Help with first care plan

  1. I am a nursing student in the RN program and am having difficulties writing my first care plan. My client is a 89 year old and is totally dependant for all care. She has osteoporosis, HTN, Dementia, and is on coumadin for a DVT in R leg. I was going for risk for impaired skin integrity r/t physical immobilization, and excretions and secretions. I need an AEB and a couple of short term goals. I don't know if I am on the right track, any helpwill be greatly appreciated!
  2. 1 Comments

  3. by   Daytonite
    there is information on how to write a care plan on this sticky thread: help with care plans. you will find a number of replies to this thread that explain how nursing diagnoses and goals are determined.

    you have a problem with the construction on your nursing diagnostic statement. the construction of the 3-part diagnostic statement follows this format:

    p (problem) - e (etiology) - s (symptoms)

    • problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
    • etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
    • symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
    you ask. . .i need an aeb and a couple of short term goals.
    the problem i have in responding to your request is that there are no aebs (symptoms) for a nursing diagnosis of risk for impaired skin integrity. the reason is because this is a potential nursing problem--a nursing problem that doesn't even exist yet. aebs (symptoms) are only present when there are actual nursing problems. the r/ts (risk factors) will be things that according to nanda are "antecedent to, associated with, related to, contributing to, or abetting [inciting wrongdoing]" [page 420, nanda international nursing diagnoses: definitions and classifications 2009-2011] the nursing problem which in this case would be skin breakdown. you already identified those as physical immobilization, and excretions and secretions. by your diagnostic statement of risk for impaired skin integrity r/t physical immobilization, and excretions and secretions you are saying that because the patient is physically immobile (not moving much) and has the presence of urine, stool and other body fluids against her skin that she could develop skin breakdown. the long-term goal for this is simply to prevent impaired skin integrity. other goals will be a reflection of the predicted results of your nursing actions and interventions. and, very specifically, the nursing interventions for a risk for impaired skin integrity nursing diagnosis will be limited to the following:

    • strategies to prevent skin breakdown from happening in the first place
    • monitoring for the specific signs and symptoms skin breakdown
    • reporting any symptoms of skin breakdown that do occur to the doctor or other concerned professional
    information on assessing skin and skin breakdown can be found on this website (you will need this information for your "monitoring for the specific signs and symptoms skin breakdown" interventions): - pressure ulcer training tutorial
    she has osteoporosis, htn, dementia, and is on coumadin for a dvt in r leg.
    for a patient with the above diagnoses, risk for impaired skin integrity should not be your primary or only nursing diagnosis. the way nursing diagnoses are determined is by following the steps of the nursing process and starting with an assessment of the patient and then making a list of all the person's abnormal assessment data. nursing diagnoses (nursing problems) are based upon what we find to be abnormal about the patient's physical examination and not what is normal. osteoporosis, htn, dementia and dvt are all medical diagnoses that are based upon abnormal assessment data that the doctors found. that same assessment data can be used by us nurses to determine what the patient's nursing problems are. you can see how this is done on the help with care plans thread referenced above. here are previous threads about care plans for patients with dvts. by reading these threads you will see that you have missed a few nursing problems related to dvts:

    since you also say this patient is dependent on all care, i would also expect several self-care deficit diagnoses because she probably needs help with all her adls (activities of daily living).