Desperately Need Help With Care Plans

Students Student Assist Nursing Q/A


You are reading page 3 of Desperately Need Help With Care Plans

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.
alexan18 said:
Need help with care plan for mrsa..

Any help would be appreciated...

MRSA is methicillin-resistant staphylococcus aureus. Can't give you any specific help without knowing what you need. Is this a real patient or a case study? Did you do an assessment of the patient? Is the infection in a wound or an organ system? Do you have a listing of the non-normal symptoms you developed from your assessment? What working nursing diagnoses have you come up with so far?

When doing nursing care plans you have to get away from thinking so much about the medical diagnosis. It's ok to use the same symptoms that also determine the medical diagnosis. Symptoms are not for the sole property and use of the physician. However, nurses are going to turn those symptoms into nursing diagnoses. Your care plan is going to ultimately end up having nursing interventions that address these symptoms the patient has--not the medical diagnosis per se. We will have some collaborative responsibility in reporting progressive or developing symptoms of a medical condition.

Here are links to information about MRSA:

Staphylococcal Infections - Medscape

Methicillin-resistant Staphylococcus aureus (MRSA) - CDC

Staphylococcal Infections - MedlinePlus

Specializes in Tele, ICU, ER.

Ok I'll see if I can help a little, remembering from when I learned it...

You use the nursing process all the time for problem solving, just worded differently for real life...

Using ADPIE, you might say...:

Assessment: Closet full of clothes that haven't fit you in years

Diagnosis: Lack of wardrobe appropriate to office X-mas party, related to losing 30 pounds, as evidenced by a closet full of clothes size 18.

Plan: Buy a decent dress that shows off your new figure, for the party

Implementation: Dash over to Ross Dress for Less, on the way home from work.

Evaluation: DAMN but that dress looked good and everyone commented on how much weight you lost!

The basic problem solving layout is something we all do, generally without even realizing it, so it's not as new as you think it is ;)

Now, to bring it to the hospital.. a Medical Diagnosis simple says, "This is wrong with the patient". A doctor's plan, so to speak, would resolve around how to cure or get rid of THAT problem. So when the patient is lying in the hospital bed, the docs job revolves around how to fix that problem, what drugs might work, what procedures, etc. The nurse, on the other hand, says to him/herself... "ok this guy is lying in bed after abdominal surgery to fix a crapped out bowel. He's got the right meds, etc, from the doc." Yay good so far right? Now the nurse thinks..."This guy is 300 lbs, he likes to lie flat in bed to sleep, he's afraid his new incision is gonna open, he won't look at his stoma, he doesn't want to get out of bed cause his belly hurts and his family is eating McDonalds in front of him!"

Soooo... as a nurse you're gonna say, sit him up semi-fowlers, teach him to splint with a pillow to cough and deep breathe, work with him to learn out his stoma works and how to care for it as he's ready, encourage him to move and get out of bed as appropriate and explain to his family that if he really loves McDonald's but can't have it, maybe they should eat in the cafeteria.

The doc can fix the problem, but that problem (and its treatment) do lots of things to the patient that aren't the medical problem themselves, but are pretty major for the patient and his recovery. To choose an easy one from the above bowel guy...

Assessment: Pt. family eating McDonald's in the room is driving pt. nuts!

Diagnosis: Knowledge Deficit (family), related to lack of knowledge of patient's diet limitations as evidenced by pt. complaining that he wants McDonald's.

Plan: family will avoid eating in patient's room while his diet is restricted

Implementation: Teach family about diet restrictions, and how the smell of their food can cause the patient to have cravings that can't be satisfied right now.

Evaluation: Family has their meals in the cafeteria and encourages patient in his recovery so he can eat favoriate foods when appropriate.

These things are all hard to put into writing and words, because you learn to think like this automatically - that's why NANDA has a list, so you can use it to put your thinking-process into words . It comes with time, that is why you practice in nursing school.

Good luck, hope this helped!


Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

Critical thinking is very simply making judgments based on facts rather than making random guesses based on nothing. Some of the steps in the nursing process provide you with the facts you need to continue onward to make judgments in the later steps. Critical thinking is nothing more than reasoned, logical thinking where each step of the process has rationale supporting it.

