assessment of the patient - you can't be there in person, but the scenario did tell you some thing: has a large gash to left lower leg, has had sutures.
• assessing ADL's - again, you can't be there in person so you have to assume what might be a problem for the patient when it come to mobility in dealing with what in going on. However, your scenario told you: she requires daily dressing, is living on her own and is struggling with ADL's.
• look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - although you weren't given a specific medical disease in this case, you were told about a specific medical condition: a large gash to left lower leg
  • Here is some information on wounds and suture care that you should read:
    • http://www.emedicinehealth.com/cuts_...article_em.htm - cuts and lacerations
    • http://www.emedicinehealth.com/cellu...article_em.htm - cellulitis
    • http://www.emedicinehealth.com/sutur...article_em.htm - suture care

And as you can see you already have been given assessment information. Some of it you will need to do a little research on, particularly on wounds on how they heal. All of the above is information that supports actual problems that the patient has. It is sometimes easier to make a list of them (see Step #2 of the nursing process)

• large gash to left lower leg with sutures
• fell
• living on her own
• struggling with ADL's

In problem solving the above would be called symptoms or evidence, of the problems the patient is having. What has to be done now is to put labels, better known to us nurses as nursing diagnoses, with these symptoms or evidence. I usually recommend that when you are new at doing this that you use some sort of a nursing diagnosis reference book until you get familiar with using the same diagnoses over and over and know them well. There are a number of ways to acquire this information.

• Your instructors might have given it to you.
• You can purchase it directly from NANDA.
• NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International. Cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
• Many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. This information will usually be found immediately below the title of a nursing diagnosis.
• There are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/
  • http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

Nursing diagnoses, like medical diagnoses have specific signs and symptoms only we don't call them signs and symptoms. The organization that writes this information on nursing diagnosis, NANDA, wants us to call them defining characteristics. Defining, as in they define and describe the patient's problem. So, when you are new at diagnosing you have to find diagnoses that have defining characteristics (symptoms) that match with the actual symptoms you found in the patient when you did your assessment. For this 78-year old lady those are:

• large gash to left lower leg with sutures
• fell
• living on her own
• struggling with ADL's

From these 4 symptoms, are these actual problems (nursing diagnostic statements) that I have listed in the priority that they should appear on a care plan:

• Impaired Tissue Integrity R/T trauma AEB a large gash to the left lower leg (Impaired Tissue integrity)
• Feeding Self-Care Deficit R/T xxx AEB struggling with feeding (Feeding Self-care deficit)
• Toileting Self-Care Deficit R/T xxx AEB struggling with toileting
• Bathing/Hygiene Self-Care Deficit R/T xxx AEB struggling with bathing and hygiene (Bathing/hygiene Self-care deficit)
• Dressing/Grooming Self-Care Deficit R/T xxx AEB struggling with dressing and grooming
• Risk for Falls R/T elderly age, history of a fall with injury, and living alone (Risk for Falls)

Now, you also asked about potential problems. A potential problem would be a complication of care or a complication of a disease or condition. It carries a lower priority in the care plan because it doesn't exist. These are nursing diagnoses that begin with the words "Risk for". As you see above, this patient's problem of falling in the future is a potential problem and is because of her age, the fact that she has already had a fall and because she lives alone. These are risk factors of this particular nursing diagnosis listed by NANDA. You can verify that yourself by seeing them on this webpage about that diagnosis: Risk for Falls.

To determine other complications, you need to look at the medical treatments, I think. The scenario doesn't say whether or not this lady is ambulatory or bedridden. I wouldn't presume she is bedridden. With any open wound you have a break in the skin which means you have a portal for microbes to enter the body. So, infection is a danger. The doctor should have, in addition to suturing the wound, put her on an antibiotic. But the scenario doesn't say that. Nevertheless, I would diagnose

• Risk for Infection R/T broken skin as a result of trauma (Risk for Infection)

You also wanted to know about interventions. Interventions, in a nutshell, are intended to modify the "related to" part of your nursing diagnostic statement, the defining characteristics (or symptoms) and in the case of potential problems the risk factors. For the most part, your interventions are basically aimed at the symptoms you discovered during your assessment of the patient. Interventions come in 4 varieties:

• Assess/monitor/evaluate/observe (to evaluate the patient's condition)
• Care/perform/provide/assist (performing actual patient care)
• Teach/educate/instruct/supervise (educating patient or caregiver)
• Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

Interventions for the potential problems are a tad different and you can read about how to approach them on this post: http://allnurses.com/forums/2751313-post8.html

The best way to find nursing interventions is in a care plan book or a nursing textbook. I also gave you weblinks to online resources where they exist.

