HELP!!!!! Care Plan

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I am new to this site, so I hope this works. I really could use some help. I am in LPN nursing school and I have 10 wks til graduation. Unfortunately, I am not the best at Care Plans and we have to do a big one now. I hope it is not too late to write this, the CP is due tomorrow. I have to have 4 Nsg Dx with 4 interventions/4 rationales/4 expected outcomes. I have one already. Impaired mobility r/t dysequilibrium AEB unsteady gait. I was thinking of using Disturbed Sensory Perception r/t CVA AEB A&O x1. But, after reading some posts on here, I think I may be misusing that dx. Hx of falls, CVA, Brain Tumor, HTN, anemia...any HELP???

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Specializes in LTC, rehab, medical review.

Judging from the hx of this pt, I am guessing that they have some neurological impairments as well (A&Ox1). Do you have a care plan/nursing diagnosis book? I graduate in 3 weeks and my book has helped me IMMENSLY in school!!:D Congrats to you graduating soon, too!!! Ok, so here are a few that I think may apply to your pt (just judging from the neurological impairment factor), that are on the Nanda list.

Risk for falls

Self-care deficit (specify level): feeding, bathing/hygiene, dressing/ grooming, toileting

Confusion (chronic)

Risk for injury

Risk for impaired skin integrity (if this pt is in a wheelchair a lot or bed...whatever :coollook:)

Does this pt have any constipation issues d/t immobility? Any incontinance issues d/t mental status?

These are just a few...I hope this helps you! Good luck!!!:up:

Missy

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I do have a care plan book...but as far as I am concerned it STINKS!!! ha ha It is very generic and does not really help all that much. Maybe I should look into getting your book. :up: I like the confusion (chronic) A LOT. That is much better than the sensory perception that I had. Pt seems to have no issues w/ elimination. She has a foley, so no prob there. She acutally sits up to the bedside and takes a little bath all by herself. So, mental she is there...but she's not there. Does that make sense? I think confusion might be the way to go. Do you think that risk for falls is better than impaired mobility? I read somewhere that actual is better than risk. I did have risk for fall first, then switched it after reading something on here.

This helped me so much...you have NO idea!!! Thank you!!!!!!!!!:yeah:

Congrats on your School graduation as well. Good luck with everything,

Rachel

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Specializes in LTC, rehab, medical review.

No problem with the help! The book I have is Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationals by Marilynn Doenges. I think it's the book I have used the most next to my Drug book :):).

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Specializes in LTC, rehab, medical review.

I would think that actualy is better than risk for, I have not heard that personally, but it makes sense! She has a foley, you say? Risk for infection is BIG with foleys :):) I know it's another risk diagnosis, but with foleys I think that is a very relivant one!

Missy

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I just looked the book up online. It looks great! My book is by the same authors, but it just simply called: Nursing Care Plans. It is very generic and not a lot of help to me. Thanks a million again!!

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I did Risk for Infection already with her. She has big gaping open wounds on her arms from falling in ALF. this is what I have done so far...

1. Risk for Infection R/T open wounds on arms

2. Confusion (chronic) r/t CVA w/ Brain tumor AEB A&O x1

3. Impaired mobility r/t dysequlibrium AEB unsteady gait

4. Impaired skin integrity r/t anemia AEB open wounds on arms

Do these work? I HATE care planning :no: I know it is part of my future, especially if I go on to be an RN. Most of the hospitals these days do computer generated CP. The more I do them...the better I will get at them. In the mean time, I need help. lol

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i didn't see your post until now. it's unfortunate that you posted this the day before this care plan was due. i answer care plan questions all the time on allnurses, but only check the questions on this forum each morning. i see you are new to allnurses. there is a sticky thread (always stays at the top of the thread listings) on the general nursing student discussion forum that has a lot of information on how to construct a care plan and specifically on how to diagnose which you might want to look at: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

i put together the information from your 4 posts about this patient that you have listed. i am not sure if you have run across any of my care plan postings. i suspect not or you would have posted your question on the nursing student assistant forum where i mostly post. i want you to know that i am an rn who started out many years ago writing care plans for residents of nursing homes. there is a technique to writing care plans and there is nothing magic or secretive about it. it involves using the nursing process. many of the writers of those care plan books are nursing instructors. if people take the time to read the introductions and beginning chapters of them the nursing process is mentioned and given a lot of credit.