As you work through the steps of the nursing process for just one nursing diagnosis ask yourself these questions: what did i find in the patient's chart about him that wasn't normal? What did i find during my assessment that wasn't normal? What are those abnormal things telling me? If i put all those abnormal things together, do some of them look like they might belong together or be related in some way? What's causing them? When i look at this particular nursing diagnosis i see some of my patient's symptoms listed with it? Is this one of my patient's nursing diagnoses? I see that one of the related factors (cause) for this nursing diagnosis is something my patient has as well. That makes sense that this is the cause of these abnormal symptoms that the patient has. This sounds like it might be the correct nursing diagnosis because my patient has some of the symptoms that are listed with this diagnosis. Now, what about goals? Well, i want to see his symptoms get better, right? So, my goals are going to focus on how his symptoms are going to get better or go away. To do that, i'll need to choose nursing interventions to help that happen. Let's see, the first symptoms is ____. What, as a nurse, can i do for that? If i do this intervention, is that going to make the problem better or worse?

That is critical thinking. Taking facts you have and making some judgment and decision in working with them. That is how you use critical thinking skills to use the nursing process. Now, i know i may have exaggerated a bit, but i was trying to demonstrate to you the kind of thinking process that should be going on in your mind. When you've been a nurse for a while this critical thinking process of the nursing process happens so fast, that you'll miss it if you don't think about it. It will go painfully slow for you at first because doing this is all new to you. What you do is just follow the steps and keep asking yourself those questions as you go through each and every symptom every one of your patients has. Over your career you will do this thousands of times. The care plan is nothing more than the written documentation and evidence of your critical thinking.

Does that help you out?

I think that for now, just know that a nursing diagnosis is exactly what nanda defines each one to be. They are each defined by symptoms--the same symptoms that doctors use to formulate their medical diagnoses. A symptom is an objective observation or a subjective perception of the patient--facts. The doctors do not have exclusive use of symptoms, or facts. We nurses can use them too. With a care plan you are addressing problems, or symptoms, that a patient has. What nanda has done is grouped many of those problems, or symptoms, into what they are saying are related groups and put a label on them. They call the label a nursing diagnosis. The label that the doctors put on groups of symptoms are called medical diagnoses. We nurses have exclusive use of the nursing diagnoses. Use of medical diagnoses in our written care plans are forbidden territory to us. Got it?

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

Outcomes are the predicted results of our independent nursing actions. Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. An expected outcome is measurable, patient centered, and specific. When you identify an outcome, you accept responsibility and accountability for helping the patient achieve that outcome.

Goals are the predicted results of collaborative nursing actions. Collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. Goals may also be measurable, patient centered and specific. What differentiates a goal from an outcome is that the nurse cannot take full responsibility and accountability for helping the patient to achieve a goal. Goals are achieved because of the collaborative management of many.

The major ideas you will see in the formulation of outcome and goal statements are the following:

  • improvement of the patient's condition
  • stabilization of the patient's condition
  • support for the deterioration of the patient's condition

While we would all like patient's to improve and get well, the facts are that some will not. It is perfectly legitimate to have outcomes that assist the patient in the deterioration of their physical conditions.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

Collect All Your Data.

You need to make a list of the symptoms for all the medical diagnoses that were given for this patient, and there were quite a few!

Copd (scant sputum production with emphysema, excessive sputum production with chronic bronchitis, exertional dyspnea, chronic productive cough with chronic bronchitis, hypoxia with emphysema and cyanosis with chronic bronchitis, tachypnea, prolonged expiration, hyperresonant chest, diminished breath sounds, coarse rhonchi and wheezes in bronchitis, s3 gallop, edema)

CHF (decreased left ventricular ejection fraction, decreased contractility, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, unexplained confusion or lethargy, fatigue, lower extremity edema due to venous insufficiency and lymphedema, hepatic engorgement and/or ascites, s3 gallop, jugular vein distension, pulsatile liver, rales, pulsus alternans and tachycardia, poor capillary refill, cool distal extremities, altered mental status)

