help with my first careplan

[vivaBM_lpn]

Hey everyone, I just joined this site, and I am hoping I can find a little help with my first care plan. I am having trouble picking where to begin (my nursing diagnoses). My instructors basically said for us to pick the admitting diagnoses and go from there on what would be of the highest importance. My patient is a 97 year old woman with dementia. She has contractures on her arms and legs, she is unable to speak. she is a total care patient. She doesn't have a Foley, but she is incontinent of her bowels and bladder, she also has a peg tube. I was thinking I could do a self care deficit, but she is also on O2 so circulation and airway are first on Maslow's heiarchy over self care deficit? Any ideas on where to start would be awesome. thanks so much!

[Daytonite, BSN, RN]

is this a real patient that you cared for or a scenario you were given? a scenario gives you specific information to work with.

a care plan is a collection and determination of a patient's nursing problems. the nursing diagnoses are merely names that are given to the nursing problems. the remainder of the care plan is strategies to do something about the nursing problems that the patient has. in order to determine what the nursing problems are we use the nursing process. the first step is to do a thorough assessment of the patient. in doing so, abnormal data point the way to what the nursing problems are. dementia is a medical evaluation. what are her signs and symptoms of the dementia? look up the definition in a medical dictionary and see what symptoms she displayed. (see http://www.merck.com/mmpe/sec16/ch213/ch213c.html - dementia) some of them will be symptoms of a nursing problem that fits a nursing diagnosis. what is the result of her having contractures of her arms and legs? how does it affect her ability to move? can she walk? turn in bed? do you see that i am getting at how she responds to what has happened to her. those responses are important because they tell us exactly what her nursing problems are. step 2 of the nursing process is identifying the nursing problems and adding the nursing diagnostic names to them. if she is totally incontinent of bowel and bladder these are nursing problems:

• total urinary incontinence - definition: continuous and unpredictable loss of urine (page 403, nanda international nursing diagnoses: definitions and classifications 2009-2011)
  
• bowel incontinence - definition: change in normal bowel habits characterized by involuntary passage of stool (page 101, nanda international nursing diagnoses: definitions and classifications 2009-2011).
  

a peg tube and oxygen are medical treatments that are ordered by physicians, but often left to nursing to carry out. what is the underlying problem for these treatments and any symptoms connected with the underlying medical problem? that is where to find the real nursing problem for them.

maslow's hierarchy is used to sequence the nursing diagnoses once you have determined what they are.

[acjordan]

I remember my first care plan. It was the first time I was frustrated enough to cry. Take a deep breath and look at it logically. The most important things are your A,B,C's. Airway, breathing, and circulation. It doesn't mean too much if you have a heart that is beating and no oxygen entering the body. So, why is your patient on oxygen? Is it because she has an underlying condition? Possible pneumonia? Look at the NANDA nursing diagnosis. Here you have a patient who is in need of O2, isn't able to move freely, has dementia, has a PEG, and is incontinent. If someone isn't able to move you should always be concerned about oxygenation, perfussion, breakdown. With what you have said about your patient you should be able to come up with a care plan to knock your instructors socks off. There's not many of the NANDA's which wouldn't fit it. Just remember to support your nursing Diagnosis with data such as meds, labs, assessment findings ( there should be a place for every one of these). You can get a careplan book but beware of depending on it. You need to process what's going on with your patient and learn how to make a care plan specific. It will all come in time, and soon you will be looking back at your first care plan and laughing. Good luck.