Big Challenge: Dementia, Aphasia NCP

Daytonite, BSN, RN · Nov 29, 2008

i am working on a reply for you. it is going to take me some time.

i have to go out and spend time with relatives today
my dsl service is not working correctly and i am having to go back to using dial up connection which takes ages getting connected
based on the problems the scenarios lists (dementia, aphasia, confused, obtunded, doesn't respond to visual stimulation, very faint response to hearing, complete bed rest, use hoyer lift, contractures-neck, shoulder, right, left arm and knees, urine incontinent and bowel incontinent, needs complete care) and the top 3 nursing diagnoses you chose, i'm not being mean here, but you missed the mark. you hit only one physiological need (the needs maslow says we must meet in order to live--and, you put it third on the list over a safety need and then a love and belonging need. see http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
i see problems with the construction of some of these diagnoses and i've just skimmed them. it generally takes me a couple of hours to sort through the information students have provided and work up a care plan myself, so please be patient. if you look at the most recent posts to https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans you will see that i follow the nursing process in doing this and if there is something i have to stop to look up about a medical condition, i will. i have new information myself on interventions for dementia that i might want to review.

pretty much everything for a care plan is based upon the assessment that you do and anything abnormal coming out of the assessment. the abnormal assessment data becomes your signs and symptoms (defining characteristics) for the physiologically based nursing diagnoses. for nursing diagnoses that have a psychosocial basis you are also looking at data that indicates that the patient is not responding correctly to socialized norms. it helps immensely to look up the signs and symptoms of the patient's medical diseases or conditions (dementia, aphasia, obtunded, very faint response to hearing [deafness], contractures, incontinence) and what the rules and complication of certain treatments are (complete bed rest, use of the hoyer lift, complete care) because they will affect the care planning. you can use the weblinks on this thread to help you: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

can you give me an idea of the comments you have been got red-marked about your nursing diagnoses on your last care plan so i can help you not repeat these errors?

starlette_sky · Nov 29, 2008

I was so relief that there was at least a response, so I want to say thank you, first. And I hope you have a nice time with your relatives :)

I don't mind the criticism. I chose in that order of priority, thinking ABC, and in our text book says life threatening has high priority; health threatening-medium; then normal developmental needs should be low priorioty. I guess I have understood these concept wrong, in applying..

Just want to add that client has edema on both leg 1+, NPO GI tube (jevity 1.5 cal)

Admitting Diagnosis (es)

H/O GI bleed, Erosive Gastritis, Dementia, S/P peg insertion, Esophageal Reflux, OA, Transient Cerebral Ischemia, Syncope, Vomiting, symptoms involving head, Cardiac Dysrhythmias, HTN, Nonpsychotic Brain Syndrome.

Medical History: HTN, CAD, Dementia, Seizure, reoccurring UTI large bladder stone, bradyarrhymia

Current Diagnosis (es): HTN, Dementia, UTI, GI hemorragia, TIA

Red Marks:

For the NCP1 diagnosis:

Alteration in tissue perfusion-peripheral related to decrease hemoglobin concentratrion in blood as evidenced by left leg edema, she crossed out "by left leg edema" and wrote "cool, pale". I chosed edema b/c it was listed in the nursing diagnosis book by Doenges. I thought this applies to the client.

Other diagnoses are not from the care plan, but they are diagnoses from different assessments that we were assigned for the week and got red marks:

>>Impair tissue integrity related to imppaired physical mobility manifested by damaged tissue (pressure ulcer stage II and stage IV on the right foot)

Risk for unstable blood glucose related to physical immobility/ limited activity level

>>Activity Intolerance related to immobility as evidenced by left side weakness and not able to get out of bed without assistance.

>>Impaired physical mobility related to neuromuscular impairment as evidenced by left side weakness for this one she corssed "left side weakness" and wrote "unable to start or transfer into w/c by self"

>>Self care deficit: Bathing/hygiene, dressing/grooming, and toileting related to neuromuscular impairment as evdenced by left side weakness "evidenced by left side weakness" was crossed out.