HTN (b/p over 140/90)

Depression (sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)

Anxiety (nervousness, irritability, dread, insomnia, exaggerated startle response, easily distracted, unable to concentrate, muscle twitching, tremors, restlessness, shakiness, fatigue, muscle aches or tension, paresthesias, palpitations or tachycardia, shortness of breath, dyspnea on exertion, chest pain, sweating or cold palms diaphoresis, choking sensation, dysphagia, heartburn, nausea or vomiting, abdominal pain, anorexia, frequent urination, dizziness, lightheadedness, faintness, headache)

Atrial fib (dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)


CAD (angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)

MI (aka acute coronary syndrome) (chest pain similar to angina, pain often worse with activity and better with rest, pain radiates to arm, shoulder, hand, upper back, neck, jaw or throat; nausea, sweating, apprehension; pallor; tachycardia; s3 and/or s4 gallop; rales; jugular vein distension)

Osteoarthritis (deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)

Osteoporosis (usually asymptomatic until a fracture occurs in the vertebrae, distal radius or femoral neck, progressive deformity, kyphosis, loss of height, decreased exercise tolerance, low back pain, neck pain, elevated creatinine, history of tobacco abuse

Your scenario gave you the following abnormal data:

  • hyperglycemia (elevated glucose of 151)
  • low h&h
  • rales in the lll
  • pulse ox of 86% on room air

Let me backtrack a minute and say that all of the labwork is normal except for the glucose which is elevated, the h&h which is low and the bun which is only very slightly elevated and could be normal for an elderly man. Glucose will be elevated in diabetes, of course. But, it will also be elevated in acute stress, cushing's syndrome, pheochromocytoma, chronic renal failure, glucagonoma, acute pancreatitis, as a result of diuretic therapy and corticosteroid therapy and in acromegaly. I'm opting for corticosteroid therapy in this patient since he has copd and it's very common to give steroids to people with chronic lung disease. The low h&h indicates this person is losing blood. Probably slowly. Probably through the gi track. However, you don't have any other information to go on. So, it remains a mystery. I would care plan it as a potential problem and monitor for signs and symptoms of gi bleeding. Just fyi, the atrial fib, hypertension and tobacco abuse contribute to the chf.

Group Together Abnormal Data into Nursing Diagnoses.

That's going to be a big job because this patient has gobs of problems and a whole big list of symptoms! There are so many abnormal symptoms here that 5 different nurses could come up with a set of 5 different nursing diagnoses and each would be right. So, I'm going to give you my short list. This is your assignment, however. You know what the instructions are, I don't. Feel free to go your own way.

The first thing I see sticking out like a sore thumb is respiratory problems--big time. Including your lab data, this is what I come up with in priority order (by maslow's hierarchy of needs):

  • Impaired gas exchange r/t alveolar-capillary membrane changes aeb tachycardia, irritability, hypoxia, dyspnea, pulse ox of 86% on room air, skin pallor, hypoxemia, headache, and diaphoresis)
  • Ineffective airway clearance r/t chronic obstructive pulmonary disease aeb dyspnea, orthopnea, rales, rhonchi, wheezes, sputum production, and cyanosis
  • Decreased cardiac output r/t altered contractility and heart arrhythmia aeb rales, paroxysmal nocturnal dyspnea, decreased ejection fraction, s3 and s4 heart sounds, tachycardia, palpitations, jugular vein distention, fatigue, edema, prolonged capillary refill, elevated blood pressure, and atrial fibrillation
  • Impaired physical mobility r/t pain and physical deformity aeb limited range of motion and changes in gait
  • Fatigue r/t anxiety, depression and disease aeb lethargy, inability to concentrate, and sleep disturbances
  • Risk for deficient fluid volume r/t occult blood loss [that means blood loss whose reason is not known]


Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. Your nursing interventions will actually be based on the items you have after the "aebs" of each of your nursing diagnoses. If you have a nursing diagnosis book it will be very helpful with choosing interventions.

