ANOTHER careplan question!

ZooMommyRN, ADN, RN · Feb 13, 2008

Any pt with a walker or cane automatically gets a risk for injury R/T use of ambulatory aid , risk for decreased tissue perfusion R/T decreased lung expansion AEB SOB upon exertion (it common in elderly to have decreased chest wall compliance which makes it harder for them to breath upon exertion and in some just breathing at all is difficult) for incontinence, since she wears a pad, risk for tissue break down R/T use of urinary incontinence pads I'd have to dig out my books for more if these don't work out for your careplan. I'm a nutt because I loved writing out the long form care plans lol

Daytonite, BSN, RN · Feb 14, 2008

The patient's problems on a care plan are ALWAYS based upon the patient's symptoms. The symptoms come from the assessment that you do. You must follow the five steps of the nursing process in writing a care plan and the first step, assessment, is the most important because everything else to come after it is based on what you found out during your assessment activities.

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

From what you've posted, these are some of the symptoms your patient has:

walks with the assistance of a walker
c/o SOB when she gets in a hurry
c/o short-term memory loss
dribbles urine but knows when she has the urge to go

Every nursing diagnosis has a set of symptoms that are called defining characteristics. In order to assign any diagnosis to a patient, the patient must have at least one or more of those defining characteristics. If you look at the steps of the nursing process above, step #2 says you need to match your abnormal data (your patient's symptoms) with likely nursing diagnoses. And, that's exactly what I am going to do for you with the four symptoms you listed. In priority order, by Maslow:

Overflow Urinary Incontinence R/T [either detrusor external sphincter dyssynergia or detrusor hypocontractility] AEB dribbling urine when bladder is full and knowing she has to void
Impaired Walking R/T [impaired balance? and deconditioning?] AEB need to walk with the assistance of a walker and SOB when in a hurry
Impaired Memory R/T [? depends on her medical diagnosis and underlying pathophysiology] AEB inabilty to recall events in short term memory

I cannot give complete related factors (the R/T information) because you did not mention anything about the patient's medical diseases or the medications she is taking (all clues as to what is going on with her). That information factors into the etiology and underlying cause of most of the problems (the R/T part of the nursing diagnostic statement), so you will have to take that information into account and correct anything I may have assumed incorrectly in these diagnostic statements.

mistiffy · Feb 21, 2008

Thanks so much for your replies, they were really helpful and got me pointed in the right direction. On the impaired memory, I don't think I can use that one because my pt. has the beginning of Dementia/ALZ and when I looked that up in my nursing DX book, it said that dx wouldn't qualify due to her medical dx of dementia/alz, but I didn't state that in my previous post! I guess it's all a matter of learning how to think like a nurse! Im working on it!!

bblueyes · Feb 21, 2008

One of the first things I do is write down all my subjective and objective data obtained from my assessment. Then I group those into coordinating groups and then put those groups into the context of Maslow's to get the most important. Sorry if it sounds confusing, bu tit really works for me. I usually come up with at least a few dx's. Good luck!

Daytonite, BSN, RN · Feb 22, 2008

on the impaired memory, i don't think i can use that one because my pt. has the beginning of dementia/alz and when i looked that up in my nursing dx book, it said that dx wouldn't qualify due to her medical dx of dementia/alz, but i didn't state that in my previous post!

i don't know what reference book you are using, but the nanda taxonomy goes by the symptoms the patient has. no where does nanda qualify this diagnosis as not being appropriate for someone with dementia or alzheimer's that i know of.

[color=#3366ff]impaired memory

other choices would be chronic confusion or disturbed thought processes, but the patient still has to have the symptoms in order to support using either of them. you listed your patient's symptoms as "memory loss" and so impaired memory is the diagnosis that best fits that symptom. you choose diagnoses according to the symptoms the patient has not based on the discussion in a care planning book.