Care Plan Help

[RNicoleM]

I have to construct my first careplan and I am so lost!!! Please help me!!

Here is my scenerio:

A 76 year old white male with a stage 2 decubitus ulcer on his left heel has just been admitted to your floor. He is alert and oriented x3 but does have periods of forgetfulness. Past medical history revels that he has been diagnosed with hypertension, diabetes. He has smoked 1 1/2 pack of cigarettes for 60 years and has at least 3 beers a day for the past 10 years. The patient has a history of falls within the last 6 months related to diabetic neuropathy in his lower extremities, but refuses assistance with mobility.

My care plan needs to be on the falls.

I am thinking the Maslow level would be Safety & Security and the nursing diagnosis would be At risk for falls r/t history of falls and diabetic nueropathy in lower extremities, I am thinking the desired outcome is to remain fall free but I don't know what time frame to put.

I am having a hard time with the nursing interventions/rationale part because of the fact the patient refuses assistance with mobility and I am thinking I am suppose to link it back to managing the neuropathy somehow. I could also be way overthinking this!!

I am completely lost when it comes to care plans, I have the Nursing Diagnosis Handbook but I can't understand that thing yet!!

[Daytonite, BSN, RN]

there is a thread on allnurses that will help you with construction of a care plan: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

when sitting down to write a care plan the best tool you can use is the nursing process. by following its 5 steps it will keep you focused on the task at hand. step #1 is assessment of the situation. since you are to focus on falling you want to look at all the data that contributes to falls. your nursing diagnosis handbook is going to help you with this. if you look at the diagnosis for risk for falls you will find a listing of the risk factors. read through them because you missed a few that were mentioned in the scenario that apply to this patient. step #2 of the nursing process is determining the nursing problem and then naming it--in this case that has been done for you--risk for falls. step #3 is to determine your goals and develop nursing interventions. now, a "risk for" diagnosis is a little different because it is a potential problem and not an actual problem. the nursing interventions for potential problems need to be:

• strategies to prevent the problem from happening in the first place
  
• monitoring for the specific signs and symptoms of this problem
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  

goals in relation to them are really what you expect will happen as a result of any interventions you perform being done [if we do this, then this is what will happen]. time frames for goals are always difficult, but you have to pick something that makes sense and fits along with the intervention that matches with it. you've got to give the interventions some time to work so the goal can be achieved. in some cases a goal can be achieved immediately; in others it may takes hours, days or weeks.

your interventions for monitoring the patient's neuropathic condition can be included, e.g., doing periodic neuro checks to assess his ability to feel, assessing his balance. rationales are merely explaining why you are doing those interventions. if you can't find or think of why, a care plan book will have them. this is often one of the more tedious parts of a care plan because it requires some thinking as well as good writing on the part of the nurse.

one last suggestion i have for you is to check the beginning of your nursing diagnosis handbook and see if it doesn't have some discussion about care planning or the nursing process. i have found that many of these books do and people neglect to read this important information. it sometimes takes several readings to comprehend the information. it also takes doing several care plans to get the hang of this nursing process business because it is a new way of thinking and processing information for many students. however, it is how we problem solve in nursing and must be learned.