The first site actually has a lot more nursing diagnoses than are listed, so if there isn't one on the list that you need, pm me and I'll check my list and let you know if what you are looking for exists on the gulanick site.

Implementation & Evaluation.

I don't know how far you are into doing that part of the nursing process for this assignment. Most of the time people have the worst time getting through the first 3 steps so step 4 and 5 are usually a breeze.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

I've expanded on two of your nursing diagnoses for you and added goals and outcomes. Outcomes are the predicted results of our independent nursing actions. Independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. Goals are the predicted results of collaborative nursing actions. Collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. Both outcome and goal statements should be measurable, patient centered and specific. Below the outcomes and goals I've listed weblinks to specific nursing diagnosis pages on two different care plan constructor sites where you can get not only information about the definition of that particular nursing diagnosis, it's related factors, defining characteristics and outcomes, but nursing interventions with rationales as well.

Chronic pain r/t progressive enlargement of tumor secondary to cancer of the pancreas with metastasis to the liver aeb patient's subjective rating of pain on a numeric scale of 1 to 10

Outcome: by ____ the patient will be able to perform normal adls with minimal interference from pain and the side effects of his medication.

Goal: by ____ the patient will state his pain is improved.

Imbalanced nutrition: less than body requirements r/t increased metabolic demands of tumor secondary to cancer of the pancreas with metastasis to the liver aeb 91% of body weight loss and poor appetite

Outcome: by ____ the patient will state the importance of a well-balanced diet

Goal: by ____ the patient will ingest nutritional requirements in accordance with his level of activity and metabolic needs.

Goal: by ____ the patient will maintain his current weight of ____.

Ineffective coping r/t

(You need to look at both of the sites below. Decide what it is that is making coping with his cancer difficult for this patient and you will then be able to complete your "related to" part of this diagnostic statement. Why do you feel this patient is not coping with his disease well?)

A soap note, generally, looks like this:

S - "This is my very first care plan and I do not feel as if I was given enough instruction on how to do this." "How do I come up with interventions and evaluations and goals."

O - Completed data collection, no grouping of abnormal data into nursing diagnoses, no goals or outcomes, no nursing interventions. care plan halted at step #2.

A - Readiness for enhanced knowledge of nursing process r/t an expressed interest in learning how to write a care plan aeb a written plea for help

P - Assist student with formulation of nursing diagnostic statements, provide information on difference between outcomes and goals, provide references for nursing interventions, provide information on soap charting.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.
yadis572002 said:
What is the difference between nanda nursing diagnosis and wellness diagnosis?

A nursing diagnosis is a patient problem that has been identified through the collection of information obtained in assessing the patient. There are currently 188 official nanda nursing diagnoses [as of 2007] that have specified definitions and criteria. Among these nanda nursing diagnoses are several wellness diagnoses.

Nanda defines the wellness nursing diagnosis as "describ[ing] human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. This readiness is supported by defining characteristics. As with all diagnoses, nurse-sensitive (sensitive to nursing interventions) outcomes are identified and nursing interventions are selected that will provide a high likelihood of reaching the outcomes." (page 332, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)

Here are the wellness nursing diagnoses in the Nanda II Taxonomy:

  • readiness for enhanced comfort
  • readiness for enhanced organized infant behavior
  • readiness for enhanced nutrition
  • readiness for enhanced self-care
  • readiness for enhanced sleep
  • readiness for enhanced spiritual well-being
  • readiness for enhanced religiosity
  • readiness for enhanced urinary elimination
  • readiness for enhanced fluid balance
  • readiness for enhanced therapeutic regimen management
  • readiness for enhanced communication
  • readiness for enhanced community coping
  • readiness for enhanced family coping
  • readiness for enhanced coping
  • readiness for enhanced decision making
  • readiness for enhanced hope
  • readiness for enhanced knowledge (specify)
  • readiness for enhanced family processes
  • readiness for enhanced parenting
  • readiness for enhanced self-concept
  • readiness for enhanced power
  • readiness for enhanced immunization

(Reference: pages 282 - 294, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)


3 Posts

I want to thank everyone at this site, it has made understanding careplans manageable. I have shared the information with the other students in my class.