>>Alteration in comfort: pain related to immobility evidenced by leftside weakness "immobility evidenced" was crossed out

>>Diversional activity deficit related to physical limitations as evidenced by left side weakness

Assessment for the 2 diagnosis on the bottom:

nail bed on feet- hard, yellow; exposed to respiratory irritant- air from ventilation (smells unpleasant), cleaning chemical used on the floor; feels pain, sometimes, on the left leg-left side hemiplegia due to CVA (resident described as severe); irregular apical rhythm. History of HTN, CHF, CVA, Diabetes. Takes Furosemide 40mg Tab-1 tab by mouth every day (diuretic); Metoprol 25mg Tab-1/2 tab (12.5 mg) by mouth twice daily (antihypertensive and cardiac medication). Low CO2 level: 19mEq/L (normal:20-37mEq/L)

>> Activity Intolerance related to immobiltity as evidenced by left side hemi[plegia "left side hemiplegia" was crossed out

>>Alteration in comfort-pain to immobility as evidenced by left side hemiplegia "to immobility as evidenced by" was crossed out

She just included another diagnosis:

Risk for altered tissue perfusion

Risk for decreased cardiac out put

(those I didn't mention "crossed out"- the whole thing was, supposedly, wrong)

Daytonite, BSN, RN · Nov 30, 2008

this was a real patient? i got the impression this was a scenario you were given to work on and that this was a fictional patient. i went with the information you posted in the first post. it's too bad you didn't post more because i went with what you originally posted.

the first thing i did was break the first part of your post down on a word document, literally word for word, and some interesting things emerged about this assignment. i broke the patient down into the following data. she is:

89yo
medical conditions
- advanced dementia - s/s are loss of memory (long and short term), disorientation, confusion usually more severe as the evening comes, apathetic in advanced stages, poor judgment and decision making, impaired thought processes and illogical thinking, may be socially inappropriate, facial expressions are inappropriate and do not match affect, may focus attention on one thing, normal sleep, behavior fluctuates and may be agitated, apathetic , ability to walk may be impaired along with motor coordination, bowel and bladder incontinence occur as a result of brain damage, they are incapable of performing basic adls
- aphasia - inability to speak (this is a safety issue)
- contractures-neck, shoulder, right, left arm and knees
[*]medical orders
- use hoyer lift
[*]signs and symptoms
- urine incontinent and bowl incontinent
- confused - not aware of person, time or place
- obtunded - blunted affect
- doesn't respond to visual stimulation
- very faint response to hearing
- complete bed rest
- needs complete care

your assignment specifically tells you that you need to do assessments of:

self actualization - the ability to achieve growth and autonomy
need for rest, sleep and pain relief
nutrition & fluid
urine & elimination

were you given lectures or some kind of handouts on how to assess these particular needs? i recognize them as being needs on the maslow hierarchy of needs. oxygen, the need for rest, sleep and pain relief, nutrition & fluid, and urine & elimination are all physiological needs that occur on the lowest level of the maslow hierarchy. self actualization is the highest level human need that should only be satisfied after physiological needs, then safety and security needs, then love and belonging needs, and finally self-esteem needs have been met. even within each of these tiers of needs there are priorities. within the physiological needs, the priority goes like this:

oxygen
nutrition & fluid
urine & elimination
need for rest, sleep and pain relief

your assessment of this patient will involve picking up abnormal assessment data within those categories. just as a detective collects clues to prove their case for a crime, a nurse collects clues (abnormal assessment data which you will call signs and symptoms) to prove the existence of nursing problems (which you will call nursing diagnoses). many of the categories that you are being asked to do assessments in have nursing diagnoses that address problems in these areas so it was no coincidence that you were asked to assess these areas or to come up with 3 nursing diagnoses.

i can start to organize the information from the scenario by maslow's hierarchy before going any further:

oxygen
nutrition & fluid
- needs complete care

[*]urine & elimination

urine incontinent and bowl incontinent

[*]need for rest, sleep and pain relief

[*]self actualization

assuming you have told me all the information about this patient, and some of the things i read in the nursing diagnoses you wrote are fictional, a patient with severe dementia who is pretty much needing complete nursing care has a lot of self-care deficits. the scenario told you the patient was incontinent, had contractures of the upper body and knees and needed to be moved with a hoyer lift. that's 3 nursing diagnoses right there.