let me show you how the nursing process works for you. in looking at the information you supplied, i still believe there is some more information about this patient that you have not revealed. you also need time to become more experienced in assessing patients. a care plan is based upon abnormal information that is collected about the patient. we don't concern ourselves with the normal information because what is normal isn't a problem. we are looking for problems. your care plan will be 4 nursing diagnoses, or 4 nursing problems, that must have evidence to support that they exist. that evidence will be abnormal assessment data. that is how we recognize that something isn't right and that there is a problem.

step 1 assessment - assessment consists of:

  • a health history (review of systems) - patient had a cva, brain tumor, htn, anemia, a history of falling and you also mentioned there are open wounds on their arms from a fall.
  • performing a physical exam - the only physical assessment data that i could find in your postings was that she has an unsteady gait, actually sits up at the bedside and takes a little bath all by herself, mentally she is there...but she's not there, and that there are big gaping open wounds on her arms which need to be described much more specifically with measurements, and description of the wounds including their depth and the presence of any drainage and what it looks like. with a cva a patient should be assessed for confusion and mobility since people who have had cvas generally have paresis or hemaplegia along with mental disturbances, speech and visual problems, swallowing problems, balance problems. a brain tumor causes the same as well as disturbances with thinking and processing of information and behavior. htn is a cardiac problem with manifestations. was there any peripheral edema, facial edema, oliguria, obesity? this falling is a concern. falling occurs for many different reasons: dizziness, loss of balance, inability to sustain weight, cognitive inability to recognize that they can't stand because they will fall. we can't solve the problem adequately until we know the cause of the falling.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - you stated, she actually sits up at the bedside and takes a little bath all by herself, but we are more interested in what she can't do. when i first started care planning i had to think about how i did those 6 adls that are listed as the 6 minimums and then compared how each patient i assessed fell short and what needed to be done to get them up to my standard. the reason a patient is in a nursing home or hospital is because they can't do their adls by themselves. they need some kind of assistance.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to always look up information about the patient's medical disease or condition if you are not familiar with it. the pathophysiology is needed to jog your memory about the physical symptoms the patient has and to get the cause and formulate the related factor (r/t) part, or etiology, of the diagnostic statements of the physiologic nursing diagnoses. you need to look up cva, brain tumor, htn, and anemia.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - a foley catheter is a medical treatment. it caught my eye that you said "so no prob there" in regard to the foley catheter. you couldn't be more wrong. uti, injury to the tissues during insertion, bladder spasms, the possibility of accidental removal are complications of having a foley catheter that need to be considered. what medications were ordered for this patient and what are the side effects of them? some may explain some of the patient's behaviors.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

  • unsteady gait
  • has big gaping open wounds on her arms
  • mentally she is there...but she's not there, disoriented to place and time
  • foley
  • history of falling

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to defining characteristics of nursing diagnoses, decide on the nursing diagnoses to use. every nursing diagnosis has a set of signs and symptoms called defining characteristics. you can find them in recently published care plan books or the appendix of recent editions of taber's cyclopedic medical dictionary. the diagnoses get sequenced according to maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). what will kill the patient fastest gets sequenced first. actual problems are always sequenced before potential (risk for) problems.

  • impaired physical mobility r/t neuromuscular impairment and loss of balance secondary to cva and brain tumor aeb unsteady gait
  • impaired skin integrity r/t trauma aeb [description of wounds on the arms]
  • chronic confusion r/t neurological changes secondary to cva and brain tumor aeb disorientation to place and time (+ symptoms of dementia)
  • risk for infection r/t invasive procedures (foley catheter)
  • risk for falls r/t history of falling, altered mental status, anemia, unsteady gait, impaired balance, and impaired physical mobility

step #3 planning (write measurable goals/outcomes and nursing interventions) - for each nursing diagnosis you determine goals and begin the process of developing nursing interventions aimed at the aebs. we treat the aebs (symptoms) of the problem just as the docs treat symptoms of a medical disease. so, for impaired physical mobility r/t neuromuscular impairment and loss of balance secondary to cva and brain tumor aeb unsteady gait you will develop nursing interventions for the patients unsteady gait. your goals will be what you predict will happen as a result of those interventions. moving on, you will do the same thing for each of the other nursing diagnoses. you see, we are doing our best to solve the problems by doing something about the symptoms that make up the problem.