I have a new pt and some more questions. Pt has mets breast cancer, stage 4 and it has spread to her bones. She needs help with ALDs but can stand (for a moment) on her own and can move around in bed and PT is working on her walking short distances.

She has HTN, DM II, depression, bipolar, anemia, asthma, constipation, sleep apnea, migraine, incontinence. These are all being treated with numerous meds. She has had breast cancer for past 10 yrs and both breasts removed and reconstruced, she did XRT in the past and has just started on oral chemotherapy that is given a difficult but slight chance of being effective. she is in a long term care unit with a full code. She wants to be able to walk again so she can go home to her mother that is in a wheelchair.

She is on oxycodone q4h and is in bed or in her chair a lot- a 19 on the Braden scale.

What I have come up with for my three nx are chronic pain, inadequate nutrition:less than body requirements, and risk for injury r/t DM- hypo or hyperglycemic. My question is: Are these good or should I have other priorities & how do you put DM related NX when the DM is under control and she is not on insulin. She has HTN put no complication currently, She has asthma and gets RT treatments.

Am I on the right track. the problem I have currently is I am not sure how to prioritize- I keep looking at Maslows and reading more about it but when someone is on palliative care I am not sure how that impacts Maslows.

Thank you in advance


Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

Some thoughts for tygge on your care plan. . .You ALWAYS, ALWAYS, ALWAYS let your patient's abnormal assessment data guide you in the choosing and prioritizing of nursing diagnoses. As I was reading your post I was making a list of them. What is your supporting assessment data for using Imbalanced Nutrition: less than body requirements? Has she been losing weight? Or, is she having nausea secondary to the chemo? Is there a reason you didn't address her incontinence? Breast cancer often metastasizes to the lung as well as the bone. With a history of asthma I would be thinking this patient is at risk and needs watching for breathing or airway problems. Getting this lady back into her home is going to be a discharge and social service project because it sounds like her mother is not going to be able to be much help to her. Since she has stated that getting back home is one of her desires, it would seem to me that this needs to be included in the care plan.

Maslow has defined the levels of his hierarchy. Most understand that in his theory physiological needs must be addressed first. However, the physiological needs are further prioritized and sequenced in the following order of importance:

  1. oxygen requirements (brain first, then the heart, lungs, kidneys and peripheral tissues)
  2. food and fluids (this includes electrolytes)
  3. elimination (urine and feces)
  4. thermoregulation (fevers)
  5. sex
  6. movement
  7. rest
  8. comfort (pain control, some of the self-care deficits)

The next tier of priority is safety needs. They are prioritized in the following order of importance:

  1. safety from physiological/psychological threats
  2. protection
  3. continuity
  4. stability
  5. lack of danger

Your proposed nursing diagnoses as listed, plus the one you decided to add that you mentioned to me in a private message would be prioritized according to Maslow and following NANDA guidelines this way:

  1. Imbalanced Nutrition: less than body requirements
  2. Impaired Mobility
  3. Chronic Pain
  4. Risk for Injury

Anticipated problems are always sequenced last. If there are more than one, they are prioritized and sequenced according to where they would fit on the Maslow hierarchy as if they were real problems, but within their own little grouping of "Risk for" diagnoses at the end of the diagnostic list.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.
hotdog19d said:
Ok, I understand that aeb is not required,but can anyone help find a source that states this in black and white? I looked through my nursing diagnosis book and although it doesn't provide defining characteristics for "risk for's". I can't find anywhere in the book that states why.

Per nanda, the term "risk" belongs in one of the seven axial systems of taxonomy ii (for nursing diagnoses). It is classified under axis 5 health status and officially defined as "vulnerability, especially as a result of exposure to factors that increase the chance of injury or loss." (page 237, Nursing Diagnoses: Definitions & Classification 2005-2006 published by nanda international). With regard to using any of the terms within the seven axes to construct nursing diagnostic statements, nanda states the following: "some words of caution as well as encouragement: Using a multiaxial structure allows many diagnoses to be constructed that have no defining characteristics and may be nonsense (such as "impaired activities of daily living, fetus"). We urge you to use only those diagnoses that are approved for testing and thus have defining characteristics. (page 239, nursing diagnoses: definitions & classification 2005-2006 published by nanda international). Color and boldface added by me.