I also left the etiology of the self-care deficits blank. I think you should do a little searching and reading on your own about the elderly and what kinds of problems they may have that would result in them having difficulty performing their ADLs. If you need guidance in this, the webpages I linked you to for the Feeding and Bathing/Hygiene Self-Care Deficit will have a list of the related factors (the lists will be identical) that are the cause of this insufficient ability to perform these ADLs.

I feel that she is a actual falls risk (I agree) and has potential of infection (I agree) and poor wound healing due to inadequate diet and fluid intake (what's your evidence?). Also feel that she is at risk of DVT.

Infection is always due to invasion by a microbe (bacteria, protozoa, fungi, virus, worms). It begins with the inflammatory reaction and this is straight out pathophysiology. It has nothing to do with adequate diet and fluid intake.

A DVT is caused by development of a thrombus. You need to be able to make an argument for why the patient is going to be able to develop a blood clot. See the related factor for this diagnosis (Risk for Injury). Personally, I think she's covered with the Risk for Infection and the only added factor would be immobility.
http://www.emedicinehealth.com/blood...article_em.htm

I've shown you how to figure out the actual and potential problems with some links to interventions. That should get you started. Good luck. Care planning takes time and patience when you are first learning it.

[178round]

Thank you so much for sharing your wealth of knowledge and experience, you have been a great help. Have you ever thought about teaching? you would be a valuable asset to so many nusing students.
I hope you have a great day and Thanks again.

Originally Posted by Daytonite

On the sticky thread in the General Nursing Student Discussion Forum http://allnurses.com/forums/f50/help-care-plans-286986.html - Assistance - Help with Care Plans, I give directions on how to write a care plan as well as give links to several other threads with directions. After reading my reply you might also want to read them.

All care planning begins, and is based upon, assessing the patient. It doesn't matter if the patient is real or hypothetical (not real). You work from the information you are given. To care plan, you follow the steps of the nursing process. The nursing process is a fancy name for a method of solving problems which is what we nurses are expected to do on the job. It does, however, have a few special things that need to be done in each of the steps.

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

As you can see. the first step, assessment involves:

• collecting data from medical record - well you can't do that if this is a hypothetical patient. But you can get information from the scenario you are given. 78 years old, has a large gash to left lower leg following a fall, has had sutures and requires daily dressing, she is living on her own and struggling with ADL's.
• doing a physical assessment of the patient - you can't be there in person, but the scenario did tell you some thing: has a large gash to left lower leg, has had sutures.
• assessing ADL's - again, you can't be there in person so you have to assume what might be a problem for the patient when it come to mobility in dealing with what in going on. However, your scenario told you: she requires daily dressing, is living on her own and is struggling with ADL's.
• look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - although you weren't given a specific medical disease in this case, you were told about a specific medical condition: a large gash to left lower leg
  • Here is some information on wounds and suture care that you should read:
    • http://www.emedicinehealth.com/cuts_...article_em.htm - cuts and lacerations
    • http://www.emedicinehealth.com/cellu...article_em.htm - cellulitis
    • http://www.emedicinehealth.com/sutur...article_em.htm - suture care

And as you can see you already have been given assessment information. Some of it you will need to do a little research on, particularly on wounds on how they heal. All of the above is information that supports actual problems that the patient has. It is sometimes easier to make a list of them (see Step #2 of the nursing process)

• large gash to left lower leg with sutures
• fell
• living on her own
• struggling with ADL's

In problem solving the above would be called symptoms or evidence, of the problems the patient is having. What has to be done now is to put labels, better known to us nurses as nursing diagnoses, with these symptoms or evidence. I usually recommend that when you are new at doing this that you use some sort of a nursing diagnosis reference book until you get familiar with using the same diagnoses over and over and know them well. There are a number of ways to acquire this information.

