here in the u.s. we follow the steps of the nursing process to care plan. you actually have given me all the necessary information to put a care plan together for this patient. using the nursing process let me show you how that will help you organize the information. the nursing process as we use it is actually a problem solving method and we think of the care plan as listing the patient's nursing problems along with strategies to do something for the nursing problems. you've already identified that you want to focus in on one specific problem, sleeping and settling.
you also need to know that nursing diagnosis, like medical diagnosis, is based on sound principles of assessment of the patient and then determining a diagnosis exists because the patient has signs and symptoms (or diagnostic cues, evidence) that the problem is a matter of fact. we construct nursing diagnostic statements in the format of p-e-s
is the problem
, or nursing diagnosis; e
is the etiology
of the problem, or the "related to" part of the diagnostic statement; and s
are the symptoms
of the problem, or the "as evidenced by" or "as manifested by" part of the diagnostic statement. here is a little more explanation about each of these 3 subjects areas:
step #1 - assessment.
- problem- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. in the u.s. copies of taber's cyclopedic medical dictionary the appendix has this complete information.
- etiology- also called the related factor by nanda, this is what is causing the problem. pathophysiologies of medical diseases need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
- symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
assessment consists of:
step #2 - determining the nursing problem/nursing diagnosis.
- a health history (review of systems) - this is a confused 82 year old woman with alzheimer's disease who is going into residential care home.
- performing a physical exam - none
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - she wakes during the night needing to urinate and is unable to recognise the need to empty her bladder. she is unable to find the toilet by herself; not able to recognise where the toilet is.
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this part of assessment requires looking up information about alzheimer's disease. learning about the pathophysiology of the disease will help you determine the "related factor" for your diagnostic nursing statement:
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - i worked in residential facilities. when i read your post i immediately wondered if this patient was on any drugs that could be causing diuresis or had a side effect of affecting her cognition any worse than it already was. review the side effects of her drugs. was her urine recently tested for a uti?
step #3 - planning (write measurable goals and nursing interventions)
- 30 minutes before going to bed has a cup of warm milk to help her settle (this is a problem because it puts liquids into her just before hs--hour of sleep--which sets her up to have to get up to the bathroom during the night and is something i would stop. there are other ways to settle a patient for sleep that do not involve giving them fluids)
- wakes during the night needing to urinate
- unable to find the toilet by herself; not able to recognise where the toilet is
- these cues lead to this nursing diagnosis: toileting self-care deficit r/t cognitive impairment secondary to alzheimer's disease aeb unable to find the toilet by herself or not able to recognise where the toilet is.
- at this point you proceed to write goals and interventions for the problem. the problem that i identify is a toileting self-care deficit (see http://www1.us.elsevierhealth.com/me...ex.cfm?plan=43
- self-care deficit for suggestions for goals and interventions)
. its definition is impaired ability to perform or complete own toileting activities.
doesn't that sound more like what is going on here? your interventions will be things like checking on her regularly and assisting her to the bathroom.
as far as settling goes that is more of a confusion issue and has to do with the patient's dementia. you should also diagnose chronic confusion r/t neurological impairment (see [color=#3366ff]chronic confusion)
based on her symptoms of dementia and develop strategies specifically for quieting her down at night, but i would not give her any fluids. play quite music or give her a back rub instead.
goals will be what you anticipate will happen as a result of your nursing interventions. if you need a guideline in how to write goals, see post #157 on this thread: http://allnurses.com/general-nursing...se-121128.html
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in order to use a diagnosis of disturbed sleep pattern
you must have the signs and symptoms for it. disturbed sleep pattern
is now being called insomnia
and its definition is a disruption in amount and quality of sleep that impairs functioning.
i don't think you have the evidence for this. the defining characteristics (signs and symptoms) of this nursing diagnosis are:
- observed changes in affect
- observed lack of energy
- increased work/school absenteeism
- patient reports changes in mood
- patient reports decreased health status
- patient reports decreased quality of life
- patient reports difficulty concentrating
- patient reports difficulty falling asleep
- patient reports difficulty staying asleep
- patient reports dissatisfaction with current sleep
- patient reports increased accidents
- patient reports lacks of energy
- patient reports nonrestorative sleep
- patient reports sleep disturbances that produce next-day consequences
- patient reports waking up too early
additionally, the pathophysiology of alzheimer's is not a related factor of this diagnosis.