Help! I'm doing my nursing care plan homework and i'm stuck

  1. 0
    I'm a nursing student. My homework is forming a nursing care plan

    My patients medical diagnosis is Infantile Tay-Sachs (Genetic incurable neurodegenerative disorder that only gets worse and is 100% fatal typically by age 5)

    We are going to assume my patient is progressed and need full time nursing care

    My 2 nanda DX are impaired skin integrity r/t paralysis and Self Care Deficit Syndrome r/t paralysis.

    The first one I think I am good on but I'm 100% stuck on the 2nd one because there is no hope for improvement with this type of patient and I have to improve them in a nursing way (theoretically).

    This is due tomorrow.

    I am looking for a little tutoring right now so I understand this better. This is my weakest subject in school

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  2. 9 Comments...

  3. 0
    Can you focus on improving their quality of life through nursing measures?
  4. 1
    Is this a hypothetical patient? I would guess in real life that it would depend on the individual. For self-care deficit, for what ADL? I had a patient with a self-care deficit (feeding) and my interventions were to provide the patient with modified utensils, plates, cups in order to gain more independence. Are you only looking at Activity-Exercise type NANDA diagnoses? I was thinking more along the lines of family coping diagnosis in your case.
    Wise Woman RN likes this.
  5. 0
    Yes this patient is an imaginary tool my teacher is using to make me better at this. My patient has feeding tubes normally due to dysphagia. My patient is a toddler who can't move, has dementia and muscle atrophy.
  6. 0
    Quote from bluefrog87
    Yes this patient is an imaginary tool my teacher is using to make me better at this. My patient has feeding tubes normally due to dysphagia. My patient is a toddler who can't move, has dementia and muscle atrophy.

    i love the added dementia.. for the kid..
  7. 1
    Typical toddlers cannot care for themselves so I would direct this more toward the family and teaching care to the family. For kids, it's all about family centered care and involving the family in that care and letting them make decisions.
    Wise Woman RN likes this.
  8. 0
    I can't go for any risk for diagnoses .... I thinking either I need to change direction and go for a knowledge deficit or grieving diagnosis now...

    Yes my young imaginary patient's brain and nerve cells aren't doing well. They are filling up with gangliosides and dying. Idk the age of the patient because I am making it up as I make my care plan. The goal right now is not having public humiliation in front of my class after putting a good amount of effort.
  9. 1
    OK, so it was due today and it's too late. But for the future, listen up.

    If I pull out my NANDA-I 2012-2014 book -- which no student should be without even if the faculty forgot to put it on the bookstore list, free 2-day shipping from Amazon for nursing students-- I see things like these (sorry about the spacing and the indents.... they are all free-standing, independent nuring diagnoses, no hierarchy implied, I just can't make the all line up here). Note, I do not put this huge list here to blow your mind away and make you hopeless-- "I'll never learn all that stuff!" No, you may not memorize it all. But you can learn where to look for it when you need it, and learn what possibilities there are, get a larger view. I'm all about expanded consciousness. NANDA-I. Get it. Make it your friend, because it IS your friend.

    Don't ever forget that the kid's parents are your patients too. Some of these could apply to them.

    • Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function (Domain 2, Nutrition; Class 1, Ingestion)

      • Risk for Disuse Syndrome At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity (Domain 4, Activity/Rest; Class 2, Activity/Exercise)

