Care plan guidance

[zenweaver]

I think I've read every forum post re: the dreaded Care Plan! (and I still need guidance in prioritizing the Nurs. Dx)

48 yr old single female (music teacher)

Dx MS 6 months ago

residual symptoms of primary flare-up (hands and feet numb)

c/o extreme fatigue, imbalance, and depression (recently prescribed Prozac)

has fallen x1 in home

states: unable to cope with present lifestyle

feels too tired to clean, pay bills, shop, cook for herself

c/o social isolation

states she knows she needs to do something, however can't think clearly and doesn't have the energy.

My nursing Dx in order of priority:

1 Self Care Deficit related to neuromuscular impairment, intolerance to activity, fatigue, and depression

2 Ineffective Individual Coping related to perceived present lifestyle secondary to fatigue and residual symptoms of MS flare-up

3 Impaired Physical Mobility r/t fatigue, weakness, and imbalance

4 Activity Intolerance r/t generalized fatigue, depression

5 Health-seeking Behavior related to altered health status secondary to fatigue

Any guidance greatly appreciated!

Zenweaver

[anonymousstudent]

You might get better help with this on the NS assistance board.

Based on your scenario, r/t the fact that she has already fallen once and that her feet are numb, safety would be my primary Dx.

[zenweaver]

You might get better help with this on the NS assistance board.

Based on your scenario, r/t the fact that she has already fallen once and that her feet are numb, safety would be my primary Dx.

thanks for the input anonymous! I'll repost to student forum.

I should have mentioned that the actual Ns Dx was "Impaired physical mobility r/t fatigue, weakness, and imbalance as evidenced by verbal report of feeling tired all of the time, falling at home, and inability to perform normal ADL's"

I chose this route to because of safety concerns as well it will follow through to my teaching plan.

[AgentBeast, MSN, RN]

Adult Failure to Thrive . . .

[zenweaver]

Scott,

That's exactly what I was looking for! However, I couldn't find that specific dx in my Care Plan book! (Have they changed the name??)