Care plan help!

  1. 0
    Hi everyone,

    I am having difficulty with my care plan. My patient had a stroke a while back and is doing pretty well now. She lost 40 lb and is 162 lb and 5'3. She has a very good appetite and just recently went from using a wheelchair to getting around, to walking with a walker. She has dysphagia so she is on a mechanical diet. Her hemoglobin is abnormal at 9.6 L, but im not too sure if she is taking any supplements. She also has a feeding tube in her stomach but hasnt used it in a while since she is finally eating by herself.

    Our clinical groups diagnosis for the week is nutrition so for my nursing diagnosis I have that she has Altered Nutrition: Less than body requirements. But im not sure what to write for the Related To part. My professor told me that im not going to say she has more than requirements because she doesnt want me to put my patient on a diet although the pt is overweight. So she told me to put less than requirements and to look at all the aspects of the pt's diet. The thing is, the patient eats everything, about 100% of her meals so I dont really see a deficiency in anything.

    Can anyone please help me? Im a little lost.
    Last edit by freckles23 on Feb 28, '13
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  4. 3 Comments so far...

  5. 2
    This is interesting... You have a group diagnosis for your whole clinical group? This is a prime example of what NOT to do when writing a care plan. You cannot just choose a diagnosis and mold your patient to fit it. You have to assess your patient and make a diagnosis based on the assessment findings. At this point, your patient may not have altered nutrition and that's the reason you can't find related to data. I'm really surprised, and rather appalled, that your instructor is teaching care plans in this manner.

    I suppose my advice is to look at your patient's symptoms earlier in her illness when she was losing weight and was unable to meet her nutritional requirements by oral intake. Why did she have altered nutrition then? Since you're not even choosing a diagnosis that fits your patient, I see no reason why you should have to use current assessment information to complete your care plan.
    GrnTea and Esme12 like this.
  6. 1
    I'm looking at the NANDA-I 2012-2014 section on Nutrition right now (page171-189). Class 1: Ingestion seems to be where you ought to be looking, but, as we always say, you don't start with the diagnosis and then try to find facts to cram your patient into it.

    Go to that section and thumb through the diagnoses given. See if some defining characteristics match your assessment findings. The "related to" are listed there, too, so you can see all you need to make the diagnosis.

    If your faculty is giving you these very confusing (and frankly inappropriate) directions, I'll bet they didn't put the NANDA-I 2012-2014 on your reading list. It's not a huge book, it's not really costly, but it is THE defining work on what nursing diagnosis is and what they are. It will so jumpstart your process towards thinking like a nurse, which is, when you think about it, what you are in school for. Preparing, ordering, and delegating nursing plans of care will be your responsibility, so you owe it to yourself to get a leg up on your classmates by having this. Free 2-day shipping fr students on Amazon. If you order it tonight you can have it by Tuesday.
    Esme12 likes this.
  7. 0
    Quote from freckles23
    Hi everyone,

    I am having difficulty with my care plan. My patient had a stroke a while back and is doing pretty well now. She lost 40 lb and is 162 lb and 5'3. She has a very good appetite and just recently went from using a wheelchair to getting around, to walking with a walker. She has dysphagia so she is on a mechanical diet. Her hemoglobin is abnormal at 9.6 L, but im not too sure if she is taking any supplements. She also has a feeding tube in her stomach but hasnt used it in a while since she is finally eating by herself.

    Our clinical groups diagnosis for the week is nutrition so for my nursing diagnosis I have that she has Altered Nutrition: Less than body requirements. But im not sure what to write for the Related To part. My professor told me that im not going to say she has more than requirements because she doesnt want me to put my patient on a diet although the pt is overweight. So she told me to put less than requirements and to look at all the aspects of the pt's diet. The thing is, the patient eats everything, about 100% of her meals so I dont really see a deficiency in anything.

    Can anyone please help me? Im a little lost.
    I agree with GrnTea and Ashley.....however......maybe think about what limitations a mechanical soft diet has and would she be missing any nutrients that she would normally get with a regular diet?


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