Originally Posted by RadfordSN 
Alright, so I'm finally breaking down and coming here for help.
Last week I had a patient with dementia. He was noncommunicative; however, he responded to auditory stimuli, and was able to respond with a "yes" or "no" to pain (denied pain). The nursing home brought him to the hospital with abdominal distention r/t fecal impaction. The impaction was removed, stool softeners/enemas/laxatives/bulking agents were given and he now has constant diarrhea. He also has an unstageable pressure ulcer of the sacral area and is immobile. He is fed through a PEG tube (I have no information that explains the need for the feeding tube or when it was placed).
My problem is coming up with nursing diagnoses for this concept map. I already have adult failure to thrive, impaired nutrition:less than, insomnia, impaired physical mobility, and impaired skin integrity. I also added r isk for impaired environmental interpretation syndrome (risk because I could not get him to talk to assess his orientation to person, place, time, circumstance) and risk for deficient fluid volume. I just feel like I'm missing a lot of other diagnoses and that some of the ones common for dementia do not apply to this patient (or do but how am I to know without being able to properly assess).
If anyone could provide me with some assistance it would be greatly appreciated. :]
Even if you never knew any of the patient's medical diagnoses, nursing care planning is based on what we learn about the patient's response to their situation. Nursing diagnoses are merely labels for nursing problems. They are based upon abnormal assessment data that is obtained during the nurse's investigation of the patient.
Assessment consists of:- a health history (review of systems)
- performing a physical exam
- assessing their ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- reviewing the signs, symptoms and side effects of the medications they are taking
From what you posted, this patient has the following abnormal data:
- fed through a PEG tube - does this mean he is incapable of swallowing at all? Is he at an abnormal weight? Too small for his height indicating he isn't getting enough nutrition (not likely with a PEG tube in place)?
- abdominal distention r/t fecal impaction (impaction was removed, stool softeners/enemas/laxatives/bulking agents were given and he now has constant diarrhea) - Is the abdominal distension resolved? Is the diarrhea still going on? Is he incontinent? Bowel incontinence? Bladder incontinence, too?
- immobile - Describe the immobility. What extremities can he move or not move? Is he bedridden? Is this causing skin and circulation problems?
- unstageable pressure ulcer of the sacral area - All ulcers are stageable which is why we do assessments, take measurements of these wounds and describe them. See
- dementia - What are this patient's symptoms of the dementia beside not speaking? Dementia usually involves memory deficits, impaired thinking, disorientation and behavioral problems. Patients with dementia usually require lots of assistance with their ADLs
- noncommunicative, but responded with a "yes" or "no" to pain (denied pain) - So how does this patient make his needs known? If he gets thirsty or wants to change position in bed--how does he let the nurses know?
Assessment is a skill that will take a long time to master. You also need to look up medical conditions like dementia to find the pathophysiology going on to help you understand the related factors of the nursing diagnoses you will use.
Adult Failure to Thrive is not a diagnosis I would use unless the patient is showing declining weight loss which can only be found in his chart over successive months, or if the physician has stated this. Listing
Adult Failure to Thrive with
Impaired Nutrition: less than body requirements and
Impaired Physical Mobility is redundant. Read the definitions of each of these diagnoses.
I do not understand your use of
Risk for Impaired Environmenal Interpretation Syndrome. This diagnosis is used with patients who are confused and out of touch with reality. It is used when there are
safety needs. If interventions are needed for the confusion,
Chronic Confusion should be used instead. (1) saying "Risk for" means this would be a potential problem. (2) If the patient has this problem, what is his confusion putting him in danger of? If you could not get patient to talk, he simply has
Impaired Verbal Communication which is not uncommon with people who have progressively deteriorating dementia.
I will often concede that patient's on tube feedings are at
Risk for Deficient Fluid Volume. Bet you don't know why. They don't get enough supplemental water (
Risk for Deficient Fluid Volume R/T inadequate water administration). Nurses, for some reason, don't think to throw glasses of water down theses tubes throughout the day unless it is written down somewhere on a MAR.
Other nursing diagnoses to consider are
- Diarrhea (could be related to high osmolarity of tube feeding formula)
- Total Incontinence
- Impaired Physical Mobility
- Impaired Skin (or Tissue) Integrity R/T pressure [assessment will determine if you use Skin or Tissue as the diagnosis]
- Risk for Infection
Re: Help with Care Plans
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