Falls and weakness Care plan help

Daytonite, BSN, RN · Apr 6, 2009

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.

the related factor for acute pain must be something that has caused injury. in this case the patient fell and sustained a hematoma (bruise) to the wrist. so, why is he having pain? trauma. what is your evidence of the pain? a

swollen, discolored wrist

is not proof of pain. however,

patient states pain score is 7

is evidence of pain, but there is a better way to put that:

patient statement of pain of 7 on a scale of 0 to 10.

where is this pain? the right wrist. so, your diagnostic statement should read

acute pain r/t trauma aeb

patient statement of right wrist pain of 7 on a scale of 0 to 10.

now,

anyone

reading that gets a picture of pain that was caused by trauma of some sort, where the pain is, and that it is an intensity of 7/10.

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.

that has nothing to do at this point with the diagnosing of the problem. problem determination is based on the facts of the situation. the doctor did an assessment and determination of the situation just as you did. do we want to consider it? yes, when we get to the point where we begin to develop our nursing interventions. but we don't do that until we have figured out what his nursing problems are first. the nursing process requires that of us. (1) assess (2) determine the problem (3) plan of action (4) implement the plan (5) evaluate. you are still at problem determination.

once you have the problem nailed down, you look at the evidence that supports it:

right wrist pain of 7 on a scale of 0 to 10.

then you develop nursing interventions to address this symptom. they will include interventions to:

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)

there are things you can do such as contacting the physician to help in the management of the pain. however, don't be fooled into thinking that giving pain medication is the only nursing intervention. there is much more than we nurses can do without a doctor's order for this man's pain.

impaired urinary elimination r/t incontinence

i think he's outright incontinent unless there is something you didn't add to the assessment.

incontinence

cannot be a related factor for

impaired urinary elimination

. if the person is incontinent then you need to use one of the incontinence diagnoses.

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

you need to state the risks (reasons) why the skin would break down. it would be moisture of sitting (remaining) in urine. you don't need to mention the incontinence.

am i on the right track?

you haven't really addressed the reasons the patient was admitted: falls and weakness. it's probably related to his diabetes or his heart, i'm betting. what are you going to do about his blood pressure?

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

jayebird28 · Apr 7, 2009

Thank you so much for your help and your advice. I do want to say that I guess I need to be a little more specific when posting to the board. I do TONS of research. I am a learning machine. I knew about every one of the meds and why he was taking them. I don't go anywhere without my Drug book. I was also alarmed at his BP. I guess I am just getting confused as to where my role begins and ends as a nursing student. He was in pain and he told me that he already told the nurse. I guess my issue is that he was sitting there in pain with no pain relief. Why couldn't the nurse give him something or contact his doctor? Also, the vitals were charted and his nurse had already reviewed them....why hadn't she done anything about his BP? I guess my main concern is stepping on toes while I am at the hospital and ******* people off. I know that I don't know how things run yet in the hospital setting but as I go through my care plan all of these questions are just swirling around in my head. Anyway, I hope all of that made sense. Thank you so much for replying to me. You always out do yourself. Oh and by the way... You had great advice on my last care plan for CHF and I passed with flying colors, so...THANK YOU!!!

Daytonite, BSN, RN · Apr 7, 2009

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.