Fatigue/Failure to Thrive/??? Help please

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I'm just desperate! It's my first care plan and I spent a week trying to come up with my nursing diagnosis:crying2: Please, if anyone could help me..

My patient is 78 yo, hypertension, lives alone after recent death of his wife who did all home work for him (cooking, laundry etc.), had a superficial injury of thigh due to fall in the bathroom. Was refereed to community center 4 assessment and follow-up care if needed.

Home Assessment

HOME small freestanding house, bedrooms are fairly clean (doesn't use them?), timber floor with mats, a couple of power cords from heater and a TV crossing the leaving room (spends all his time watching TV?), has steps up to a small veranda; daughter visits once in two weeks and brings food

Verbalizes: weakness, lack of appetite, lack of energy, doesn't change clothes because he doesn't know how to use the washing machine, doesn't go shopping for food, doesn't play bowls anymore 'cause it's lonely to play without his wife, says "I don't have enough energy to do very much at all"

Demonstrates: pale, disheveled, unkempt, smells bad, friendly, alert and oriented, weight loss

Vitals BP 145/90, T norm, P 66, RR 17, O2Sats 95%

I put symptoms into clusters and came up with:

weakness caused by malnutrition?

inability to maintain everyday life

apathy, loneliness, isolation

obstacles at home

I came up with FATIGUE r/t malnutrition and negative life event: FAILURE TO THRIVE, ADULT : INEFFECTIVE HEALTH MAINTENANCE, but I'm not sure because there are risks for basic needs for my guy. Maybe I should ignore his psychological status and think about nutrition and safety??? because if I'll administer fatigue it doesn't guarantee that he will eat well and will be able to wash his clothing... So, I need to feed him first, and exclude risks of falls. Maybe it's just Risk of falls, but there was a fall already.

I'm totally embarrassed:eek:

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forgot exactly what it is but look in nanda book under impaired grieving process or something along those lines. this is the cause of all the other problems

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Thanks for the reply! I think you mean Complicated Grieving in NANDA list - a disorder that occurs after a death of a signufucant other in wich the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment. It looks fine, but defining characteristics don't look like right. My guy verbalized nothing of defining characteristics of C.Grieving

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Specializes in Geriatrics, Home Health.

His grieving seems dysfunctional. (Seems that there are a lot of dx involved with the grieving process)

the Risk for falls (or injury) would be important to me, even though he already fell...there is a big chance that he will again at home, so it needs to be explored. Maslow's hierarchy of needs will guide you to the most important issues that need to be addressed for your care plan. :)

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Specializes in LTC.

I'd say Risk for Falls, Imbalanced Nutrition: Less than Body Requirements, and Social Isolation.

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Thanks for your replies guys!

I thing i will go with nutrition

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Ineffective coping? Spiritual distress?

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