Falls and weakness Care plan help

you may have only had a few hours of actual time with the patient, but you have lots of time to do some investigation of his medical diagnoses and the side effects and reasons for why he is receiving his medications. as a student, that is part of your care planning process.

assessment consists of:

• a health history (review of systems) - he has a lot that has happened to him: diabetes, chf, htn, a pacemaker, dysrhythmias, a spinal fusion, bilateral cataracts (his vision may not be very good), an overactive bladder (you know he's incontinent) and peripheral neuropathy. you should be looking up every one of these things and learning about them so you can see if you remember seeing the symptoms in this patient.
  
  
• performing a physical exam - the first thing that caught my eye about the pe was his b/p: 198/108! he's already on 4 medications for hypertension! i think that is something important to pursue.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - you said he was incontinent and his wife cleaned him up. how long has that been going on? what else needs to be done for him?
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to know the pathophysiology of his medical conditions because they become the "related to" parts of any nursing diagnostic statements that you eventually come up with. that is why you have to look up and read about these different medical diseases. you cannot wait until you cover them in your nursing classes.
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking
  
  • enalapril (ace inhibitor - for chf and hypertension)
    
    
  • furosemide (loop diuretic - for chf and hypertension)
    
    
  • glimepiride (antidiabetic - type ii diabetes)
    
    
  • insulin aspart (rapid acting insulin)
    
    
  • metoprolol (beta blocker - hypertension)
    
    
  • solifenacin (anticholinergic - for overactive bladder) a side effect is frequency
    
    
  • terazosin (adrenergic blocker - for hypertension)
    
    

acute pain r/t injury from fall at home aeb swollen, discolored wrist and patient states pain score is 7.

i only had a few hours with this patient and my issue with this is that he had no pain meds prescribed. is this normal? what am i missing here. so should i still use this diagnosis even though there is no pain management with meds. i didn't see his nurse do any type of pain management honestly.

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
  
• care/perform/provide/assist (performing actual patient care)
  
  
• teach/educate/instruct/supervise (educating patient or caregiver)
  
  
• manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
  
  

impaired urinary elimination r/t incontinence

risk for impaired skin integrity r/t moisture from urinary incontinence

am i on the right track?

• decreased cardiac output r/t altered stroke volume
  
• fatigue
  
• self-care deficits
  
• risk for falls r/t age, history of falling, on antihypertensives, diuretics, ace inhibitors. weakness, incontinence, overactive bladder, peripheral neuropathy and visual problems
  

I understand what you are feeling when you are at clinical and that is appropriate. But, when you are sitting down and writing this care plan you are engaged in a thinking, logical activity. Put your feelings aside for the moment and do the logical, rational part of what the nursing job requires. This is now where it is most appropriate for all that TONS of research that you do needs to come in. Have at it and knock yourself out. Ask questions now and look for the answers. Find out the ways to have helped this patient so you will be better when the next patient like this comes your way. That is part of the reason you are doing these care plans--learning. When the next patient comes along you will have a better understanding of what to look for, what questions to ask, what protocols don't look right. Later, when you are a working nurse you will not have these opportunities to just sit, read and research. There will be times when you will long for them, believe me.