Published Mar 6, 2009
jmassey01
1 Post
I have been reading a lot of the posts on this website related to care plans and notice (from what I've read so far) that the Nursing Diagnosis is not being r/t the medical Dx. This is what I am being told to do. I just turned in my first 2 and even though I passed, I have no idea what I'm doing!
I am doing clinicals at a nursing home and need some advice on what I can do to get the information I need for my care plan with the limited amount of time I have with my patient. My patient is Dx with Alzheimer's Dementia, Hyperlipidemia, Osteoporosis, Osteoarthritis, Depression, Exacerbation of COPD. Within the last year she has had 4 CBCs with decreased RBC, HGB, and HCT; 1 Basic Metabolic with decreased Potassium and increased Glucose; 2 CMPs with decreased GPT/ALT, Albumin, and increased Globulin; 1 Urinalysis with Protein 30. No other abnormal labs. Her medications are for her Alzheimer's Dementia, OA, and OP. Also on vitamin supplement and Acetaminephen for increased temp/pain.
On my Physical Assessment of her, I found no issues until I took her socks off. Her legs literally went from a normal color to completely purple with thickened, hardened, and yellowed toe nails. It was impossible to check cap refill time b/c of the color and her pedal pulses were almost non existant. I did not feel any Edema even though my instructor did (small). I'm not sure I'd know if I felt it though, unless it was very obvious, so it is possible I missed it. Her T P R were within normal range, but her B/P was 152/86.
When I toileted/bathed her, I noticed that from below her pubic symphysis all the way back to the bottom of her sacral area, was a reddened area about 2-3 inches wide. Apparently due to being left to sit in her urine and feces for extended periods of time.
She is 5'5 and 173.8lbs; 20 of which she has gained in the 1 1/2 years she has been in the nursing home.
My instructor recommended Ineffective Tissue Perfusion R/T COPD. I also think I have enough evidence for Risk for Impaired Skin Integrity R/T Alzheimer's Dementia and Depression. Any advise on which direction I should take would be greatly appreciated. My instructor has very little time for one-on-one time due to class size, so, please help!!
Daytonite, BSN, RN
1 Article; 14,604 Posts
nursing diagnoses are actually nursing problems. the "related to" parts of the diagnostic statements are actually given to us in the nanda diagnostic taxonomy (a listing and classification of all the nursing diagnoses). so, if you have a nursing diagnosis reference you can look up the related factors for any of the nursing diagnoses you use. for many of the physiologically based nursing diagnoses the related factors are based upon knowing the pathophysiology of the person's medical disease. i have information on how to write a care plan on this thread in the general nursing student discussion forum: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. care planning follows the steps of the nursing process. you can, if you want, buy a copy of the book, nursing care planning made incredibly easy, to help you. however, when i help students with care plans i pretty much follow the same advice given in this book.
step 1 assessment - assessment consists of doing the following:
a person with alzheimer's dementia could have some of these behaviors: disorientation to person, place or time; poor judgment; agitation; sleeplessness; paranoid ideation; gradual dependence on others for help in accomplishing adls; and as alzheimer's reaches its late stages they become physically immobile. someone with one of the diseases of copd would probably have some respiratory symptoms: a cough or shortness of breath with activity.
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - just as our legal system won't charge anyone with a crime without evidence, we don't diagnose a patient with a nursing problem unless we have evidence to back up our claim as well. here is the evidence you presented that i can use for care planning:
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - using a nursing diagnosis reference i can match that evidence above to these nursing diagnoses and form these nursing diagnostic statements:
i have no doubt that with more evidence there could be more diagnoses.
risk for impaired skin integrity r/t alzheimer's dementia and depression
ineffective tissue perfusion r/t copd