hi, jeannie. . .before i start in to get you started off in a direction you should go with this care plan, let me first tell you that you should also be checking out these two very informative threads in the nursing student forums here on allnurses:
and while i'm giving you those links, you should also be checking out threads on these two nursing student forums, particularly the nursing student assistance forum because that is where the student nurses often post threads asking for help with their care plans:
i just posted a reply tonight to a student looking for help with a care plan for a patient with dehydration on this thread:
before i dig into this care plan, let me first tell you that a written care plan is nothing more than the written expression of the nursing process. it has five steps. they are, in order: assessment, choosing a nursing diagnosis, deciding on goals, outcomes and nursing interventions (developing the plan of care), implementation of the plan of care, and evaluation of the plan of care. all care plans begin with the patient assessment. this includes collecting all the information you can get about the patient from the chart and from your own physical examination and questioning of the patient. you then, pull out all the data that is not what we would call "normal". they become defining characteristics, or symptoms. it is that information that is used to determine what nursing diagnoses to use for that patient. each of the current 172 nanda nursing diagnoses have a definition, related factors (causes), defining characteristics (symptoms), noc outcomes and nic interventions linked to them. for this reason, it is important that you have access to a good book of nursing diagnoses. there are some online resources to them, but they are not complete. the ackley/ladwig care plan constructor which rn007 gave you the link to has only 52 nursing diagnoses listed on that site. their updated site for their newer online edition of the constructor (i'll give you links later in this post) contains 75 nursing diagnoses, still 97 short of the 172 officially in use.
now, what is the cause of the patient's dehydration? does the doctor know? is it because of loss of fluids? is it because the patient is not taking fluids properly? is he on diuretics that may have dehydrated him? it is important to determine this because your choice of nursing diagnosis rests on this. if the dehydration is due to loss of fluids, then deficient fluid volume is the nursing diagnosis you want. however, if the dehydration is because of the patient failing to take in enough fluid volume due to his cognitive impairment then you need to consider something else, such as self-care deficit: feeding or ineffective therapeutic regimen management if diuretics are the culprit. if the patient has another person at home who is an overseer of his care then there may also be issues of knowledge deficits with his therapeutic management as well as issue involving family and community resources. so, i really can't help you much beyond this point without you answering those questions at the beginning of this paragraph.
the nursing diagnosis to use for a patient who has not been eating adequately is imbalanced nutrition: less than body requirements r/t ???? aeb [i.e., weight loss, reported lack of eating] again, there is a missing reason for why he hasn't been eating that needs to be known to help in formulating the nursing diagnosis.
with an n/g tube he is at risk for aspiration of the tube feeding. this is a safety issue. the nursing diagnosis for this would be written as: risk for aspiration r/t presence of a nasogastric tube and tube feedings
. one of your outcomes will be to maintain a patent airway. one of your goals will be to give adequate nutrition through the n/g tube. i distinguish between a goal and outcome by whether or not a doctor's order is required to achieve the predicted result.
another safety issue you have with this patient is that he is at risk for physical injury. when i read that he had mits, i assume his wrists are also restrained. that means his mobility is to some extent compromised. is he likely to develop any kind of pressure ulcers or skin sheering? we know that if he yanks the n/g tube he could do damage. so, risk for injury r/t presence of physical restraints
. an obvious outcome would be that the patient will remain free of physical injury.
you might consider using impaired physical mobility r/t physical restraint aeb limitations on physical range of motion
or impaired bed mobility r/t physical restraint and cognitive impairment aeb inability to turn and sit up in bed
. outcome would be for the patient to maintain current level of mobility.