HELP!!-- Care plan first one for med-surg

a care plan is about determining the person's nursing problems. nursing problems develop as the patient responds to their medical problems and living situation. most of what you told us is all about her medical problems. every medical diagnosis comes with signs, symptoms and potential complications that we must be aware of and monitor for. as nurses our primary function is to assist patients in accomplishing their adls (activities of daily living) as well as assisting the physician's in administering and carrying out their medical plan of care. how are you assisting this lady with her adls? with a fractured right humerus (the humerus is the bone of the upper arm) that pretty much leaves her with only one functional arm, how will she dress, eat, brush her teeth, use crutches or a walker? is she right handed or left handed and was the dominate arm the fractured one? how did she manage to fall in the first place? that is something that needs to be investigated because we don't want to send her back to the same situation to fall again. she will need major help with her adls. look at how low her hemoglobin and hematocrit are. what is going on there? what symptom will they produce that will affect her physical activity? you need a lab reference for some clues. what are you doing for her about her diabetes? her copd? her hypertension? with hypertension, copd and the immobility that will be imposed by this injury what complication(s) is(are) likely to occur and how can you care plan for them?

before any diagnosing is done, an assessment of the patient is carried out first. assessment consists of:

• a health history (review of systems)
  
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
  

you can see many examples of how i do this assessing on this thread before actually getting to the diagnosing: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

#1. . .there is no official NANDA diagnosis of Impaired Walking.

#2. . .even if there were, your nursing interventions would be based on treating the symptoms and perhaps even address the cause that led you to name this problem as Impaired Walking. The same applies to the interventions for your fluid balance problem (Imbalanced Fluid Volume is not an official NANDA diagnosis). Treat the symptoms that are your evidence of this problem.

#3. . .Goals are always what you predict are going to happen as a result of the performance of the nursing interventions you will order.

My fault, sorry. I still work from the 2007-2008 taxonomy. I see the Impaired Walking, but only Risk for Imbalanced Fluid Volume is in the new 2009-2011 taxonomy. I don't like using the new taxonomy because it is not alphabetized and its hard for me to find these newer diagnoses. Just make sure your nursing interventions treat the symptoms and you will be OK.