another care plan help

  1. hi,first semester and lost on care plans. I have to write one on a woman who is 71,lives in the nursing home and has a mental illness. she has been disabeled her whole life and has always lived in housing complexes which offered help. she did live alone til she fell and broke her ankle,had surgery on it,she developed an infection in her wound and thats when she went to the nursing home for re-hab. That was 5 years ago. Feeds self,is up to date on news,enjoys going to mass everyday and participates in all activities. She did have uterine cancer which resulted in a hysterectomy and radiation.she is cancer free. she has high BP,insomnia and anxiety. which she is on meds for. i have to have 3 diagnosis from her admission diagnsis which is mental illness....i can not for the life of me come up with any...i looked in the NANDA book but i cant seem to relate any to this person.
    The only thing i had to do for her was wash her up before bed. so the only thing i came up with so far was...bathing or hygiene self-care deficit. i was also thinking of impaired social interaction,but she is social. i was going to use risk for fall as number 3 cause we cant use "risk for" for the first 2. i want to use this cause she walks with a limp due to her ankle. i am SO lost on this!!
    I am sorry if this is a mess. I am not feeling well.
    any suggestions would be GREAT
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    About momtojosh

    Joined: Jan '08; Posts: 529; Likes: 216
    LPN; from US
    Specialty: 8 year(s) of experience


  3. by   Esme12 are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, 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)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
  4. by   Esme12
    So what does she complain of? Does she have pain? What meds is she on? What are her vitals? What does she need what does she complain about? Is she oriented?
  5. by   momtojosh
    thank you for that...i have read your post over and over and still cannot get it.

    we never did a head to toe assessment...havent even begun that yet. this is what we did....first day of clinicals in the nursing home we were assigned to our person. mine has a history of mental illness. then we had to have therapueitc conversations,that was our focus for that week. then it was back to our room to look over their careplans and write down info for our careplans...our instructor wants us to make a care plan for what they were admitted for. i only met with this woman once in the 4 weeks we were there. the other days we were there we helped the CNAs do care. the only material i have to go on is her careplan for the facility and not sure what to use. and yes here i ago again, trying to do the plan around the diagnosis. but thats what our intructor wants....i am so lost and confused
  6. by   Esme12
    I have to write one on a woman who is 71, lives in the nursing home and has a mental illness. She has been disabled her whole life and has always lived in housing complexes which offered help. She did live alone until she fell and broke her ankle ,had surgery on it, she developed an infection in her wound and that's when she went to the nursing home for rehab. That was 5 years ago. Feeds self, is up to date on news, enjoys going to mass everyday and participates in all activities. She did have uterine cancer which resulted in a hysterectomy and radiation. She is cancer free. she has high BP, insomnia and anxiety. which she is on meds for. i have to have 3 diagnosis from her admission diagnosis which is mental illness."
    I hate it when the assignment is on something other than the patient assessment.....that is what makes it confusing. A few more she oriented? Is she able to care for herself? Does she have pain? What is her "mental illness" diagnosis? Depression? Schizophrenia? Schizo affective? What meds is this patient on? Did you talk to her? What did you talk about?

    Does you CI require they pertain to the patient?
  7. by   momtojosh
    A few more she oriented?yes she is, Is she able to care for herself? she needs help washing, Does she have pain?she denied any pain the only time i talked with her, What is her "mental illness" Schizophrenia, What meds is this patient on?i do have a list of all meds she takes, Did you talk to her? yes What did you talk about? we talked about how she likes watching the news and her game shows at certain times,also about her sisters and where she was born, her hysterectomy and radiation,she showed me her certificate of completion of radiation. she was a hard one to get talking though. and we were only allowed 30 mins to talk,then it was reading careplans on them. it just seems so laxed.
    i must of left some sort of impression on her cause we were at the nurisng station and she called and asked for me by name and to see if i was coming down to help with her nightly wash up (her words)..and thats the only time i had with her the whole 4 weeks we were there, i did pop in on her while i was on the floor though just to chat,but she was never in the CNAs group i was working with so i didnt have much interaction with her.
  8. by   Esme12
    She could have activity intolerance due to her unsteady gait from her ankle injury AEB her limp.

    NANDA describe activity intolerance as....
    Insufficient physiological or psychological energy to endure or complete required or desired daily activities
    Defining Characteristics

    Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness
    Related Factors (r/t)

    Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle

    She has anxiety as apart of her mental illness?
    NANDA defines anxiety as......

    A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat

    Is she at risk for falls due to her unsteady gait? NANDA describes risk of an increased susceptibility to falling that may cause physical harm.

    She has insomnia........NANDA describes this as.....Frequent complaints of disruption in amount and quality of sleep that impairs functioning.

    I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition who actually has a care plan for common mood disorders for deficient knowledge, social isolation.

    what did she talk with you about what do you think?
  9. by   Esme12
    So some of this can be about schizophrenia......I'm sorry you weren't able to fully assess this patient...this is what makes it so hard for you guys starting out.....this may help Nursing care plan for schizophrenia.(click on the link) There are certain meds/toxic levels that need monitoring on schizo patient and can in them selves cause problems

    These may help as well.

    NANDA Nursing

    Disturbed thought processes, organic mental disorder secondary to Alzheimer€™s disease
    Nursing Resources - Care Plans
    Nursing Care Plans, Care Maps and Nursing Diagnosis
    Nursing Care Plan
    Nursing Care Plan | Nursing Crib

    Last edit by Esme12 on Oct 12, '12
  10. by   momtojosh
    thank you!!
    i think my brain is starting to kick in....

    i do have those written down. i think i am begining to see how this is suppose to work.

    now to get it all down on paper
  11. by   momtojosh
    could i use alteration in thought processes as evidenced by cognitive defects?
  12. by   Esme12
    What are the cognitive deficits? What is the NANDA definition? Is that a NANDA diagnosis? what nursing diagnosis book do you use?

    The answers you seek maybe here.... Nursing care plan for schizophrenia.(click on the link)

    nanda list as contributed by vickirn (assistant administrator)
    nursing diagnoses 2012 - 2014.pdf‎
    Last edit by Esme12 on Oct 12, '12
  13. by   momtojosh
    we use Sparks and Taylors Nursing Diagnosis refrence manual

    the alteration in thought processes i found on a website called RN central, its for careplan help. I probably shouldnt use that eh?
    thank you for the site with schizophrenia
  14. by   Esme12
    Yeah.......I'm not crazy about that one. (sparks and Taylors )

    RN central has some useful stuff.......I find a ton of old stuff, reliability can be an issue.......that diagnosis is old.........I gave you a current PDF document with all the current NANDA diagnosis NANDA list as contributed by vickirn (assistant administrator)
    nursing diagnoses 2012 - 2014.pdf‎

    That schizophrenia site/NANDA nursing has good stuff.