Quick Care Plan question

Daytonite, BSN, RN · Nov 25, 2009

impaired physical mobility r/t dementia aeb altered mental status

dementia is not listed as a related factor in the taxonomy for

impaired physical mobility

, so i don't know where you got that impression. dementia is "cognitive impairment" which is listed as a related factor in the nanda taxonomy. "altered mental status" is not evidence of

impaired physical mobility

and tells us nothing about how there is

limitation in independent, purposeful physical movement of the body or of one or more extremities

(the definition of

impaired physical mobility

). you can see the related factors and defining characteristics (signs and symptoms) for this diagnosis on this webpage:

impaired physical mobility

- - - - - - - - - - - - - - -

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

squishy11 · Nov 25, 2009

Ok, I see what your saying.. I dont have my plan in front of me... but I know I wanted to incorporate dementia into it... so I suppose a more appropriate dx would be impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremeties, pt states "My legs feel very weak when I stand".

right?

:)

Thanks Daytonite, as I have said, you really helped me get thru my last 2 plans, and for some reason the task seems a little more daunting now because I have 3 to write up.. I don't understand it.. I did very well on the first two.. it's strange.. I almost feel more lost this time which is crazy becuase I have my first two to go off of. (Altho these 3 include meds...)

Thanks again!

J

Daytonite, BSN, RN · Nov 25, 2009

Ok, I see what your saying.. I dont have my plan in front of me... but I know I wanted to incorporate dementia into it... so I suppose a more appropriate dx would be impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremeties, pt states "My legs feel very weak when I stand".
right?

That's right.

squishy11 · Nov 27, 2009

Another question :) ... could I have Risk for infection r/t IV lock... or would I have to add more into that?

thanks!

squishy11 · Nov 27, 2009

Can I just get a wording check? I have some diagnosis... and they are coming from the info I gathered from my pt. I know you cant tell me if they are appropriate to the patient, but is the wording OK for a priority list...?

1) Ineffective airway clearance r/t excessive mucous AEB inability to cough effectively.

2) Impaired skin integrity r/t tissue breakdown AEB redness on sacral area.

3) Impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremities, pt states “my legs feel very weak when I stand”.

4) Activity intolerance r/t generalized weakness AEB pt states “I feel very weak all the time and don’t get out of bed much”.

5) Risk for deficient fluid volume r/t diarrhea.

6) Risk for falls r/t diminished mental status.

7) Risk for infection r/t IV lock.

thanks again! (slow day at work :) )

Daytonite, BSN, RN · Nov 29, 2009

could i have risk for infection r/t iv lock... or would i have to add more into that?

it is ok as it is.

correct priority sequencing:

ineffective airway clearance r/t excessive mucous aeb inability to cough effectively.
activity intolerance r/t generalized weakness aeb pt states "i feel very weak all the time and don't get out of bed much".
- this diagnosis is used when there are respiratory and cardiac symptoms when the patient attempts any activity and results in them having to stop the activity and sit down. weakness and not getting out of bed much is really a cause of this problem. you really haven't listed any respiratory or cardiac symptoms.

[*]impaired physical mobility r/t impaired balance aeb limited muscle strength in lower extremities, pt states "my legs feel very weak when i stand".

[*]impaired skin integrity r/t tissue breakdown aeb redness on sacral area.

you should be more specific about the cause of the tissue breakdown. it would probably be due to pressure and immobility

[*]risk for deficient fluid volume r/t diarrhea.

[*]risk for infection r/t iv lock.

[*]risk for falls r/t diminished mental status.