total urinary incontinence r/t impaired cognition aeb urinating without awareness
bowel incontinence r/t impaired cognition aeb expelling formed stool without awareness
impaired physical mobility r/t contractures of neck, shoulder, right, left arm and knees and cognitive impairment aeb inability to move either arm or bend either leg.

the interventions for bowel incontinence would be to plan to get the patient to have one bm at a specific time each day. this is bowel training. the patient is then placed on a bedpan during morning care, has the bm and bowel incontinence isn't worried about for the remainder of the day.

for urinary incontinence skin care is addressed as well as checking the patient at least q2h and changing them and doing skin care.

impaired physical mobility will address some rom that can be accomplished and the movement and turning of the patient. some prevention of pressure ulcers can also be addressed.

goals will be the expected results of these interventions. over the long term it is not realistic to expect improvement in this patient because this patient is deteriorating, so maintaining the status quo is reasonable. take the signs and symptoms of the nursing diagnoses and try to find something positive that you can report about them in a long or short term goal statement. it doesn't have to be earth shattering, just stated positively rather than negatively--it's the way you word it. for example, when you assess the patient you can say they are dying, but when you get around to evaluating the care plan they are living. dying is a negative statement whereas living is a positive statement of their life situation. a long term goal of bowel incontinence is for the patient to have a bm daily at a regular time.

bowel incontinence related to impaired cognition as evidenced by using diaper and bm during perineal care

"using diaper" is a treatment, not evidence of bowel incontinence, and really doesn't prove that the patient has a bowel incontinence problem. i know nurses who wore disposable diapers when they were having their periods because they had such a heavy flow and didn't want to chance getting blood on their white pants. that makes them incontinent by your reckoning.

starlette_sky · Nov 30, 2008

Thank you so much for helping me out.

The diagnosis that I have posted on my first one, are actual nursing diagnosis that I came up by doing each of assessement on the real patient. I thought it would be too much to post all the info here...

Like I have mentioned, I have trouble putting the diagnosis correctly, structurally. Do you think those diagnosis are correct?

I just put down the assessements that were made.

I also have a question on the three diagnosis that you have suggested so those are more prioitized than the one I have chosed?

I was thinking, nursing intervention will be not realistic for urine and bowl incontinence, she is in advanced dementia... and for rom, I thought the nursing intervention will not be realistic either...

so I wanted to stick to the 3 diagnosis that I have mentioned.

Also you have asked me about the red marks that I have gotten from the professor, and I have listed several, let me know, if you can, what I could have done to improve on those diagnosis

Thank you again~

ASSESSMENT CATEGORY: Self Actualization

ASSETS: No weeping, crying, anger.

DEFICITS: confused, inability to concentrate, lack of awareness of surroundings, inability to remember, unable to meet own basic needs, aphasia, no control over body movements, unable to make decisions, not able to practice usual religious rituals,

DIAGNOSIS (ES):

Anxiety related to stress as evidenced by confusion, lack of awareness of surroundings, inability to remember, and unable to make decisions.

Ineffective coping related to impaired of cognitive as evidenced by aphasia: not able to express discomfort to meet own needs and unable to make decisions.

ASSESSMENT CATEGORY: Assessing the need for Oxygen

ASSETS: Normal respiratory 20 breaths per min; regular rhythm; non smoke; no cough. Skin color consistent with genetic back ground, warm, good turgor. Mucous membranes-pink; conjunctiva-pink; nail bed- slightly pink; no finger clubbing. Capillary refill

DEFICITS: Shallow breathing; loud bronchial; Skin: dry; nail bed on feet- hard, yellow, black; Weak pulse-radial, posterior tibial and pedal-bilaterally. Edema- left and right leg 1+ ; History of HTN, CAD, cardiac dysrhythimas, seizure, Transient Cerebral Ischemia, GI Bleed . Amlodipine 5mg tab (Norvasc) 1 tab via G tube every day Dx: HTN; Trileptal 300mg/5ml oral susp-5ml (300mg) via G tube twice daily Dx: seizure; Ipratropium/Albuterol INH solution 1 vial via nebulizer every 4 hr as needed SOB