• Your instructors might have given it to you.
• You can purchase it directly from NANDA.
• NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International. Cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
• Many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. This information will usually be found immediately below the title of a nursing diagnosis.
• There are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/
  • http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

Nursing diagnoses, like medical diagnoses have specific signs and symptoms only we don't call them signs and symptoms. The organization that writes this information on nursing diagnosis, NANDA, wants us to call them defining characteristics. Defining, as in they define and describe the patient's problem. So, when you are new at diagnosing you have to find diagnoses that have defining characteristics (symptoms) that match with the actual symptoms you found in the patient when you did your assessment. For this 78-year old lady those are:

• large gash to left lower leg with sutures
• fell
• living on her own
• struggling with ADL's

From these 4 symptoms, are these actual problems (nursing diagnostic statements) that I have listed in the priority that they should appear on a care plan:

• Impaired Tissue Integrity R/T trauma AEB a large gash to the left lower leg (Impaired Tissue integrity)
• Feeding Self-Care Deficit R/T xxx AEB struggling with feeding (Feeding Self-care deficit)
• Toileting Self-Care Deficit R/T xxx AEB struggling with toileting
• Bathing/Hygiene Self-Care Deficit R/T xxx AEB struggling with bathing and hygiene (Bathing/hygiene Self-care deficit)
• Dressing/Grooming Self-Care Deficit R/T xxx AEB struggling with dressing and grooming
• Risk for Falls R/T elderly age, history of a fall with injury, and living alone (Risk for Falls)

Now, you also asked about potential problems. A potential problem would be a complication of care or a complication of a disease or condition. It carries a lower priority in the care plan because it doesn't exist. These are nursing diagnoses that begin with the words "Risk for". As you see above, this patient's problem of falling in the future is a potential problem and is because of her age, the fact that she has already had a fall and because she lives alone. These are risk factors of this particular nursing diagnosis listed by NANDA. You can verify that yourself by seeing them on this webpage about that diagnosis: Risk for Falls.

To determine other complications, you need to look at the medical treatments, I think. The scenario doesn't say whether or not this lady is ambulatory or bedridden. I wouldn't presume she is bedridden. With any open wound you have a break in the skin which means you have a portal for microbes to enter the body. So, infection is a danger. The doctor should have, in addition to suturing the wound, put her on an antibiotic. But the scenario doesn't say that. Nevertheless, I would diagnose

• Risk for Infection R/T broken skin as a result of trauma (Risk for Infection)

You also wanted to know about interventions. Interventions, in a nutshell, are intended to modify the "related to" part of your nursing diagnostic statement, the defining characteristics (or symptoms) and in the case of potential problems the risk factors. For the most part, your interventions are basically aimed at the symptoms you discovered during your assessment of the patient. Interventions come in 4 varieties:

• Assess/monitor/evaluate/observe (to evaluate the patient's condition)
• Care/perform/provide/assist (performing actual patient care)
• Teach/educate/instruct/supervise (educating patient or caregiver)
• Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

Interventions for the potential problems are a tad different and you can read about how to approach them on this post: http://allnurses.com/forums/2751313-post8.html

The best way to find nursing interventions is in a care plan book or a nursing textbook. I also gave you weblinks to online resources where they exist.

I also left the etiology of the self-care deficits blank. I think you should do a little searching and reading on your own about the elderly and what kinds of problems they may have that would result in them having difficulty performing their ADLs. If you need guidance in this, the webpages I linked you to for the Feeding and Bathing/Hygiene Self-Care Deficit will have a list of the related factors (the lists will be identical) that are the cause of this insufficient ability to perform these ADLs.


I feel that she is a actual falls risk (I agree) and has potential of infection (I agree) and poor wound healing due to inadequate diet and fluid intake (what's your evidence?). Also feel that she is at risk of DVT.

Infection is always due to invasion by a microbe (bacteria, protozoa, fungi, virus, worms). It begins with the inflammatory reaction and this is straight out pathophysiology. It has nothing to do with adequate diet and fluid intake.

A DVT is caused by development of a thrombus. You need to be able to make an argument for why the patient is going to be able to develop a blood clot. See the related factor for this diagnosis (Risk for Injury). Personally, I think she's covered with the Risk for Infection and the only added factor would be immobility.

http://www.emedicinehealth.com/blood...article_em.htm

I've shown you how to figure out the actual and potential problems with some links to interventions. That should get you started. Good luck. Care planning takes time and patience when you are first learning it.