help with careplan from "other realm"

PCU RN · Apr 1, 2012

i think i'm going to go with acute confusion.. any thoughts??

Esme12, ASN, BSN, RN · Apr 1, 2012

okay. i am in my second semester of nursing school, and for each clinical week we need 2 care plans.. from 2 different "realms" we are on our 8th week of clinicals for the semester and i am officially stumped.
my patient this week is 82 yrs old, ,female, has a sacral ulcer stage ii, aphasic, hx of cva, she has a dx of depression, and she has dementia
she also has a peg tube which she has pulled out twice! (and the peg tube is due to her aspirating)
so, with all this info i don't really have a problem coming up with a "physical" realm dx.. it's the other one i am having a problem with
when i went into her room to talk with her, she had a very difficult time trying to communicate with me, and was crying the whole time i was in there.
i thought i could do a depression dx, but there isn't one. then i though ineffective coping, but the definition of that dx doesn't seem to fit her. any ideas on what else i could use?
thanks in advance!!
oh! she has also had to have upper extremity restraints put on (r/t) pulling out foley and peg)

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans.

daytonite.

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories.

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

https://allnurses.com/nursing-student-assistance/first-care-plan-689164.html#post6283634

so with your patients information what do you have? do you have a care plan book......you really need one. first....what is the disease process.

what is dementia?

dementia is not merely a problem of memory. it reduces the ability to learn, reason, retain or recall past experience and there is also loss of patterns of thoughts, feelings and activities. additional mental and behavioral problems often affect people who have dementia, and may influence quality of life, caregivers, and the need for institutionalization. as dementia worsens individuals may neglect themselves and may become disinhibited and may become incontinent. (gelder et al. 2005).

depression affects 20–30% of people who have dementia, and about 20% have anxiety.psychosis (often delusions of persecution) and agitation/aggression also often accompany dementia.

dementia - mayoclinic.com

does she have impaired verbal communication? nanda defines this as.....impaired verbal communication

nanda-i definition: decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.

aeb

inability to find, recognize, or understand words difficulty vocalizing words (crying?)

inability to recall familiar words, phrases, or names of known persons, objects, and places

unable to speak dominant language

problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding

is dementia a type of injury to the brain? there

is she chronically confused? nanda defines this as......

chronic confusion

nanda-i definition: an irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior

aeb

alzheimer's disease (dementia of the alzheimer's type)multi infarct dementia

cerebrovascular accident (cva)

or, one of my personal favourites..... :bugeyes:

disturbed energy field

nanda-i definition: disruption of the flow of energy surrounding a person's being that results in a disharmony of the body, mind, or spirit

aeb

maturational age-related developmental crises

age-related developmental difficulties

physiological

illness

fatigue

depleted nutritional state

pain

psychological

anxiety

fear

grieving

pain

stress

depression

spiritual

minimal spiritual nourishment

(i've always wanted to post this one:lol2:)

gulanick: nursing care plans, 7th edition

can she care for herself with the dementia/depression? does she have feelings of hopelessness? is she crying from depression of from a manifestation of the dementia? what are her safety risks? what would be a consideration to be aware of due to her restraints. could her peripheral circulation be impaired due to the restraints?

this should give you a good start. :paw:

SubSippi · Apr 1, 2012

I had a patient that sounds similar to that...two ND that I remember using were disturbed thought process and risk for social isolation. From what you said, ineffective coping sounds appropriate to me. If she's depressed, and then was crying with you, she is obviously not coping well. Could you use something like self care deficit? A lot of time, depression will cause people to quit taking care of themselves, so that might apply to the "other realm."

nurseprnRN, BSN, RN · Apr 2, 2012

i'm thinking you could look in the nanda-i 2012-2014 under perception/cognition, coping/stress, and self-perception. i know she's demented, but who's to say she doesn't retain enough self-awareness to feel lonely, have compromised dignity, fear, grieving, powerlessness, stress overload? poor thing.