care plan help ... naturally.

[katiebry1031]

i just need a little bit of guidance. i need to write a 3 part nursing dx from our clinical this week. this pt was admitted to the facility for s/p fall but her actual diagnosis upon admission was acute metabolic encephalopathy, anemia, and htn. she is mildly confused but alert and oriented x3 but just has to think about the answer for a minute. pt does have ecchymosis on her upper extremities related to anemia. she has also decreased ROM in her RUE due to osteoarthritis and rotator cuff. she has B/L hand osteoarthritis. she is a very pleasant female. she also has urinary incontinence but its more nocturia. does wear briefs, but didnt have incontinence while i was present. I was thinking of writing mild confusion r/t chronic illness as evidenced by ... and then i got stuck. I need some help or some guidance would be nice. thanks. we only had a half day of clinical so its hard for me to gather that information.

[katiebry1031]

i just need a little bit of guidance. i need to write a 3 part nursing dx from our clinical this week. this pt was admitted to the facility for s/p fall but her actual diagnosis upon admission was acute metabolic encephalopathy, anemia, and htn. she is mildly confused but alert and oriented x3 but just has to think about the answer for a minute. pt does have ecchymosis on her upper extremities related to anemia. she has also decreased ROM in her RUE due to osteoarthritis and rotator cuff. she has B/L hand osteoarthritis. she is a very pleasant female. she also has urinary incontinence but its more nocturia. does wear briefs, but didnt have incontinence while i was present. I was thinking of writing mild confusion r/t chronic illness as evidenced by ... and then i got stuck. I need some help or some guidance would be nice. thanks. we only had a half day of clinical so its hard for me to gather that information.

the patient also has has an unsteady gait related to her fall. she is seeing PT, OT and speech therapy. she does state she uses a cane at home. not sure if i could write a dx on this one.

[Hopefulee]

I have a care plan due this week too, it is driving me crazy. Have you considered.....

Impaired mobility r/t decreased rom in ue, impaired skin integrity r/t incontinence, is there any pain?? Acute pain r/t recent fall, impaired sleep r/t nocturia, these are off the cuff, I don't know if they are actual nanda....good luck

[Constantly Surprised]

Acute metabolic encephalopathy combined with anemia scream out for some nutritional balance Dxs... And with impaired mental state, impaired nutrition, impaired mobility, incontinence, and impaired tissue perfusion r/t anemia, skin breakdown is huge.

Just my 2 cents...

[xtxrn, ASN, RN]

OK.....

Falls is a big one...definitely include that :) (with a history of falls, you can go with actual or potential)

Anemia and ecchymosis? Low red blood cells/H&H isn't likely to cause bruising. Falls would, as would other blood cell deficiencies. :)

What chronic illness causes confusion?

Incontinence is also a risk for falls. (sliding on the pond)

Self care deficit w/ROM limitations (arthritis and rotator cuff)

Pain?

Do you know what the metabolic encephalopathy is from? There are a lot of options and that could make a difference as to what needs to be focused on

[xtxrn, ASN, RN]

I'd say the fall was r/t the unsteady gait, not the gait r/t the falls... wording is everything

[Hopefulee]

What if you have a pt upon assessment has no abn or issues with a system, what do yu do then?

[OB-nurse2013, BSN, RN]

What if you have a pt upon assessment has no abn or issues with a system, what do yu do then?

Then you can use knowledge deficient..readiness for blahh blahh theres a whole list of wellness diagnoseses

[nurseprnRN, BSN, RN]

"admitted to the facility for s/p fall but her actual diagnosis upon admission was acute metabolic encephalopathy, anemia, and htn. she is mildly confused but alert and oriented x3 but just has to think about the answer for a minute. pt does have ecchymosis on her upper extremities related to anemia. she has also decreased rom in her rue due to osteoarthritis and rotator cuff. she has b/l hand osteoarthritis. she is a very pleasant female. she also has urinary incontinence but its more nocturia. does wear briefs, but didnt have incontinence while i was present."

encephalopathy, poor mobility, and anemia-- all of this says "fall risk, safety awareness risk" to me. why would she be at risk for that? what is it about those three factors, singly and together, that is a bad thing for safety?

ecchymosis is bruising- it isn't caused by anemia (which is usually understood as low hematocrit) per se. does she have low platelets and that's why she bruises? if not, what makes her bruise more easily? why might that be a potential or actual problem? what would you do to assess for more complications of an easy-bruising body (inside and outside)? by any wild chance is her metabolic encephalopathy related to liver problems? how does that affect clotting? how might anemia figure in here?

we all have rotator cuffs -- you can look it up. "rotator cuff" is not a diagnosis, it's an anatomic structure. what is the matter with hers, and how did it happen? if you don't know, what is its effect on her?

briefs, incontinence-- skin risk?

nutrition? healing?

[PsychNurseWannaBe, BSN, RN]

Then you can use knowledge deficient..readiness for blahh blahh theres a whole list of wellness diagnoseses

------------------------ wrong post sorry

[SnMrsSmiley]

you need a nuring diagnosis book. It basically does the work for you. We ue carpenito

[PsychNurseWannaBe, BSN, RN]

What if you have a pt upon assessment has no abn or issues with a system, what do yu do then?

Everyone is a little screwed up to have at least one nursing diagnosis stick!!

No actuals.... consider Risk for, or wellness