I need help with a care plan for Chronic Confusion!!
- 1Nov 23, '13 by AshleyNWesleyI am in my first semester of nursing school. I am still trying to figure out how to word things. I know what I want to say in my head but when it comes to documenting and phrasing it appropriately I am having trouble. I know I will get the hang of it eventually buuuut that leads to my question..
So my Dx for my pt is Chronic Confusion. The short term goal I have is: the patient will remain safe and free from harm by the end of shift. Ok the problem with the short term goal is its not SMART (specific, measurable, attainable, realistic, timely). I am missing specific and measureable. Could someone give me an example for a short term goal for chronic confusion that would meet all of the SMART requirements.
Little bit of background on my pt. She has Hx of dementia, HTN, angina pectoris, generalized weakness, RLS, constipation, depression. She is completely independent and walks with a walker. Anything else you would need to know in order to answer my question just ask.
ANY AND ALL ADVICE IS HELPFUL!!
Here is the care plan for anyone who would care to critique it!
Chronic Confusion R/T dementia AEB taking dementia medications, impaired short term/ long term memory, progressive long standing cognitive impairment, and scoring 24 on SLUMS.
Interventions with rationales:
1. Administer medications as ordered- medications may be used to manage symptoms of psychosis, depression, or aggression.
2.Remove potential hazards such as sharp objects and harmful liquids- Pts with dementia lose ability to make good judgments
3.Keep environment quiet and non-stimulating- sensory overload can result in agitation
4. Maintain reality and orient to environment with use of clocks, calendars, and seasonal decorations- to help orient pt back to reality and reduce confusion
- 0Nov 24, '13 by MewsinI think I would probably do risk for isolation r/t disease process (you can add the meds in here also I think).
Now keep in mind I'm from Canada but in my experience I have never heard of the term chronic confusion. Also we don't reality orientate so I wouldn't use that intervention.
- 0Nov 24, '13 by Levitas, RNOkay, well, she's ambulating on her own. One thing I can think of is to have the patient sit up for 'x' amount of minutes, with her feet dangling off of the bed, to prevent orthostatic hypotension (and subsequently, preventing falls, or promoting the patient's safety).
Specific - Sure
Measurable - Absolutely
Attainable - I don't see why not
Realistic - Everyone's got a few minutes
Timely - Again, it only takes a few minutes
So, to put it into wording: Patient will sit up in bed, feet dangling, for 10 minutes prior to ambulating.
- 0I learned that writing out the interventions THEN finding the goal (wording) afterwards was far easier and it looks like you're going that route as well. I think I might be the only person that actually enjoys doing them too. haha I hope you have a Nurses Pocket Guide because those things are a god send.
I would do something like "Client will remain safe and free from harm while maintaining maximum independence by *insert time frame here*." OR you could do impaired environmental interpretation syndrome. If you have the nurses pocket guide (12th edition) it's on page 324.Last edit by quirkystudent on Nov 24, '13 : Reason: I can't spell apparently
- 0I am concerned about your wording....nursing diagnosis are based on patient assessment. What the patient needs. What your assessment told you.
GrnTea has the best explanation of how to word a nursing diagnosis....There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition
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.
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. From what you posted I do not have the information necessary to make a nursing diagnosis.
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.
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
- 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)
- 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)
- Planning (write measurable goals/outcomes and nursing interventions)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
- 0Chronic Confusion R/T dementia AEB taking dementia medications, impaired short term/ long term memory, progressive long standing cognitive impairment, and scoring 24 on SLUMS
Ackley: Nursing Diagnosis Handbook, 10th Edition
Chronic Confusion: NANDA-I Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior
Defining Characteristics: Altered interpretation; altered personality; altered response to stimuli; clinical evidence of organic impairment; impaired long-term memory; impaired short-term memory; impaired socialization; long-standing cognitive impairment; no change in level of consciousness; progressive cognitive impairment
Related Factors (r/t): Alzheimer’s disease; cerebrovascular attack; head injury; Korsakoff’s psychosis; multi-infarct dementia
so where are your defining characteristics?Altered interpretation; altered personality; altered response to stimuli; clinical evidence of organic impairment; impaired long-term memory; impaired short-term memory; impaired socialization; long-standing cognitive impairment; no change in level of consciousness; progressive cognitive impairment
- 0I agree with Esme12... Make sure you have enough evidence (objective and subjective) data to support this diagnosis. The reason I mentioned impaired environmental interpretation syndrome is because it's defining characteristics includes chronic confusional states and also relates to the alzheimers disease process.
Esme12 is right. You need to double check that. I'm still learning too so I just assumed you had that info since that was the diagnosis you chose.
- 0Quote from Esme12I have a terrible habit of assuming things just in day to day activities. It's a hard habit to break because I don't realize I do it till later. Bad habit.One thing we as nurse should not do is assume.....that is a very good point. The OP is in their first semester and as many students do that first care plan is tough.