I am new and I need HELP

  1. This is my first year as a student nurse and new to this site. I am about ready to loose my mind over these care plans Can anyone help me with nursing diagnoses on a client who is 67 and has cerebral palsy. I need 3 diagnoses and this is what I have so far:

    1. Impaired nutrition:less than body requirements
    2. Impaired physical mobility

    my problem is what they are related to.. I am still having trouble grasping the concept on how to related these diagnoses.

    Please can anyone help me or at least offer some sites that will help.
    Last edit by smokes06 on Nov 25, '06
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  2. 4 Comments

  3. by   EricJRN
    Welcome to the site! I moved your post to the Nursing Student Assistance Forum for more responses. Good luck to you.
  4. by   Daytonite
    hi, smokes06!

    yes! i can see you have a big problem. i love to help students with their care plans, but i have a big problem here, too. that is, that you have provided no assessment data. your nursing diagnoses have to be based on the assessment data that you have gathered about this patient. so, tell me what you've got on them and i will be able to help you more effectively.

    the impaired physical mobility is pretty much a foregone conclusion. it is due to neuromuscular impairment. your related to (r/t) part of the diagnostic statement is the reason, or what is causing the problem (nursing diagnosis). in the case of cerebral palsy you need to know the pathophysiology behind the disease to understand that this is the related factor causing his immobility.

    tell me how you came to choose imbalanced nutrition: less than body requirements for this patient.

    some other things that came to my mind just thinking about people with cerebral palsy are does this patient have any speech problem? is there any risk for falls or injury? one of my sister-in-laws has a sibling with cerebral palsy, and i swear to god we are always running alongside or behind her waiting for an inevitable fall because her balance is so bad when she is walking. how she keeps herself upright is a mystery to me. these potential problems can all be care planned for.

    since you've discovered allnurses, please take some time to explore these threads on the nursing student forums on which you will find a lot of information to help you with care plan writing:
    this information on the nursing process is also posted there, but let me repeat it for you in case you get lost in all the posts on those threads since it is very important. the nursing process is a repeating cycle. the practical application of the steps in the nursing (written care plan) process is:
    1. assessment of your patient and gathering data
    2. choosing nursing diagnoses after grouping abnormal data together
    3. planning care by developing outcomes and nursing interventions
    4. implementing the plan of care (putting it into action)
    5. evaluation of the plan of care
    without looking at your abnormal data and grouping it into nursing diagnoses you are going to continue to be stuck.

    here is some information on:
    impaired physical mobility
    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=35
    http://www1.us.elsevierhealth.com/ev...replan_047.php

    imbalanced nutrition: less than body requirements
    http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=37
    http://www1.us.elsevierhealth.com/ev...replan_049.php


    please join the rest of the nursing students on the nursing student forums. here is a list of the nursing student forums on allnurses:welcome to allnurses!
  5. by   smokes06
    I am glad that you replied back. The assessment on my client is very simple. She is not experiencing any problems; however, she is a 2-assist person with everything. She is 5' tall and 85lbs. She is very hard to understand. I know this is not much but I am still new at all this and have no idea what I am doing
  6. by   Daytonite
    a list of the signs and symptoms of cerebral palsy are listed here at the website below. if you patient has any of these, then use them for your aeb items to support your nursing diagnoses:
    http://www.fpnotebook.com/ped39.htm
    http://www.emedicine.com/cgi-bin/fox...mr/topic24.htm - information on cerebral palsy including the pathophysiology and symptoms.
    http://www.emedicine.com/neuro/topic533.htm - another article from emedicine on cerebral palsy
    http://www.emedicinehealth.com/cereb...article_em.htm - this is a site within emedicine written for the health consumer so is a little easier to read. there is a link to an 18-page (not long pages) write up about the symptoms as well as for treatment and therapies. well worth reading.

    you should probably use diagnoses like this (i have sequenced them in order of priority by maslow's hierarchy of needs):
    1. imbalanced nutrition: less than body requirements r/t feed and swallowing difficulties due to spasticity aeb body weight 20% below ideal for a 60 inch tall female, patient reports that it is difficult to physically feed herself, and patient reports of difficulty swallowing [physiological - food]
    2. impaired physical mobility r/t neuromuscular impairment aeb by spastic movements and poor balance aeb observed unstable posture while standing and attempting to perform adls, observed limitation in gross motor movements of arms and legs, spastic gait, swaying while standing and walking and difficulty beginning a step [physiological - movement]
    3. impaired verbal communication r/t facial muscle spasticity aeb physical difficulty forming words, slurring of words and drooling [safety] http://www1.us.elsevierhealth.com/me...ex.cfm?plan=11 http://www1.us.elsevierhealth.com/ev...replan_015.php
    4. risk for injury r/t inability to control spasticity [anticipatory problem - safety] http://www1.us.elsevierhealth.com/ev...replan_043.php
    i've only given you items for your diagnostic statements that i think might apply to your patient. they are based on my experiences over the years with patients who have cerebral palsy. of course, only you know what your patient was like and capable of doing or not doing. it's very hard at first to put down on paper what we observe with our eyes so very quickly. so, it helps to look at some written resources. that is why i've given you four websites to go to for information about cerebral palsy. as you read through those sites think back to what you observed in your patient. if she had one of those signs or symptoms, then write it down immediately before you forget it again. that will be usable information for your care plan. feel free to change anything i've given you as this is your patient.

    you should address your nursing interventions to the items that follow the aeb part of each of your nursing diagnoses. these are the actual signs and symptoms (abnormal data) that you observed in your patient. these are the things that as a nurse you will assist in helping her with. you may need to do some hunting around in nursing and other textbooks to find appropriate interventions. if you have to develop outcomes, the websites for the nursing diagnoses i've listed for you have outcomes listed for them.

    for all your subsequent patients, go through their charts. take down information from the doctor's history and physical, any consultant's reports, labwork results, x-ray results, physical therapy evaluations (would have been very helpful in writing this patient's care plan), dietary evaluations, speech therapy evaluations, respiratory therapy notes, the nursing admission history items especially those things addressing the patient's ability to perform adls, medications being taken, treatments ordered, and the doctor's progress notes. this is all data that is going to prove important to use when putting together a care plan for a patient. just because you weren't the person who got this information from the patient doesn't mean you can't use it. it's in her chart, it's up for grabs to be used. you don't have to duplicate their work with the exception of your own review of systems and physical examination.

    hope this gets you moved along farther in completing this care plan. good luck. you can always feel free to private message me for help with a care plan.

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