NURSING DIAGNOSIS (ES):

Ineffective breathing patterns related to body position as evidenced by shallow breathing, loud bronchial

Alteration in tissue perfusion-peripheral related to interruption of blood flow as evidenced by edema-both legs and weak-posterior tibial, pedal- bilaterally

DIAGNOSIS (ES):

Anxiety related to stress as evidenced by confusion, lack of awareness of surroundings, inability to remember, and unable to make decisions.

Ineffective coping related to impaired of cognitive as evidenced by aphasia: not able to express discomfort to meet own needs and unable to make decisions.

ASSESSMENT CATEGORY:Assessing the need for rest, sleep and pain relief (neruo-hormonal)

ASSETS:

Sleeps well through the night

DEFICITS:

Contractures-neck, shoulder-(slanted to the right), right and left arm, right and left knee. Confused, obtunded; not oriented to time, place and person. Guarding and moaning (during bed bath, BP measure, dressing). Dementia; seizure; not able to do activities to meet the need for rest and leisure.

NURSING DIAGNOSIS (ES):

Diversional Activity deficit related to bedridden as evidenced by confusion, obtunded and not oriented to time, place and person

Altereations in comfort: pain related to immobility as evidenced by guarding and moaning.

ASSESSMENT CATEGORY: Assessing the need for elimination: Urinary & Bowel

ASSETS:

10.12g -Fiber intake: Jevity 1.5 cal (22 g of dietary fiber in 1 liter)

BUN 18mg/dL (normal value7-25mg/dL), Creatinine 0.58 mg/dL (normal value 0.20-1.50), Bilirubin 0.4mg/dL(normal value 0.1-1.4mg/dL)

DEFICITS:

No control of urinary sphincter- urine on diaper, yellow, scanty, faint aromatic. No control of anal sphincter-uses diaper, initially observed streak mark on diaper, BM during perineal care- light brown, approx 45cc, watery, aromatic. History of UTI, reoccurring large bladder stone, GI bleeding. Lactulose 10 g/15ml solution 30ml via G tube very day-Constipation; Miralax 14 days power-1pkt via G tube at bed time –Constipation

NURSING DIAGNOSIS (ES):

Urinary incontinence related to impaired cognition as evidenced by no control of urinary sphincter-urine on diaper

Bowel incontinence related to impaired cognition as evidenced by using diaper and BM during perineal care

ASSESSMENT CATEGORY: Nutrition and Fluid

ASSETS:

Normal sodium: 140mEq/L (normal range: 133-145 mEq/L), normal potassium 4.7mEq/L (normal range: 3.5-5.1 mEq/L), normal chloride 103 mEq/L (normal range: 98-109 mEq/L), normal glucose 74mg/dL (normal range: 65-99 mg/dL), normal calcium 9.1mg/dL (normal range: 8.1-10.3 mg/dL), normal albumin 3.8 g/dL (normal range: 3.5-5.7 g/dL).Skin-warm, good turgor; mucous membrane -mouth is moist and pink.

DEFICITS: NPO, GI tube, Jevity 1.5 at 85 cc hr x 12hrs up at 6pm-down at 6am (started at 12am)- intake 460ml. Weight 159.8 lb- (gained 5.6 lb in one month), overweight based on the BMI calculation 27.0 kg/m^2 (over weight range: 25.0-29.9kg/m^2). Cannot feed self related to right and left arm contractures and dementia.Regurgitation, diarrhea-light brown watery approx: 45ml; Dx: GERD, Erosive gastritis, GI bleeding, esophageal reflux, vomiting; Omeprazole pow 2mg/ml oral susp-10ml (20mg) via G tube twice daily at 9am & 9pm-GERD; Lactulose 10 g/15ml solution 30ml via G tube very day-Constipation; Miralax 14 days power-1pkt via G tube at bed time –Constipation; Multivitamin liquid 5ml via G tube every day. Dry skin; edema right and left leg 1+; bowel sound hypoactive; Urine yellow, scanty.