What that all means, hotdog19d, is that there will be no nanda approved "risk for" nursing diagnoses that are going to have any defining characteristics as said in the post by bookwormom.

Most people find the materials from nanda kind of boring to read. However, if knowing about these things from the source is important to you, you can get a copy of Nursing Diagnoses: Definitions & Classification from nanda very easily.

Go to their website and order a copy.

This is how I got my copy of the 2005-2006 edition I referenced above. A new edition is coming out for 2007-2008 and the cost is $24.95.

Besides listing all the approved diagnosis (this information is reprinted in scores of nursing care plan books), it also gives an explanation of what the taxonomy and classification system is as well as lists of all the words that are included in each of the seven axes that comprise the taxonomy (not often included in nursing care plan books). Warning! This is taxonomy stuff is something that only geeks are likely to be interested in.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

I have read both the threads you have posted on this case scenario. Based on what you've posted to both threads this is my reply.

With regard to the incontinence. . .

It sounds like the scenario is describing stress incontinence which is the inability to prevent urination during the stress of such activities as coughing, sneezing, lifting or laughing. It is normally due to muscle weakness and is common in women who have had a history of vaginal deliveries of children. Assessment questions you want to ask with regard to incontinence are things such as:

  • When does it occur?
  • Is the incontinence related to any activity such as coughing, sneezing, lifting or laughing? (yes)
  • Does the incontinence occur at any other times?
  • How long has this been happening?
  • Did it start suddenly? or did develop gradually over time?
  • What was the normal pattern of urination during the day? during the night?
  • Has the urine changed color?
  • Has the urine developed a change in odor?
  • Is there any urgency?
  • Is there any starting and stopping of the urinary stream?
  • What kind of fluid and how much is being drunk during the day? is the fluid restriction being followed?
  • Is the patient on any medication that could be affecting urination?

With regard to the problem of falling. . .

The elderly frequently fall due to gait and balance problems. This is a link to 3 gait and balance assessment tools that are used for elderly patients that will give you an idea of what is assessed in patients who might be at risk for falling and the questions you should ask.

Assessment questions you want to ask with regard to falling might be such things such as:

  • Are there any physical deformities of the lower extremities?
  • How much range of motion does the patient have in each of the joints of the lower extremity?
  • How much muscle strength is present in the muscles of the lower leg?
  • Does the patient have any weakness in one or both legs?
  • Is the patient unable to move one or both legs?
  • Does the patient stumble or trip when walking?
  • Does the patient have difficulty getting out of the bed?
  • Is the patient having any muscle spasms or cramps in one or both legs upon standing? if so, what makes it worse? what makes it better? is the patient on any diuretics?
  • Does the patient have any pain or stiffness in the joints of the hip, knee or ankle? describe the pain. is it radiating, burning, sharp, dull or aching in nature?
  • Does anything make the pain worse? does anything make the pain better?
  • Is there any swelling or pain anywhere in the lower extremities that might be interfering with movement?
  • Is there any stiffness in the joints upon attempting to arise from the bed or a sitting position?
  • Is the patient overweight?
  • Can you palpate pulses?
  • Is the skin warm to touch? or, cool?
  • What did the last set of electrolytes look like?
  • When did this falling during the night begin?
  • Has it happened before? or, is it a new problem?