      • Impaired Bed Mobility Limitation of independent movement from one bed position to another (Domain 4, Activity/Rest; Class 2 Activity/Exercise)
      • Impaired Wheelchair Mobility Limitation of independent operation of wheelchair within environment (Domain 4, Activity/Rest; Class 2: Activity/Exercise)
      • Impaired Physical Mobility Limitation in independent purposeful physical movement of one or more extremities (Domain 4, Activity/Rest; Class 2: Activity/Exercise)
      • Impaired Transfer Mobility Limitation in independent movement between two nearby surfaces (Domain 4, Activity/Rest; Class 2: Activity/Exercise)
      • Impaired Walking: Limitation of independent movement within the environment on foot (Domain 4, Activity/Rest; Class 2: Activity/Exercise)
      • Self-Care Deficit: A constellation of culturally framed behaviors involving one or more self-care activities in which there is a failure to maintain a socially accepted standard of health and well-being (Givens, Lauder, and Ludwick , 2006) (Domain 4, Activity/Rest; Class 5: Self-Care)
      • Self-Neglect (bathing, dressing, feeding, toileting) impaired ability to perform or complete specified activities for self (Domain 4, Activity/Rest; Class 5: Self-Care
      • Disturbed Sensory Perception: (Specify Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory ) Change in the amount or patterning of incoming stimuli accompanied by diminished, exaggerated, distorted, or impaired response to such stimuli (Domain 5, Perception/Cognition; Class 3: Sensation/Perception)
      • Impaired Verbal Communication: Decreased, delayed, or absent inability to receive, process, transmit, and/or use a system of symbols (Domain 5,Perception/Cognition; Class 4: Communication

        • Hopelessness: Subjective state in which an individual see limited or no alternatives or personal choices available and is unable to mobilize energy on his own behalf (Domain 6, Self-Perception; Class 1: Self-Concept)

        • Risk for Compromised Human Dignity: At risk for perceived loss of respect and honor (Domain 6, Self-Perception; Class 1: Self-Concept)


          • Powerlessness: Perception that oneís own action will not significantly affect an outcome; perceived lack of control over current situation or immediate happening (Domain 6, Self-Perception; Class 1: Self-Concept)
        Caregiver Role Strain: Difficulty in performing family caregiver role (Domain 7, Role Relationships; Class 1: Caregiving Roles)
      • Dysfunctional Family Processes: psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem-solving, and the series is self perpetuating crises (Domain 7, Role Relationships; Class 2, Family Relationships)
      • Interrupted Family Processes: Change in family relationships or functioning (Domain 7, Role Relationships; Class 2: Family Relationships

        • Impaired Social Interaction: Insufficient or excessive quantity or ineffective quality of social exchange (Domain 7, Role Relationships; Class 3, Role Performance)

        • Sexual Dysfunction: The state in which an individual experiences a change in sexual function during the sexual response phases of desire, excited in, and/or orgasm, which is viewed is unsatisfying, and rewarding, or inadequate (Domain 8, Sexuality; Class 2, Sexual Function)
        Relocation Stress Syndrome: Physiological and/or psychosocial disturbance following transfer from one environment to another (Domain 9, Coping/Stress Tolerance; Class 1: Post Trauma Responses)
      • Compromised Family Coping: Usually supportive primary person (family member or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manage or master adaptive tasks related to his or her health challenge (Domain 9, Coping/Stress Tolerance; Class 2: Coping Responses)
      • Disabled Family Coping: Behavior of significant person (family member or other primary person) that disables his or her capacities and the clients capacities to effectively address tasks essential to either personís adaptation to the health challenge (Domain 9, Coping/Stress Tolerance; Class 2: Coping Responses)
      • DeathAnxiety: Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to oneís existence (Domain 9, Coping/Stress Tolerance; Class 2: Coping Responses)
      • Ineffective Denial: Conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety/fear, but leading to the detriment of health (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • Grieving:A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • ComplicatedGrieving: A disorder that occurs after the death of the significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • Impaired Individual Resilience: Decreased ability to sustain a pattern of positive responses to an adverse situation or crisis (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • Chronic Sorrow: cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced (by a parent, caregiver, individual with chronic illness or disability) in response to a continual loss, throughout the trajectory of an illness or disability (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • Stress Overload: Excessive amounts and types of demands that require action (Domain 9: Coping/Stress Tolerance; Class 2: Coping Responses)
      • Readiness for Enhanced Hope: A pattern of expectations and desires that is sufficient for mobilizing energy on oneís own behalf and can be strengthened (Domain 10: Life Principles; Class 1, Values; Class 2, Beliefs; Domain 6, Self-Perception; Class 1, Self-Concept)
      • Decisional Conflict:Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenged values and beliefs (Domain 10: Life Principles; Class 3, Value/Belief/Action Congruence)
      • Moral Distress: Response to the inability to carry out oneís chosen ethical/moral decision/action (Domain 10: Life Principles; Class 3, Value/Belief/Action Congruence)
      • Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Impaired dentition: Disruption in tooth development/erection patterns or structural integrity of individual teeth (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Risk for Dry Eye: At risk for eye discomfort or damage to the cornea and conjunctiva due to reduced quantity or quality of tears to moisten the eye (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Risk for Falls: At risk of increased susceptibility to falling that may cause physical harm (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Risk for Injury: At risk of injury as a result of environmental conditions interacting with the individualís adaptive and defensive resources (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity s (Domain 11: Safety/Protection, Class 2: Physical Injury)
      • Acute Pain: Unpleasant sensory or emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (Domain 12: Comfort, Class 1: Physical comfort)
      • Chronic Pain: Unpleasant sensory or emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of greater than 6 months (Domain 12: Comfort, Class 1: Physical comfort)
      • Delayed Growth and Development: Deviation from age group norms (Domain 13: Growth/Development, Class 1: Growth)
    Esme12 likes this.
  10. 0
    I'm sorry I am late to the game. The next time....give us more than over night to help..... My kids needed homework project help last night.....

