I am doing my 1st care plan and need help! My patient is a 72 y/o Caucasian female w/ Alzheimer's and hyperlipidemia, she really doesnt have much else going on, is in a nursing home but can walk and eat and is contenent for the most part (wears pullups), she is not oriented to time, and has an unsteady gait while standing sill. I need 2 nursing diagnoses, and only 1 can be a "risk for".
Oct 11, '10
What else is going on with the client? Did you assess her spirituality? Does her family visit? How is she coping with being in a nursing home? You mentioned she eats, but does she drink? Since the thirst response diminishes with aging AND she has Dementia, perhaps she has a “Deficient Fluid Volume”. Did you check her lab work? What about her Albumin and Protein levels? This is an indication of her overall nutritional level. If her protein is low, she is at risk for impaired skin integrity. Did she have a recent CBC with Diff? You mentioned pull ups…she is at risk for impaired skin integrity if she sits in a wet pull up for extended periods of time. Did you complete a full assessment?
Sorry for all of the questions, I just cannot come up with anything given the information you provided. I was simply providing suggestions of what to look for the next time you have a care plan due on a patient. Remember, we give holistic care. I know some students look at the medical Dx and try to come up with Nursing Dx’s based upon that information, but I find that difficult.
I will chew on this tonight and check back in the morning to see if anyone else came up with anything.