Help with Nursing Diagnosis assignment needed

[refreshernurse]

Hi There,

I am new to this site, but I am hoping to find some help with a case study. I am an RN doing a refresher course and it's been so long since I have done a care plan. Now I am doing this distance refresher course and I have to come up with 3 nursing diagnoses and then an immediate, intermediate and long term goal for the patient for each diagnosis. Maybe I am thinking to hard, but I just feel like I am doing it wrong. Any help would be greatly appreciated. Also, the diagnoses must be actual rather than potential.

Ok, here goes:

an 84 y/o female living independently until a recent accident underwent a TKR 2 days ago. since surgery she's been refusing meals. foley still in place on 2nd post-op day and urine draining is concentrated amber. according to the pathway for TKR her foley should have been removed on first post-op day. she is a widow, no children. active in church but worried about going home and living alone.

Assessment info:

*T 99, P 82 and reg, Resp 16 and reg, lungs CTA (height 5'2" wt 175)

* IV of D5W @ 100ml/hr without redness or swelling. She's refusing meals stating, "I don't feel much like eating and this is a good time to get rid of some unwanted pound".

* dsg on knee clean, dry and intact

*she is doing required exercises @ bedside and when transported to PT

*She is reluctant to move about in bed and her elbows and heels are becoming reddened

So I thought the diagnoses might be:

1. Impaired tissue integrity r/t impaired physical mobility AEB reddened areas on bony prominences.

Immediate goal: tissue will remain intact and not progress to stage II for duration of her hospitalization

Intermediate goal: maintain sufficient fluid intake for adequate hydration (2500ml/day)

Long term goal: Pt will be able to verbalize importance of skin care and nutrition in maintaining tissue integrity prior to d/c.

2. nutritional requirements: less than body requirements AEB pt's refusal of meals.

Immediate goal: Pt will begin to eat at least ½ of each meal provided within 24 hours.

Intermediate goal: Pt will be able to describe a plan for making healthy food choices/ meals by d/c

Long term goal: I am having trouble with this one

3. I am having trouble coming up with a 3rd. I feel like I am thinking too hard about this and just freezing up in my head. The goals must be patient centered, measurable, realistic.

Again, thank you for any suggestions you might have for how to think about this or what direction to take.

[avahnel, ASN, RN]

Dursing Dx for knee replacement (from Nursing Care Plans by Gulanick/Myers) are:

1. Acute Pain-the assesment did not mention pain however I would think it would be a consern.

2.Impaired Physical Mobility

3.Risk for Ineffective Tissue Perfusion

4. Deficient Knowege (of disease process, treatment regimen, perscribed activity) hope this helps!!!

You could also have risk of infection to the surgery site

:wink2:

[Daytonite, BSN, RN]

use the steps of the nursing process to help you diagnose:

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

84 y/o female living independently

tkr 2 days ago (as a result of a recent accident?)

medical treatment: iv and foley still in place

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

• been refusing meals
  
• "i don't feel much like eating and this is a good time to get rid of some unwanted pound"
  
• she is reluctant to move about in bed
  
• elbows and heels are becoming reddened
  
• worried about going home and living alone

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -

• delayed surgical recovery r/t trauma and age aeb refusal of meals, reluctance to move and continued need for foley catheter
  
  
• impaired skin integrity r/t immobility and pressure aeb reddened areas on bony prominences of elbows and heels
  
  
• impaired home maintenance r/t injury and surgery aeb verbalized concerns about living alone after discharge home [you might want to make the aeb items a bit more about her specific concerns of how she will accomplish her adls at home]
  
  

regarding the diagnoses you suggested:

1. impaired tissue integrity r/t impaired physical mobility aeb reddened areas on bony prominences.

immediate goal: tissue will remain intact and not progress to stage ii for duration of her hospitalization

intermediate goal: maintain sufficient fluid intake for adequate hydration (2500ml/day)

long term goal: pt will be able to verbalize importance of skin care and nutrition in maintaining tissue integrity prior to d/c.

reddened skin is considered

impaired skin integrity. impaired tissue integrity

is used when the skin has been compromised down to the subcutaneous layer and deeper.

goals are the anticipated results of the interventions you have ordered. goals can sometimes be aimed at obliterating the cause of the problem. interventions specifically target the aeb items (the symptoms of the problem) or sometimes the cause. you are going to order things like positioning her off those reddened areas, massaging them, encouraging movement and fluids. you want to keep goals stated positively, so don't even mention anything about the skin not progressing to stage ii. if you want to maintain sufficient fluid intake for adequate hydration (2500ml/day) then make sure you have an intervention that addresses maintaining fluids intake to at least 2500 ml/day. if you want the patient to be able to verbalize the importance of skin care and nutrition in maintaining skin (not tissue) integrity prior to d/c then make sure you have teaching interventions that address this.

2. nutritional requirements: less than body requirements aeb pt's refusal of meals.

immediate goal: pt will begin to eat at least ½ of each meal provided within 24 hours.

intermediate goal: pt will be able to describe a plan for making healthy food choices/ meals by d/c

long term goal: i am having trouble with this one

i do not feel this is a necessary diagnosis and that the patient's problems with not wanting to eat are a symptom of

delayed surgical recovery

. your goals (and interventions), however, can be included with

delayed surgical recovery

. just make sure that these goals reflect the interventions you are ordering.

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem (it's cause or symptoms)

this post gives you information on how to construct a goal statement:

https://allnurses.com/forums/2509305-post158.html

goals have the following overall effect on the problem:

• improve the problem or remedy/cure it
  
• stabilize it
  
• support its deterioration
  

interventions are of four types:

• assess/monitor/evaluate/observe (to evaluate the patient's condition)
  
  • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
    

  [*]care/perform/provide/assist (performing actual patient care)

  [*]teach/educate/instruct/supervise (educating patient or caregiver)

  [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[Daytonite, BSN, RN]

Dursing Dx for knee replacement (from Nursing Care Plans by Gulanick/Myers) are:

1. Acute Pain-the assesment did not mention pain however I would think it would be a consern.

2.Impaired Physical Mobility

3.Risk for Ineffective Tissue Perfusion

4. Deficient Knowege (of disease process, treatment regimen, perscribed activity) hope this helps!!!

You could also have risk of infection to the surgery site

:wink2:

Here's the problem with care plan books and diagnosing by medical condition and why the nursing process needs to be employed when care planning:

the nursing process will take the uniqueness of the patient's situation into account every time

[refreshernurse]

Daytonite,

Thank you so much for your help! I'm going to sit down with this and I'll think it all through and repost when I come up with my answers. I sure do appreciate you taking the time to help me actually learn!