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

i wanted to address some things in your nursing diagnosis statements. . .

i was thinking of using disturbed sensory perception r/t cva aeb a&o x1

the aeb (as evidenced by) items are proof of the problem. in other words they literally are the evidence of the
disturbed sensory perception.
a&o x1
(alert and oriented to person) the way this is stated is a positive statement and means the patient is oriented to person. it is normal to be oriented to person. for a nursing diagnostic statement aeb items have to be stated as abnormal items, so it should be listed as
disoriented to place and time
.

the sequence of these is incorrect:

1. risk for infection r/t open wounds on arms

2. confusion (chronic) r/t cva w/ brain tumor aeb a&o x1

3. impaired mobility r/t dysequlibrium aeb unsteady gait

4. impaired skin integrity r/t anemia aeb open wounds on arms

it should be:

  1. impaired mobility r/t dysequlibrium aeb unsteady gait [actual physiological need for movement]

  2. impaired skin integrity r/t anemia aeb open wounds on arms [actual safety need]

    • the related factor is incorrect; you cannot use a medical diagnosis as a related factor

[*]confusion (chronic) r/t cva w/ brain tumor aeb a&o x1 [actual safety need]

  • you cannot use medical diagnoses as related factors

[*]risk for infection r/t open wounds on arms [anticipated safety need]

most of the hospitals these days do computer generated cp.

but you still have to know how to put a care plan together. the computer is just a tool to help you save time. you will need to know
what
choices to make on the computer program and
why
you are making them. nurses who are skilled at writing care plans provide the data that goes into those computer generated cps.

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Thank you for replying. Yes, I waited too late to post this. But, it was a last minute thing. I have certainly learned a lot from all your knowledge. I am very appreciative! You really did not say too many positives of anything I said, so that is not very comforting. I did not give all the "information" about the client, because no further information was asked for. A lot of times the charts I have, are incomplete. There is not 100% of needed information. We do not get time with our pts before we write our care plans. So we have to make our best judgements using the chart only. It is hard to know all the details you are talking about without ever seeing/meeting the pt. I really am doing the best I can. I will definitely keep your reply around for future use. Thank you again for writing me back!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you are doing these care plans from charted information only? in that case, really scrutinize the chart for data. you need to see post #23 of this thread: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html. it lists the important information in the chart you need to look at and collect information from. also, looking on sites like the merck manual will give you the pathophysiology and the signs and symptoms of the patient's medical disease/condition. i listed a whole bunch of helpful websites on this thread that you might want to bookmark: https://allnurses.com/nursing-student-assistance/medical-disease-information-258109.html - medical disease information/treatment/procedures/test reference websites

it was not my intention to make my post sound negative. i could tell from what you had posted that you needed major help with this care plan. do not feel badly about this. you are not alone. many students and those learning care planning are in the same boat. i was. i didn't get this care planning business until i had been doing it for some time. at some point a light bulb suddenly turned on in my brain. because i have the time to do it i will reply to each student that wants the help with care plans and is willing to learn. you will find probably hundreds of my posts now on allnurses where i have endeavored to explain how diagnosing is done. it all starts with assessment. and those 5 things that i bulleted under assessment encompass a lot. and whether someone is an lpn or rn we are always looking for that information. i worked in nursing homes with some fine lpns who were charge nurses as well as in acute hospitals and you lpns do just as much assessment as we rns did. the difference is that when it came to make decisions and calling mds it is often rns that have to do that in the acute hospitals. lpns are making calls to the docs in nursing homes though, so you guys are assessing those residents in the nursing homes and diagnosing their nursing problems. keep in mind that any skill takes practice and experience. remember what it took for you to learn to tie your shoelaces, ride a two-wheeler bike, or drive a car. care planning is also a skill. there are little tricks to it that you will learn as you do more of them. assessment skills must be honed. signs and symptoms of different medical diseases must be learned. experience with adls and assisting people with them must be acquired. and then there is the matter of learning about nursing diagnoses and how they are written. nursing school is only introducing you to these concepts. over time and with experience you get better at all of this.

if you have to do another nursing care plan and you want help or another opinion about it, post questions about it on the nursing student assistance forum where i will find them (https://allnurses.com/nursing-student-assistance/). i look there every morning unless i am on a little vacation or my doctor sticks my butt in the hospital.

good luck with your last 10 weeks of school.

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