I am curious as to why you ask if you should consider if the patient is using etoh (alcohol). Unless this question was asked as part of the scenario, i wouldn't even consider that the patient might be abusing alcohol. How would etoh figure in with a patient who was on a fluid restriction, getting up to the bathroom 4 to 5 times a night and falling when getting up? Although alcoholics are prone to falls, they are also prone to a number of other problems as a result of long term usage:

  • peripheral neuropathy
  • brain damage
  • seizures
  • hallucinations
  • severe memory problems
  • confusion
  • a number of personality disorders
  • major depression
  • anxiety
  • cirrhosis
  • vitamin deficiencies

This article from the american family physician includes a list of the symptoms of alcoholism in the elderly. You can use it as a guideline to develop a list of questions to develop for an assessment of alcoholism in your case scenario patient:

Alcoholism in the Elderly

From my knowledge of working with alcoholics in detox i would say you don't have enough evidence to suggest that this patient has an alcoholic problem unless there are other symptoms that you have not listed in your posts.

Based on the information you supplied, i believe there are only two good nursing diagnoses that you can come up with. I only have one online link to a nursing diagnosis where you can get outcomes and nursing interventions. Also, for the stress incontinence you really don't have enough information to determine the etiology (related factor) of the incontinence although we know it is most likely due to muscle weakness. One of the interventions for stress incontinence is to instruct the patient in kegel exercises.

  1. Types of Urinary Incontinence
  2. Slideshow: Urinary Incontinence in Women
  3. What Causes Urinary Incontinence in Men?

I would not use disturbed sleep pattern as one of my nursing diagnoses because the cause of the interrupted sleep pattern is related to urinating. The reason for the frequent urination is not clear to me as to whether the patient is self-waking to go to the bathroom or there is some other factor, either physical or pathological that needs to be determined. There may not be a sleep problem at all.

Likewise, I wouldn't use risk for loneliness either. Use of this nursing diagnosis presupposes that the patient would experience depression, restlessness, anxiety or unhappiness as a result of some type of isolation or deprivation. However, this patient is living in a retirement community and there is no other evidence of isolation or deprivation to support using this diagnosis.

Your goals or outcomes should reflect what you are trying to accomplish with the nursing interventions you are prescribing and they are the predicted results of your interventions. Remember to make them measurable, patient centered and specific and state a specific deadline by which they should be achieved.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.
x-tremestudent said:
thank you so much for your help. i am a lvn student and am 43 would u recommend me to go on to rn school considering my age and all

If you want to go on to become an rn, then do it. Your age won't matter. My mother went to lvn school when she was 50+ and worked as a nurse until she was 68. Right now rns are needed and the largest group of rns that are presently employed is in their 40s. Go for it!

I hope my reply to your post(s) helped to clear up some of the problems you were having with the case study. Do you have a care plan or nursing diagnosis book to help you with the goals/outcomes and nursing interventions? If so, it is important to review the first chapter(s) on the nursing process and how to write a care plan. Nursing diagnoses are always determined by the assessment data that you have. Case scenarios where you don't have a real live patient are always a little edgier because you have to work with the information given to you and sometimes you have to do a little bit of extrapolating and assume some things which you wouldn't normally do with a real patient. Like the question about the patient using alcohol. I think that the idea there was for you to do a little investigation of the use of alcohol by the elderly, or the effects of alcohol abuse in the elderly since two of the actual symptoms you were given (frequent urination and falling) are symptoms of current alcohol use. Problems with balance, which you would have to assume as a possible cause for the falls (can't assume this with a real patient) would be a long term affect of alcohol abuse. Older people who have been heavy alcohol abusers for many, many years have a lot of chronic neurological problems as a result. So even though they many have stopped drinking by the time they reach their 70s and 80s, the brain damage has already been done.

I had an older assessment book that i used to help form some of the assessment questions for you that i bought about 8 years ago called expert 10-minute physical examinations that was published by mosby-year book in 1997. I don't know that it's even in publication anymore, but the more i use it, the more i realize how simply organized and concise it is. You should explore these three threads on the nursing student forums. The assessment one, in particular, has many links to websites with assessment data on them to help you. I have no quick way to help you be a "question box". This is a skill you have to develop on your own. You have to think about all the possibilities that might be going on and ask questions designed to get you information that will confirm or deny them. That's the best explanation i can think of to tell you at this time. Assessment is not as easy a skill as some would want you to think. You will need to do many assessments of many different types of patients over a long period of time and you still will occasionally forget a question to ask or a subject to explore!

By using the site, you agree with our Policies. X