    "My patient, who has Infantile Tay-Sachs,
    The First Signs - A baby with classic Infantile Tay-Sachs appears normal at birth and typically continues to develop normally for the first six months of age. Around 6 months of age, development slows. Parents may notice a reduction in vision and tracking and the baby does not outgrow normal startle response.

    A Gradual Loss of Skills - Infantile Tay-Sachs children gradually regress, losing skills one by one. Over time they are unable to crawl, turn over, sit or reach out. Other symptoms include loss of coordination, progressive inability to swallow and difficulty breathing.

    By Age 2 and beyond - Most children experience recurrent seizures by age 2 and eventually lose muscle function, mental function and sight, becoming mostly non-responsive to their environment.Classic InfantileTay-Sachs - Symptoms, Diagnosis and Management
    has feeding tubes normally due to dysphagia. My patient is a toddler who can't move, has dementia and muscle atrophy."

    So your toddler has impaired skin integrity R/T immobility/paralysis from TSD AEB .....by what? What evidence due you have? or would this be At risk for? I hate these hypothetical scenarios for they never provide the information necessary to develop a plan of care. The plan of care is based on the patients actual needs.

    What is Tay-sachs?
    Infantile TSD, by far the most prevalent form of TSD. In infantile TSD, development is generally normal until about 3 to 6 months of age, at which time neurological deficits manifest themselves and become apparent. These deficits include weakness, hypotonia, poor feeding, and exaggerated startle reflex (hyperacusis). An eye exam will generally show a "cherry red spot" on the retina, a hallmark sign of TSD. Most of these children die by the age of 4 from aspiration pneumonia.Tay-Sachs Disease | CCJGD
    How does this disease affect these infants? Does this infant suffer seizures? how does this affect the child's care? what precautions need to be taken with a child that have seizures?

    Dysphagia? How does this affect the child's care? What precautions are necessary for aspiration protection? Normally you would ask if the patient has had aspiration pneumonia in the past.

    Care is usually focused on maintaining quality of life that they have left. Care is also focused on the family and their soping and grieving processes.

    • Turn and position frequently and regularly to prevent painful contractures and bedsores. Initially, he was so hypotonic that we tailor-made a carriage to keep him upright.

    • Give meds for seizure control. Keep seizure precautions at all times.

    • Feed by gastrostomy in small doses, with frequent checks of residual volumes, to prevent aspiration.

    • Place in a quiet atmosphere to reduce eliciting the exaggerated startle reflex.

    • Participate in a class with other children his age and disability (severe psychomotor retardation). Activities can include music therapy, physical therapy, and large amounts of physical contact. Music can be especially soothing for these patients,

    • Give special attention to oral care, PEG stoma care, and skin integrity.

    I hope this will help you next time.
  11. 0
    Welcome to AN! The largest online nursing community!

    ok...the next time................. 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 patient......in 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.


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