I need help with a care plan for Chronic Confusion!!

  1. 1 I 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
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  3. Visit  AshleyNWesley profile page

    About AshleyNWesley

    Joined Nov '13; Posts: 2; Likes: 1.

    15 Comments so far...

  4. Visit  Mewsin profile page
    0
    I 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.
  5. Visit  Levitas profile page
    0
    Okay, 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).

    SMART

    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.
  6. Visit  quirkystudent profile page
    0
    I 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
  7. Visit  AshleyNWesley profile page
    0
    quirkystudent, you're a life saver! Thank you, I like the way you worded that now all I have to do is add parameters! Seemed so simple, now I feel dumb!!! hehehe
  8. Visit  Esme12 profile page
    0
    I 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
    Care plans are all about the patient assessment.....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.

    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

    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)

  9. Visit  Esme12 profile page
    0
    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
    so the NANDA I deficition of chronic confusion.


    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
    that "prove your patient has this diagnosis? I see you copied them but what evidence in your actual assessment did your patient show you that these impairments actually exists?
  10. Visit  quirkystudent profile page
    0
    I 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.
  11. Visit  Esme12 profile page
    1
    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.
    quirkystudent likes this.
  12. Visit  quirkystudent profile page
    0
    Quote from Esme12
    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.
    I 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.
  13. Visit  GrnTea profile page
    1
    Let's take a look at what making a nursing diagnosis requires. 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). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

    I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.


    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)


    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.


    I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

    Quote from AshleyNWesley

    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
    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))__."

    Your nursing diagnosis for chronic confusion would be: Chronic confusion related to (whatever her cause is-- and you have exactly five choices in the NANDA-I 2012-2014: Alzheimers, CVA, head injury, Korsakoff's psychosis, or multi-infarct dementia) (page 265)

    as evidenced by:
    (and here you have to pick one or more of exactly ten defining characteristics which you have identified in THIS patient by your own assessment including med record findings):
    altered interpretation
    altered personality
    altered response to stimuli
    clinical evidence of organic impairment
    impaired long-term memory
    impaired short term memory
    impaired socialization
    longstanding cognitive impairment
    no change in level of consciousness
    progressive impairment

    So you can't say that you know your patient has chronic confusion because somebody is prescribing drugs for her-- it's not on the evidence-based list.

    As to your interventions, I know that a lot of people think restating medical plans of care is part of a nursing plan of care, but it's not. Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.


    You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

    So your NURSING interventions would include 2,3, and 4 as you give them (and the rationales are fine; I assume you need to cite sources for them so your faculty knows you're not just making those up too )


    I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them. It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon.



    The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

    Outcomes? How about not sustaining injury? That's why you picked one of your interventions. "Be safe" isn't specific or measurable, but not sustaining an injury is. Now take the other two and look at them like that.

    Last edit by GrnTea on Nov 24, '13
    Esme12 likes this.
  14. Visit  quirkystudent profile page
    0
    Grntea I have a question for you. When making your goals do you need to use the goals listed in the NANDA book? I know they have some specific ones in there. Maintaining safety (may not be exact wording) is listed for that diagnosis and if I remember right it was the only one listed. Or are you able to make it more patient specific? That's something I'm confused on.
  15. Visit  JustBeachyNurse profile page
    1
    There aren't goals listed in my nanda book only diagnosis, definition, defining characteristics, related factors, (or definition and risk factors) with references listed at the end of the section.

    Are you referring to a care planning book that has goals & interventions? It should always be patient specific.
    GrnTea likes this.


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