Help with my care plan

[meja]

I need some major help!!! I'm writing my first care plan and I'm sort of lost. I'm thinking Risk for injury related to loss of sensation in lower extremities. I don't know what my interventions should be. I'm totally lost with this whole care plan deal. This is a satisfactory/unsatisfactory care plan so we aren't getting much guidance for this. I'm looking for any help!!

Thanks!

[amy323red]

Did you choose this diagnosis? anyway, I'm LPN to RN student. Heavy on the care plans. Is the pt going home or LTC facility? Is loss of sensation R/T diabetes? are they mobile? is loss of sensation in feet also? if so you could do some of same teaching and interventions for diabetic foot care. well fitting shoes, inspect daily for cuts, etc., do they live alone or have caregiver. really need to taylor plan to pt situation. there are good care plan info in decent med surg books and there are care plan books as well and some websites.

[meja]

The loss of sensation is related to peripheral neuropathy. She's in a hospital rehab setting right now.

Thanks for your help. I'm having a mental block and I can't seem to get through it. Grrr!!

[Daytonite, BSN, RN]

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans for information on construction of care plans. a care plan is a collection of the patient's nursing problems and strategies to do something about them. to determine what the nursing problems are a thorough assessment must be done first to determine what is abnormal about their health status. from that abnormal data the nursing diagnoses are determined. nursing interventions, or treatments, are done for those abnormal things.

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
  

the only information you have supplied, and it is really kind of vague, is that the patient has a loss of sensation in the lower extremities. what does that mean? this is an actual abnormal piece of assessment data. there is a nursing diagnosis for it: disturbed sensory perception, specify [visual, auditory, olfactory, tactile, kinesthetic, gustatory]. because you have supplied no history about the patient i cannot give a related factor for the diagnostic statement.

"risk for" diagnoses are anticipated problems (nursing problems that do not yet exist). they are sequenced last on the list of patient problems with actual patient problems being listed before them. interventions for "risk for" diagnoses are limited to:

• strategies to prevent the problem from happening in the first place
  
• monitoring for the specific signs and symptoms of this problem
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  

because the patient has an actual loss of sensation in the lower extremities and i would anticipate this affecting their performance of adls, either disturbed sensory perception, specify, some of the self-care deficits or impaired physical mobility are probably more appropriate problems going on that are more important to focus on than risk for injury. look at your assessment of the patient more closely and compare what you can do against what the patient cannot do to help you determine what the nursing problems are here.