I have an EXTREMELY picky instructor who teaches my ASN class as an MSN course (she just graduated and we are her first class to teach).
With this being said, I am TERRIFIED to turn in my nursing plan of care which was a group assignment - my entire group has this mutual feeling.
My teammates and I chose "Acute confusion r/t acoholism as evidence by pacing, wringing of hands, disoriented x3, hallucinations, inattentiveness, denial of alcohol abuse, and beer bottles throughout apartment"
Here is the scenerio:
David Micheals lives in an urban senior citizens' apartment complex. He is a 60 year old widower and retired military man with two adult sons whom he says rarely visit. He has been referred to your hospital-based home care unit for follow-up after inpatient treatment from acute pancreatitis. He has been hospitalized three times in 6mons for this diagnosis and denies excessive alcohol use. He says, "I have a few beers every now and then, nothing I cannot handle." You have seen Mr. Micheals on a weekly basis for the past month. He has stated he doesn't know any of his neighbors and never sees his boys. "They never come to see me anymore." He is pleasant, cooperative, and oriented when you see him and always thinks you for coming to visit. His two-room apartment is usually untidy, but clean, with dishes and glasses in the sink and several plastic trash bags in the kitchen. Today, when you arrive, Robert, his oldest son, is present and looks angry when you introduce yourself. He tells you Mr. Micheals has always been a drinker, but in the past year or so things have gotten out of hand. "We don't let our kids come over here; we never know what he'll be like. I've tried to get him help, but he won't listen to me. I can't take it anymore." Mr. Micheals is in his bedroom, yelling at and calling for David. When you enter the room, he is pacing, wringing his hands, and is unable to identify you. He is disoriented to place and time and tell yous "don't step on them bugs" pointing to the patterned rug. He is inattentive when you ask questions about his condition and continues to pace. There are numerous empty beer bottles throughout his apartment. Mr. Michea;s becomes increasingly agitated and his son abruptly leaves. After checking his vital signs you notify his physician and arrangements are made to transport him to the hospital. Mr. Micheals is seen in the ER and is admitted to the psychiatric unit for detoxification and treatment.
*** I have attached our classes care plan instructions and my groups care plan
As for the assessment information, (instructor likes using arrows) how do you determine ALL the subjective and objective data. Increased uncleanliness would include is untidy apartment with beer bottles everywhere. For decreased orientation would I need to include (x2) for place and time?
Subj: no alcohol abuse, ↑ hallucinations, ↑ agitiation, ↓ social interaction.
Subjective data comes from the subject (the patient). It is what the patient tells you. Objective data is what you observe.
In my opinion, subjective data would include: denies excessive alcohol use; does not interact with neighbors; infrequent contact with his sons; does not visit with his grandchildren; visual hallucinations.
Information from the patient's family can also be considered subjective: pt's oldest son reported the patient having "always been a drinker", but in the "past year or so things have gotten out of hand"; does not allow his children to visit with the patient; offered assistance to the patient, but the patient refused.
Objective: Hospitalized 3 times in 6 months for acute pancreatitis; pleasant mood; cooperative; oriented; appreciative of visit; disorganized but clean living area; pacing; wringing his hands; unable to identify you; disoriented x2; inattentive; agitation increased after the abrupt departure of son; empty beer bottles throughout the apartment.
Remember that a nursing diagnosis cannot be a medical diagnosis! "Alcoholism" is a medical diagnosis, so if you want to use it, only use it as "secondary to" (e.g., "_____ r/t _____ secondary to alcoholism AEB _______"). Your instructor may or may not accept this, but I know mine wouldn't.
So for the NDX you chose, I would say "related to chemical intoxication of alcohol" - that's a NANDA-approved related factor, and still is relevant to alcoholism. My instructor is very anal and detail-oriented, so she would want very specific terms and complete sentences for every part of that care plan. If you get full points on yours, then your instructor grades very easily because that would be chewed up and spit out from mine!
I copy/pasted the case study, with the S/O data bolded for emphasis:
David Micheals lives in an urban senior citizens' apartment complex. He is a 60 year old widower and retired military man with two adult sons whom he says rarely visit. He has been referred to your hospital-based home care unit for follow-up after inpatient treatment from acute pancreatitis. He has been hospitalized three times in 6mons for this diagnosis and denies excessive alcohol use. He says, "I have a few beers every now and then, nothing I cannot handle." You have seen Mr. Micheals on a weekly basis for the past month. He has stated he doesn't know any of his neighbors and never sees his boys. "They never come to see me anymore."
He is pleasant, cooperative, and oriented when you see him and always thinks you for coming to visit. His two-room apartment is usually untidy, but clean, with dishes and glasses in the sink and several plastic trash bags in the kitchen.
Today, when you arrive, Robert, his oldest son, is present and looks angry when you introduce yourself. He tells you Mr. Micheals has always been a drinker, but in the past year or so things have gotten out of hand. "We don't let our kids come over here; we never know what he'll be like. I've tried to get him help, but he won't listen to me. I can't take it anymore." Mr. Micheals is in his bedroom, yelling at and calling for David.
When you enter the room, he is pacing, wringing his hands, and is unable to identify you. He is disoriented to place and time and tells you "don't step on them bugs" pointing to the patterned rug. He is inattentive when you ask questions about his condition and continues to pace. There are numerous empty beer bottles throughout his apartment. Mr. Micheals becomes increasingly agitated and his son abruptly leaves. After checking his vital signs you notify his physician and arrangements are made to transport him to the hospital. Mr. Micheals is seen in the ER and is admitted to the psychiatric unit for detoxification and treatment.
acerbia
54 Posts
Subjective data comes from the subject (the patient). It is what the patient tells you. Objective data is what you observe.
In my opinion, subjective data would include: denies excessive alcohol use; does not interact with neighbors; infrequent contact with his sons; does not visit with his grandchildren; visual hallucinations.
Information from the patient's family can also be considered subjective: pt's oldest son reported the patient having "always been a drinker", but in the "past year or so things have gotten out of hand"; does not allow his children to visit with the patient; offered assistance to the patient, but the patient refused.
Objective: Hospitalized 3 times in 6 months for acute pancreatitis; pleasant mood; cooperative; oriented; appreciative of visit; disorganized but clean living area; pacing; wringing his hands; unable to identify you; disoriented x2; inattentive; agitation increased after the abrupt departure of son; empty beer bottles throughout the apartment.
Remember that a nursing diagnosis cannot be a medical diagnosis! "Alcoholism" is a medical diagnosis, so if you want to use it, only use it as "secondary to" (e.g., "_____ r/t _____ secondary to alcoholism AEB _______"). Your instructor may or may not accept this, but I know mine wouldn't.
So for the NDX you chose, I would say "related to chemical intoxication of alcohol" - that's a NANDA-approved related factor, and still is relevant to alcoholism. My instructor is very anal and detail-oriented, so she would want very specific terms and complete sentences for every part of that care plan. If you get full points on yours, then your instructor grades very easily because that would be chewed up and spit out from mine!
I copy/pasted the case study, with the S/O data bolded for emphasis: