Care plan help, please

  1. Hi all,

    I'm working on a care plan for my second week of clinicals this Thursday and Friday, and I could use some help prioritizing my top five diagnoses.

    My pt has a G-tube, indwelling catheter, BKA and AKA, contractures in both arms, Alzheimer's, trouble swallowing (NPO), aphasia, Hx of DU (healed), rarely/never makes self understood, rarely/never understands others, upper respiratory infection, Hx of CVA, Diabetes Mellitus, peripheral vascular disease, SOB, and memory problem/no recall.

    We are supposed to make our care plan based on the subjective data from the pt's chart, then revise it as needed after gathering objective data our first day of clinical.

    So far, my top five (NUR 101 approved) diagnoses are:

    1. Mobility: physical, impaired

    2. Swallowing, impaired

    3. Skin integrity, impaired

    4. Self-care deficit

    5. Urinary incontinence

    Also, I can't use Self-care deficit this week as it was my priority diagnosis for my patient (different pt) last week.

    Any help would be greatly appreciated--I really want to give my pt the best care possible this week.

    Thanks!
    Isis73
    •  
  2. 15 Comments

  3. by   bleu_3
    Hello-

    Junior level nursing student here. When I'm prioritizing care I remember the ABCs-Airway, Breathing, Circulation. I would have made impaired swallowing my top priority nursing dx because the pt's airway could become blocked.
  4. by   nurse4theplanet
    Ineffective Breathing pattern (SOB)

    Risk for Aspiration (difficulty swallowing)

    Risk for Injury (confusion)

    Risk for Infection (invasive lines)

    Impaired Tissue perfusion (DM/PVD)

    Impaired Communication


    I also try to use the ABCs, Maslow's, and just the basic common sense of which problem is going to kill them fastest...that's your top priority! Just because nutrition is a physical need that doesn't necessarily mean it is always prioritized before safety.

    Best to speak with individual instructor because each one I had would be different from the next with their expectations.
  5. by   PsychNurseWannaBe
    When planning care, your actuals should go before any potential or risks for. The rationale is that you must be ready for the "here and now" and then plan ahead for any risks.

    Also keep in the mind the family

    Caregiver Role Strain
    Coping: Compromised, Family
  6. by   Daytonite
    in order of priority by maslow's hierarchy of needs and per nanda guidelines here are some ideas for nursing diagnoses based on the information you provided:
    • ineffective breathing pattern (due to sob and uri)
    • impaired gas exchange (due to sob and uri)
    • ineffective tissue perfusion: peripheral (due to pvd)
    • impaired swallowing (due to aphasia, effects of cva and possibly alzheimer's)
    • activity intolerance (due to amputations, contractures)
    • impaired physical mobility (due to effect of cva, amputations, contractures and possibly alzheimer's)
    • impaired verbal communication (effects of cva and possibly alzheimer's)
    • disturbed sensory perception: auditory (effects of cva?, effect of aging?)
    • impaired memory (effects of cva and possibly alzheimer's)
    • risk for fluid volume deficit (effects of cva and possibly alzheimer's)
    • risk for imbalanced nutrition (effects of cva and possibly alzheimer's)
    • risk for infection (due to uri, presence of foley and gastric tube)
    • risk for impaired skin integrity (due to pvd, presence of foley and gastric tube)
    there are complications or problems that need to be watched for with gastric tubes. likewise, the urinary incontinence was addressed with the insertion of the indwelling foley catheter. patients who have any kind of long term dwelling tubes are always at risk for infection, particularly with foley catheters.

    remember, that diagnoses starting with the words "risk for" are not actual problems and must be listed last.
  7. by   isis73
    Thanks to everyone for your help and suggestions! As far as the ABC's and Maslows, I ran into trouble with that last week since I put Ineffective breathing pattern as my number one (r/t SOB)--but there was nothing I could do for the pt in the way of interventions (dementia and no family involvement, so teaching was out, pt was out of bed >90% of the time we were there, so Fowlers position was irrelevant...).

    For our clinicals, apparently ABCs still matter, but our priority diagnosis is what we can do for our patient, since we need to apply our interventions and later evaluate them.

    I've got to run, test this morning, care planning this aft, and clinicals bright and early tomorrow--aaah. Thanks so much for the help!

    Isis73
  8. by   isis73
    Quote from PsychNurseWannaBe
    When planning care, your actuals should go before any potential or risks for. The rationale is that you must be ready for the "here and now" and then plan ahead for any risks.

    Also keep in the mind the family

    Caregiver Role Strain
    Coping: Compromised, Family
    There is no family involved and pt is in long term care facility. That certainly would be a high priority if they were, though. Thanks for the suggestion--that will be good to remember in the future.
    Isis73
  9. by   isis73
    Thanks so much for the great help, Daytonite! Your insight and years of experience speaking are invaluable. Thanks so much for taking the time to help those of us just getting started out.
    Isis73
  10. by   Roseyposey
    Swallowing takes priority over shortness of breath - airway, airway, airway...
  11. by   Daytonite
    Quote from jkcmom
    swallowing takes priority over shortness of breath - airway, airway, airway...
    that is true when the symptoms pertain to the airway. however, the nursing diagnosis, impaired swallowing, does not have anything directly to do with the airway. its definition is: "abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function." nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 195. nanda lists the causes (related factors) for it as being due to either congenital defects or neurological problems. a cva might create the neurological problem for the patient. while aspiration prevention is an outcome of this diagnosis, that does not establish it a topmost priority. in reality this nursing diagnosis would only be used if positive attempts were being made to feed the patient orally.

    the nursing diagnoses dealing with airway obstruction, airway clearance and oxygenation that take often take priority over others are:
    • impaired gas exchange
    • ineffective breathing pattern
    • ineffective airway clearance
    • impaired spontaneous ventilation
    • dysfunctional ventilatory weaning response
    in maslow's hierachy of needs, the physiological needs are also arranged in priority. that priority is:
    1. oxygenation (no oxygen getting to the brain or tissues leading to cell death)
    2. food/nutrition
    3. elimination
    4. temperature control
    5. sex/reproduction
    6. movement
    7. rest
    8. comfort
    when using nursing diagnoses you must always be familiar with the definition of the nursing diagnosis and the defining characteristics and related factors that nanda has approved as part of the descriptors for them. choosing nursing diagnoses is not something you can always do by looking at a list and picking out the ones that "seem" to fit your needs. that is not the intent of nanda or critical thinking at all! for this reason a nursing diagnosis book is much better for a beginner of care plan writing than someone who has been doing it for awhile and knows the signs, symptoms and causes of the various diagnoses. applying nursing diagnoses should be taken as seriously by nurses as physicians diagnosing medical conditions. physicians also have to learn the signs, symptoms and causes of many more diseases than the 172 current nursing diagnoses that nurses have to work with.
  12. by   Daytonite
    isis73. . .i thought perhaps you were working with ltc patients. yes, working strictly from the symptoms of their medical diagnoses is not always very practical in the case of long term and maintenance care. it's hard to come up with potential diagnoses on patients like this sight unseen. you really need to get in and assess their abilities to perform their adls. that assessment is going to provide you with all the data you will need to develop a care plan that is going to strictly address the patient's direct hands on nursing care. i can only suggest that if you have a chance to review the patient's chart before your actual clinical with the patient that you look at as many of the nursing notes and assessments you can find in the chart. there will sometimes be charting forms that the cnas are also completing that may or may not be included in the charts at the desk. in some of the nursing homes where i worked, these cna chartings were kept in 3-ring binders that were somewhere around the nursing station as well. there will usually be a great deal more about a patient's ability to perform adls in the cna charting. also, each nursing home maintains an official care plan on each patient. sometimes they are kept at the nursing station. sometimes they are kept in someone's office. if you can find out where they are, you merely have only to look at the care plan for your patient to get an idea of what is truly going on with the patient. these care plans, by law, must be up to date and reflect and incorporate all physician and nursing orders.
  13. by   isis73
    Thanks again, Daytonite. I did think to check other binders this week (after having to revamp my care plan last week) and looked at Treatments. Based on what I saw, I think impaired skin integrity will be my priority this week.

    Here's my Nsg Dx so far:

    Skin integrity, impaired r/t physical immobility, altered circulation secondary to Peripheral Vascular Disease, Hx of DU, moisture secondary to wearing briefs, hyperglycemia secondary to DM, G-tube, indwelling catheter, bowel incontinence and urinary incontinence AMB excoriation on sacrum/coccyx, AKA right leg, BKA left leg, contractures in arms and bowel and bladder incontinence.

    Too long? Anything questionable in that? Open to feedback!
    Isis73
  14. by   Roseyposey
    Quote from daytonite
    that is true when the symptoms pertain to the airway. however, the nursing diagnosis, impaired swallowing, does not have anything directly to do with the airway. its definition is: "abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function." nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 195. nanda lists the causes (related factors) for it as being due to either congenital defects or neurological problems. a cva might create the neurological problem for the patient. while aspiration prevention is an outcome of this diagnosis, that does not establish it a topmost priority. in reality this nursing diagnosis would only be used if positive attempts were being made to feed the patient orally.

    the nursing diagnoses dealing with airway obstruction, airway clearance and oxygenation that take often take priority over others are:
    • impaired gas exchange
    • ineffective breathing pattern
    • ineffective airway clearance
    • impaired spontaneous ventilation
    • dysfunctional ventilatory weaning response
    in maslow's hierachy of needs, the physiological needs are also arranged in priority. that priority is:
    1. oxygenation (no oxygen getting to the brain or tissues leading to cell death)
    2. food/nutrition
    3. elimination
    4. temperature control
    5. sex/reproduction
    6. movement
    7. rest
    8. comfort
    when using nursing diagnoses you must always be familiar with the definition of the nursing diagnosis and the defining characteristics and related factors that nanda has approved as part of the descriptors for them. choosing nursing diagnoses is not something you can always do by looking at a list and picking out the ones that "seem" to fit your needs. that is not the intent of nanda or critical thinking at all! for this reason a nursing diagnosis book is much better for a beginner of care plan writing than someone who has been doing it for awhile and knows the signs, symptoms and causes of the various diagnoses. applying nursing diagnoses should be taken as seriously by nurses as physicians diagnosing medical conditions. physicians also have to learn the signs, symptoms and causes of many more diseases than the 172 current nursing diagnoses that nurses have to work with.
    edited, never mind...
    Last edit by Roseyposey on Oct 25, '06

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