NURSING DIAGNOSIS (ES):

Alteration in Nutrition: more than body requirement related to maturational (decreased metabolic needs and/or decreased activity levels) as evidenced by BMI of 27.0 kg/m^2 and 5.6 lb weight gain in one month

Self Care Deficit: feeding related to cognitive impairment as evidenced by cannot feed self.

Potential fluid volume deficit related to gastric intubation

Daytonite, BSN, RN · Nov 30, 2008

i am finding it very difficult to understand what you are talking about. you have listed nursing diagnoses that were corrected by your instructor for a ncp 1 and ncp 2 but said originally that you were working on your second care plan. wouldn't that mean you are working on your third care plan?

please understand that when i spend a few hours working on a care plan for someone it is based on the information you post. i assume you have posted the pertinent information. when you come back with a whole bunch of other information you need to add it to what i've done. there are other students who post on these forums who are also looking for help.

prioritizing of diagnoses should be done by maslow's hierarchy of needs. i don't think that your instructors asking you to assess patients using maslow's terminology is a mistake. did you miss something in the lectures about assessing patients and how your nursing program expects patients to be assessed? the coincidence is just too uncanny for it not to be noticed. to assess a patient's self-actualization was like being hit in the face by maslow himself.

i would recommend that you get a book that includes the nanda taxonomy information in it. you needto see the definitions, related factors and defining characteristics that go along with each of these diagnoses that you are using.

alteration in tissue perfusion-peripheral related to decrease hemoglobin concentration in blood as evidenced by left leg edema, she crossed out "by left leg edema" and wrote "cool, pale". i chose edema b/c it was listed in the nursing diagnosis book by doenges. i thought this applies to the client.

the aeb stuff is proof--evidence. it

is

a symptom of this problem and must be present if you list it. if you list edema, then you are saying the patient has edema in the left leg. they would have edema if that was a symptom of the disease they had. if cool and pale was the manifestation, or symptom, of their disease then that was the better and correct answer.

other diagnoses are not from the care plan, but they are diagnoses from different assessments that we were assigned for the week and got red marks:

>>impaired tissue integrity related to impaired physical mobility manifested by damaged tissue (pressure ulcer stage ii and stage iv on the right foot)

risk for unstable blood glucose related to physical immobility/ limited activity level

>>activity intolerance related to immobility as evidenced by left side weakness and not able to get out of bed without assistance.

the symptoms on this have to be related to hypoxia or intolerance of activity because of not enough oxygen. "left side weakness" is too broad and does not apply to this diagnosis and "not able to get out of bed without assistance" belongs with

impaired

bed mobility

.

>>impaired physical mobility related to neuromuscular impairment as evidenced by left side weakness for this one she crossed "left side weakness" and wrote "unable to start or transfer into w/c by self"

i would tend to agree. what is left side weakness? it is very vague and not descriptive at all of how the patient's movement is damaged (impaired). the information following "as evidenced by" is always the proof of the problem. impaired physical mobility is limited movement of one or more extremities. "left side weakness' just doesn't describe that very well.

>>self care deficit: bathing/hygiene, dressing/grooming, and toileting related to neuromuscular impairment as evidenced by left side weakness "evidenced by left side weakness" was crossed out.

same problem as above. this diagnosis is the impaired ability to perform bathing and hygiene for oneself. "left side weakness" is not proof of how the patient fails to wash their face or brush their teeth.

>>alteration in comfort: pain related to immobility evidenced by left side weakness "immobility evidenced" was crossed out

i ring my call light. you come in the room. i say, "nurse, i have left side weakness." and from that you know to give me pain medication? you must tell me where you got your crystal ball. evidence of pain is the patient telling you they are in pain or the patient limiting their movement to avoid pain and other such symptoms.

alteration in comfort: pain r/t immobility aeb protective gestures and positioning to avoid pain.

