Another care plan question !!!

Published

hi there, i have to develpo a care plan for pt entering an aged care facility

the quest is

develop an holistic nursing care plan for pt on his admission to residential care. your care plan is to inform the reader of: the issues that youas the admitting registered nurse have identified; the way you plan to address these issues; and the rationale for doing soi understand form reading that i have to do one of these for each prblem pt has, what about alzeihemers?

p (problem) - e (etiology) - s (symptoms)

can anyone send me off in the right track?? this is my first care plan

thanks :imbar:imbar:imbar:imbarheart attack in 1984, aortic valve replacement in 1992

recently- very forgetful with bouts of confusion and disorientation

in 2004 pt had become incontinent of urine and in 2005 he lost bowel continence

pt was diagnosed with alzheimer's disease

pt gradually lost his capacity to communicate with wife

married to wife for 27 years

during that time wife stated that she "felt so low, felt like i was giving him away". whilst she knew she could not continue to physically care for pt at home her feelings about their future were "very mixed".

between them pt and wife have five very supportive children and stepchildren

Up Vote Up Vote ×

I would love to help with this but I am not sure exactly what you are looking for. Are you looking for nursing diagnoses with interventions and expected outcomes or are you looking for the different medical issues with the pathophsiology, etiology and treatment?

Up Vote Up Vote ×

off the top of my head how bout, for bowel and urinary incontinance: Risk for Impaired skin integrity, Self Care Deficit.

Alzheimers: Risk for injury, Disturbed thought processes, Impaired Social Interaction, caregiver role strain.

Holistically you will want to educate, support, teach and make appropriate referrals for respite care for caregivers.

Don't know it that helps.

A great book to assist with care planning is Thomson Delmar Learning's Medical Surgical Nursing Care Plans, by Shielda Glover Rodgers.

This is great it keeps me fresh too.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

i am not sure where you are. use of the word "whilst" in your post suggests you are not in the u.s. so i don't know if your program is teaching the use of nursing diagnosis. here in the u.s. the nursing process is used to determine problem identification in care planning. even if you do not use nursing diagnosis, nursing process needs to be used to determine p (problem) - e (etiology) - s (symptoms) which is actually how a nursing diagnostic statement is constructed. i tell students that when they read a properly constructed nursing diagnostic statement it should create a visual picture of the patient's nursing problem and explain what the problem is, what is causing it and what the symptoms of it are.

p (problem) - e (etiology) - s (symptoms)

  • problem - this is expressed as 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. the appendix of taber's cyclopedic medical dictionary has this information.
  • etiology - also called the related factor by nanda, this is the cause of the nursing problem and resulting symptoms. pathophysiologies of the patient's medical diseases need to be examined to find these etiologies. however, it is considered unprofessional to list a medical diagnosis as an etiology of a nursing problem 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. etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
  • symptoms - also called defining characteristics by nanda, are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

we use the nursing process to determine the patient's nursing problems, their causes and how to do something about them. . .

step 1 assessment
- assessment consists of:

step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- make a list of the abnormal assessment data - these are in order of maslow's hierarchy of needs (
http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
)

  • incontinent of urine

  • incontinent of bowel

  • confusion and disorientation

  • difficulty communicating

  • self-care problems (not really elaborated on)

step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - this is where the pes format is used:

  • total urinary incontinence r/t neurological dysfunction secondary to alzheimer's disease aeb incontinence of urine

  • bowel incontinence r/t neurological dysfunction secondary to alzheimer's disease aeb incontinence of bowel

  • acute confusion r/t neurological dysfunction secondary to alzheimer's disease aeb confusion and disorientation

  • impaired verbal communication r/t neurological dysfunction secondary to alzheimer's disease aeb losing capacity to communicate

step #3 planning (write measurable goals/outcomes and nursing interventions for each nursing problem/nursing diagnosis)

i don't know much more about what you are required to do for this assignment. the above is general information based on what you posted. normally, there would be a lot more specific abnormal data that would be assessed about the patient which would give more specific symptoms for diagnosing the nursing problems. step #3 of the nursing process is where you apply nursing interventions and rationales. the interventions target each of the symptoms that the patient is exhibiting. goals, if you are required to develop them, are the predicted results of your nursing interventions.

other threads on alzheimer's disease care planning:

Up Vote Up Vote ×
+ Join the Discussion