Help with Nursing Care Plan

[sambatth]

Hi everyone,

I am a first semester student and looking after 83 yo female patient in rehabilitation. Recently, she had surgery for fractured ankle (she broke her ankle because she fell). she is non weight bearing. she is incontinence of urine and continence of bowel. she had left CVA 10 yrs ago due to that she has right sided weakness plus expressive aphasia (she understands everything but is unable to expresses herself). she has a husband and a son and her son lives in US. Whenever i start conversation with her she will understands everything but is unable to articulate her thoughts and express them. pt states, "i am sorry, i can't tell you". She is hard of hearing. For ADLs, she is not totally dependent but needs lots of assistance.

I need one physical diagnosis and one psychosocial diagnosis for my care plan:

for physical diagnosis:

1) Risk for fall r/t impaired mobility secondary to CVA

2) Risk for impaired skin integrity r/t urinary incontinece.

3) Impaired physical mobility r/t neuromuscular impairment secondary to CVA aeb inability to walk

Which should i use? which one is my priority

for psychosocial diagnosis:

1) impaired social interaction r/t communication barrier secondary to aphasia aeb inability of client to express herself.

OR social isolation r/t ?

Please help me.

[sambatth]

Please help me someone its due in 2 day

[Esme12, ASN, BSN, RN]

Welcome to AN! The largest online nursing community!

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? Again........TELL ME ABOUT YOUR PATIENT...:) what care plan book do you use.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to 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. From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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: ADPIE

1. 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)
   
2. 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)
   
3. Planning (write measurable goals/outcomes and nursing interventions)
   
4. Implementation (initiate the care plan)
   
5. Evaluation (determine if goals/outcomes have been met)
   

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 the medical disease, a physical condition, a failure 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 goals 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 the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the 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 (interview skills). 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. Although your patient isn't real you do have information available.

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.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

I am willing to help ........So tell me about your patient...... What are the vitals? What is YOUR assessment of the patient? What do the complain of????

What is this patients story......TELL ME ABOUT YOUR PATIENT.

What care plan book do you use? Having a good cage plan book and/or a nursing diagnosis book is essential to do care plans. Here is a list of the NANDA diagnosis provided by VickyRN asst admin.

Nursing Diagnoses 2012 - 2014.pdf‎ (35.7 KB, 3833 views)

Here are some brain sheets made by another contributor Daytonite (RIP) for you next care plan.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

[Esme12, ASN, BSN, RN]

83 yo female patient in rehabilitation. Recently, she had surgery for fractured ankle (she broke her ankle because she fell). she is non weight bearing. she is incontinence of urine and continence of bowel. she had left CVA 10 yrs ago due to that she has right sided weakness plus expressive aphasia (she understands everything but is unable to expresses herself). she has a husband and a son and her son lives in US. Whenever i start conversation with her she will understands everything but is unable to articulate her thoughts and express them. pt states, "i am sorry, i can't tell you". She is hard of hearing. For ADLs, she is not totally dependent but needs lots of assistance.

My computer is slow as molasses in winter today......what does this tell me about your patient. What was you assessment? Is her skin intact? Is there any breakdown? Is she non ambulatory from the fall or her CVA? If she is immobile from the CVA...how did she fall? Are there any other co-morbidities?Tell me

Tell me about HER.....does she have pain?What

would be your recipe/plan to care for her for a day?

[sambatth]

Thanks for reply :) I was only with my patient for 2 days (both days few hours).

Here is what i got from her chart:

She had right ankle fracture, right sided weakness with residual aphasia due to stroke. she is non-weight bearing. Fall risk: mod-high

Here is my assessment during time i was with her:

Her vital signs were R 20 shallow, pulse 69, oxygen saturation 97, T 36 degree C, BP 130/58. When i was documenting her vital signs i noticed her BP goes up sometimes (which means she is hypertensive)

First day when i saw her she said that she was in a little pain but the week after (my second day at clinical) she said that she was feeling better.

There was no breakdown of skin however, there was little redness on her bump.

She repond to loud stimuli.

ADLs i gave her full bed-bath, she is unable to do pericare. Transfer with one person, difficulty ambulating and she can feed herself but need assistance with opening food. she use commode for toiletering and is incontinence of urine (wear briefs). She almost participates in everything.

I did ask her how did she fall and she was trying to tell me about it but she was not able to express herself. she lives in banglow with stairs.

I hope it helps.

[sambatth]

yea in addition to that i asked my professor due to her inability to express herself i came up with impaired verbal communication r/t neurological impairement secondary to stroke a.e.b. aphasia.

This is what she replied me:

"Impaired verbal communication is a good start to psychosocial diagnosis, but assess it further: how might that impairment affect the patient's psychosocial world? What potential problems might arise secondary to the impaired communication?"

[Esme12, ASN, BSN, RN]

Do you have a nursing diagnosis and/or NANDA book? Which one do you have? Without a book it is impossible to do a care plan for each diagnosis has it's own definition, risk factors, symptoms (identifying traits).

What you need to do is think....it this were me ....how would this make me feel if I couldn't talk but understood everything. How could you tell someone you are hungry or in pain.........is her elevated B/P a signal of under treated or diagnosed pain? You say she lives in a bungalow....but that now she is not weight bearing......will she be able to go home? Return to her "normal" routine at home? Who will care for her if she goes home? Is she safe? That redness on her "bum" is the beginning of an impairment of the skins integrity. Does this patients incontinence cause a risk for this patient and the integrity of her skin?

If you were this patient what would be the most important to you?

When thinking priority..... think Maslows Hierarchy of Need you prioritize your needs according to Maslow's hierarchy of needs.

Maslow's hierarchy of needs - enotes.com Virginia Henderson's need theory

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

• self-actualization – e.g. morality, creativity, problem solving. least important
  
• esteem – e.g. confidence, self-esteem, achievement, respect.
  
• belongingness – e.g. love, friendship, intimacy, family.
  
• safety – e.g. security of environment, employment, resources, health, property.
  
• physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis. most important
  

assumptions

• Maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.
  

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

• the needs Maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
  
• growth needs are the highest level, which is self-actualization, or the self-fulfillment.
  
• Maslow suggested that only two percent of the people in the world achieve self actualization. e.g. Abraham Lincoln, Thomas Jefferson, Albert Einstein, Eleanor Roosevelt.
  
• self actualized people were reality and problem centered.
  
• they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
  
• they tended to be spontaneous and simple.
  

application in nursing

• Maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.
  

The bottom of the pyramid being the most important and the top being the least important in the matter of survival. so, looking at your diagnosis.....which will be the most important to full fill first. the actual diagnosis then the risk of diagnosis? right? which is then the most important.......remember abc's....airway breathing circulation, first. right?

Tell me what you think.....and I can go from there.

[nurseprnRN, BSN, RN]

Your professor has it spang on. Imagine being in your patient's position, and then think about your professor's thoughts.