>>deficient diversional activity deficit related to physical limitations as evidenced by left side weakness

this is a diagnosis about boredom and the patient who is bored because of having to be confined because of their illness so they can't do the things they normally do. again, "left side weakness" is not a symptom of boredom.

deficient diversional activity related to physical limitations as evidenced by patient's statement that he wished there was something he could do

.

assessment for the 2 diagnosis on the bottom:

nail bed on feet- hard, yellow; exposed to respiratory irritant- air from ventilation (smells unpleasant), cleaning chemical used on the floor; feels pain, sometimes, on the left leg-left side hemiplegia due to cva (resident described as severe); irregular apical rhythm. history of htn, chf, cva, diabetes. takes furosemide 40mg tab-1 tab by mouth every day (diuretic); metoprol 25mg tab-1/2 tab (12.5 mg) by mouth twice daily (antihypertensive and cardiac medication). low co2 level: 19meq/l (normal:20-37meq/l)

>> activity intolerance related to immobility as evidenced by left side hemiplegia "left side hemiplegia" was crossed out

this is a diagnosis about hypoxia and oxygenation. you have to recognize the s/s of hypoxia as a result of activity. "left side hemiplegia" was just way off base.

activity intolerance related to immobility as evidenced by irregular apical rhythm and low co2 level of 19meq/l

>>alteration in comfort-pain to immobility as evidenced by left side hemiplegia "to immobility as evidenced by" was crossed out

the scenario states: alteration in comfort-pain to immobility as evidenced by

resident description of severe pain in left leg

.

she just included another diagnosis:

risk for altered tissue perfusion

risk for altered tissue perfusion r/t interrupted blood flow (patient has hard yellow nails on feet indicating compromised circulation to the lower extremities)

risk for decreased cardiac out put

risk for decreased cardiac output r/t

altered heart rhythm

(patient has an irregular apical rhythm)

Daytonite, BSN, RN · Nov 30, 2008

You have many more than 3 diagnoses listed in your last post. List just the 3 diagnoses you want to use so I can look at them for you.

starlette_sky · Nov 30, 2008

3 diagnosis that i want to work at:

1)alteration in tissue perfusion: peripheral related to interruption of blood flow as evidenced by edema-right, left leg and weak pulse-radial, posterior tibial, pedial- bilaterally.

2)ineffective breathing patterns relate to body position as evidenced by shallow breathing, loud bronchial

3)altereations in comfort: pain related to immobility as evidenced by guarding and moaning when touched.

sorry about the confusion. yes this is my 2nd ncp. you asked me to post red marks that were made in the ncp1, which i did. and then i said, there are red marks that were not in the ncp1 but on the diagnosis that were made in different assessments that i was assigned every week. on my last post, that is the format we are assigned to do our asessments and come up with diagnosis, for ncp2. from those, we have to choose 3. if you take a look, after each assets and deficit diagnosis are made. i am not sure if those diagnosis are put in correct structure... i have put those information down to, maybe, clarify confusions, as to where i have come up with such diagnosis (since you said they are fictional).

Daytonite, BSN, RN · Nov 30, 2008

the sequencing needs correction. is english not your primary language? the grammar needs a lot of cleaning up.

ineffective breathing patterns relate to body position as evidenced by shallow breathing, loud bronchial (physiological need for oxygenation of the lung tissue - lung tissue will die faster than tissue of the leg when deprived of oxygen)
- ineffective breathing pattern related to body positioning as evidenced by loud shallow bronchial breathing

[*]alteration in tissue perfusion: peripheral related to interruption of blood flow as evidenced by edema-right, left leg and weak pulse-radial, posterior tibial, pedal- bilaterally. (physiological need for oxygenation of the peripheral tissues)

altered tissue perfusion: peripheral related to interruption of blood flow as evidenced by right and left leg edema and weak bilateral radial and posterior tibial and pedal pulses

[*]alteration in comfort: pain related to immobility as evidenced by guarding and moaning when touched. (physiological need for comfort)

pain is usually further classified as acute or chronic.
i do not know what related factors you are being taught to use under this system of diagnosing. under the nanda system pain must be caused by injury, so immobility cannot be a cause of pain since it is not an injury.

starlette_sky · Nov 30, 2008

Thank you so much for your time~