I need some direction! I have to do a care plan for an 84 year old female who is bedridden, gets in a geri chair for a few hours a day, has a g-tube since 2011 for meds and feeding (if eats less than 50%) has alzheimers, didnt talk to me much, unable to move legs or right lower are, uses a lift to get her oob q2h turn, incontinent. Diagnoses in chart: Alzheimers, abnormal posture, failure to Thrive, altered mental status, malaise/fatigue, epilepsy, 9/12 fall, femur fx, 4/10 fall, forearm fx, 6/11 UTI. My current care plan now is 1.) Failure to Thrive--goal: client will eat 75% of lunch on 3/11/14. But thats not the one I need help with. My #2 nursing dx is Impaired Bed Mobility--goal: client will maintain intact skin around the sacral area by 3/11/14 at 1400. Is this goal have to do with impaired bed mobility? I've completed my care plan to turn in TOMORROW but now im second guessing!
You can't not look at related/causative factors and defining characteristics (evidence). Those are what make it possible to make a nursing diagnosis. If you were a physician, you couldn't make a medical diagnosis of, say, anemia, without getting a CBC, or a diagnosis of heart block without getting an EKG.
Likewise, when you are planning a patient's nursing care, you have to justify your diagnosis using recognized, scientifically-validated criteria. You cannot just make up a sexy-sounding "diagnosis" or pull one off a list because it sounds good to you without knowing whether your assessment gives you the data to make that diagnosis.
If yo were that doc, you couldn't say, "Oh, she's pale, so she must be anemic," or, "Oh, he's got an regularly irregular heartbeat, so he must have 2nd degree block." Maybe yes, maybe not. What if the interventions you plan to implement have nothing to do with the approved causes and defining characteristics of that diagnosis? You need scientifically validated criteria. She could be cold, or he could be having unifocal, regular PVCs. Giving a hypothermic blood products could be harmful due to increasing acidosis, not to mention the fact that bank blood is cold. The treatment for PVCs might include a 'caine med, which would be a really bad idea in heart block. See what I mean?
Now to your specific plan for this woman's nursing care. For the "Failure to thrive" nursing diagnosis in NANDA-I 2012-2014 (the ONLY approved source of validated nursing diagnosis), there is only one, count 'em one, permitted related/causative factor, and that's depression. Depression is a medical diagnosis, not an opinion. Yes, it is perfectly possible to use a medical diagnosis as a related/causative factor for a nursing diagnosis IF it is so listed in NANDA-I. I see no evidence that your patient has a medical diagnosis of depression.
Yes, one of the defining characteristics for FTT is "consumption of minimal to no food at most meals." That's not enough. There are lots of reasons somebody might not eat well. But for a nurse to make the defined nursing diagnosis of "failure to thrive," the reason for the low food intake must be depression.
If low food intake is the big assessment feature that got your attention, let's look at something else that could apply. How about "imbalanced nutrition, less than body requirements"? Has she been losing weight? What other things clue you in that she isn't getting enough nutrition? Page 174 in your NANDA-I 2012-2014, free 2-day delivery from Amazon, $29, instant delivery to your Kindle or iPad for $25. I will leave it to you to look at the approved defining characteristics and related factors. If you were clever, you would connect the dots here to healing and tissue repair, and risk for impaired tissue integrity.
Wait! G-tube? She has a G-tube? IS she getting tube feedings? Who cares what she takes PO if she is getting adequate calories and nutrients from a tube feeding? See, there's really more than the superficial once-over you've given this situation.
If your plan for this woman is to increase oral intake, how's her airway protection? Might there be a risk there? What else is a nurse going to see when she looks at this woman?
Thanks for everyones comments. The reason that I went with impaired skin integrity was because of the g-tube site, being as the skin was broken. But obviously now I know this is not always the correct answer. my #1 priority that i should've gone with was impaired swallowing, because she has a gtube and she has to have her foods pureed.
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
You can't not look at related/causative factors and defining characteristics (evidence). Those are what make it possible to make a nursing diagnosis. If you were a physician, you couldn't make a medical diagnosis of, say, anemia, without getting a CBC, or a diagnosis of heart block without getting an EKG.
Likewise, when you are planning a patient's nursing care, you have to justify your diagnosis using recognized, scientifically-validated criteria. You cannot just make up a sexy-sounding "diagnosis" or pull one off a list because it sounds good to you without knowing whether your assessment gives you the data to make that diagnosis.
If yo were that doc, you couldn't say, "Oh, she's pale, so she must be anemic," or, "Oh, he's got an regularly irregular heartbeat, so he must have 2nd degree block." Maybe yes, maybe not. What if the interventions you plan to implement have nothing to do with the approved causes and defining characteristics of that diagnosis? You need scientifically validated criteria. She could be cold, or he could be having unifocal, regular PVCs. Giving a hypothermic blood products could be harmful due to increasing acidosis, not to mention the fact that bank blood is cold. The treatment for PVCs might include a 'caine med, which would be a really bad idea in heart block. See what I mean?
Now to your specific plan for this woman's nursing care. For the "Failure to thrive" nursing diagnosis in NANDA-I 2012-2014 (the ONLY approved source of validated nursing diagnosis), there is only one, count 'em one, permitted related/causative factor, and that's depression. Depression is a medical diagnosis, not an opinion. Yes, it is perfectly possible to use a medical diagnosis as a related/causative factor for a nursing diagnosis IF it is so listed in NANDA-I. I see no evidence that your patient has a medical diagnosis of depression.
Yes, one of the defining characteristics for FTT is "consumption of minimal to no food at most meals." That's not enough. There are lots of reasons somebody might not eat well. But for a nurse to make the defined nursing diagnosis of "failure to thrive," the reason for the low food intake must be depression.
If low food intake is the big assessment feature that got your attention, let's look at something else that could apply. How about "imbalanced nutrition, less than body requirements"? Has she been losing weight? What other things clue you in that she isn't getting enough nutrition? Page 174 in your NANDA-I 2012-2014, free 2-day delivery from Amazon, $29, instant delivery to your Kindle or iPad for $25. I will leave it to you to look at the approved defining characteristics and related factors. If you were clever, you would connect the dots here to healing and tissue repair, and risk for impaired tissue integrity.
Wait! G-tube? She has a G-tube? IS she getting tube feedings? Who cares what she takes PO if she is getting adequate calories and nutrients from a tube feeding? See, there's really more than the superficial once-over you've given this situation.
If your plan for this woman is to increase oral intake, how's her airway protection? Might there be a risk there? What else is a nurse going to see when she looks at this woman?