Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

I'm sure that "risk for" diagnoses do not require an AEB. It makes sense because a patient can't be presenting evidence of something that hasn't happened yet, correct?

If someone has a source for this I would really really appreciate it!:balloons:

This is my 1st case study. My client has urinary incontinence. A 75 yr old lives alone in a continuing care retirement home, w/no family. She has had difficulty with urinary leaking when sneezing,coughing. She gets up @ night 4-5 times a night afraid of wetting bed. Each time at night she has fallen when getting up. She drinks 4 glasses of fluid a day, and never after 5 pm. Also I need a nursing diagnosis with goals, and three interventions. I need to address:

1. What assessment questions do i need to ask regarding incontinence risk factors.

2. Formulate nursing diagnosis and goals.

3. What type of incontinence dos she have

4. Write a nursing diagnosis,a goal,& interventions

5. What questions do u ask to determine fall risks

Here is my nursing diagnoses - Am I right?

1. Incontinence urge

2. Risk for injury r/t falls

3. Sleep disturbance

4. Fear risk for loneliness r/t living by self in retirement home.

My assessment: assess gait, balance, eyes, medications, tests for UTI, parkinsons.

Should I consider alcohol use? why/why not?

Also I need to make a diagram illustrating age related changes in urinary system. Any help will greatly be appreciated. Thank you so much!

Don't forget impaired skin integrity r/t incontinence.

How about something like poor body image r/t incontinence? Maybe something on the psychological issue of continued incont? Been a while since I did a care plan, but I kinda' remember some diagnoses like that.

Bowel incontinence r/t decreased awareness of need to defecate/loss of sphincter control.

Deficient knowledge r/t lack of information on normal bowel elimination.

Disturbed body image r/t inability to control elimination of stool.

Risk for impaired skin integrity r/t prescence of stool.

Situational low self-esteem r/t inability to control elimination of stool.

Tolieting self-care deficit r/t toileting needs.

Functional incontinence r/t altered environment; sensory; cognitive or mobility defects.

Reflex incontinence r/t neuro impairment.

Risk for impaired skin integrity r/t prescence of urine.

Stress urinary incont. r/t degenerative change in pelvic muscles and structural supports.

Urge urinary incontinence r/t decreased bladder capacity (h/o PID, abd sx, indwelling cath).

Hope this helps!

Risk for falls r/t history of falls

Patient will verbalize understanding of individual risk factors that contribute to posibility of falls and take steps to correct situation

Urinary incontinence r/t weak pelvic muscles and structural supports

Patient will understand condition and interventions for bladder conditioning

Demonstrate behaviors/techniques to strengten pelvic floor musculature

Remain continent even with increase intra-abdomincal pressure.

Specializes in med/surg, telemetry, IV therapy, mgmt.
FutureNurse35 said:
Risk for falls r/t history of falls

Patient will verbalize understanding of individual risk factors that contribute to posibility of falls and take steps to correct situation

Urinary incontinence r/t weak pelvic muscles and structural supports

Patient will understand condition and interventions for bladder conditioning

Demonstrate behaviors/techniques to strengten pelvic floor musculature

Remain continent even with increase intra-abdomincal pressure.

Nice outcomes! However, you also have to put timed deadlines on them. For example:

  • In two days the patient will give a return demonstration of pelvic floor strengthening exercises and share an exercise plan with nurse.
  • After one week the patient will have no episodes of stress incontinence for one continuous 24 hours period.

I'm student in my first year nursing and i have assignment that i wish any one help me in it .

The assignment is ( give expected nursing diagnosis for male pt of 70yrs old with ihd, chf , pulmonary odema , aspiration pnemonia and past history of : mi, poor ejection fraction,, arf when the pt. Is sedative)

Specializes in Med/Surg, Home Health.

Altered Tissue Perfusion

Impaired Gas Exchange

Fluid Volume Overload

Dont forget to add the "related to" and define why you choose each dx.

example: Altered Nutrition r/t Weight loss and TPN use

Just think about the s/s r/t each of the medical diagnosis. What would you expect a patient with CHF to experience? What would they look like? What limitations would they have? Then created your nsg dx based on that and not focus so much on the medical diagnosis.

Example for the CHF:

Activity intolerance r/t weakness or fatigue.

Impaired gas exchange r/t excessive fluid in the interstitial space of lungs.

Fatigue r/t disease process.

Decrease cardiac output r/t impaired cardiac function.

Fear r/t threat to well-being.

Good luck!

I'm having a problem stating a proper Nursing Diagnosis. This is the only part of the care plan I'm having issues with. For some reason my brain is just not getting this. For instance I have a client this week that has a dehisced wound on her abdomen that is infected. The wound was caused by surgical removal of a portacath secondary to infection.

So I've got the first part of a Ndx: Impaired skin integrity r/t--- then I go blank on what to write.

Now I know her skin is impaired due to a surgical procedure that was done due to an infection.

Can someone help me with the proper way to write this Ndx?

Thanks

How about:

Surgical recovery, delayed

--r/t (not specified by NANDA) but dehiscence and infection would seem to fit

--aeb evidence of interrupted healing of surgical area

Wilkinson notes that this nurs dx is not fully developed, but I like it.

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