Help with nursing diagnosis!!

Esme12, ASN, BSN, RN · Mar 29, 2012

I am trying to find a diagnosis for a 79 yr old patient that refuses to accept that her physical condition is declining and that she needs help at home with her ADLs. She was admitted for severe dehydration primarily but she is covered in bruises from falls and she has an already healing shoulder fx. She doesn't want to bother anyone and her neighbor helps her out by shopping and getting her mail. She has limited mobility but gets around with a walker. I believe that her realizing that she needs a little help and admitting it would be a huge step forward for safety sake. How do I get a nursing diagnosis for this? Defensive coping, ineffective denial? Any help would be so much appreciated...Thanks,RN student Megan

Why is she so dehydrated? Does she have family? What are the comorbidities? Does she need a social service consult? It's hard for the elderly to admit they are losing their independence. I know I wouldn't like it at all.

What do you think? Is she in denial? Is she confused? Is she unable to manage to manage her health maintenance? Does she have impaired home maintenance? Is she depressed ? Feelings of hopelessness? Deficient knowledge about how to deal with her situation?

What does your assessment show? Does she need a PT/OT eval? Is she non-compliant? or just fiercely independent.

Meganmomtotwo · Mar 30, 2012

She was not feeling well for a few days and most not have ate or really drank in days. She is a stage III renal disease, cirrhosis and was admitted with hyperkalemia and hyponatremia and put on IV. She seems to be very cooperative but sticks with the statement that she doesnt need help and doesn't want to be a bother. She has no children and a helpful neighbor that does help her on occasion.

Esme12, ASN, BSN, RN · Mar 30, 2012

I would think maybe she has a skewed perception of her diagnosis and disease process. whart care plan book do you have?

NANDA1 describes ineffective coping as...

NANDA-I Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

So does she have ineffective coping R/T..........AEB the dehydration and/falls and refusing services? Does she have any common related factors? as......

High degree of threat

Disturbance in pattern of appraisal of threat

Inadequate support system

Inadequate available resources

with...Defining Characteristics as

Inability to ask for help

Lack of goal-directed behavior

Inadequate problem solving

Poor concentration

Fatigue

Destructive behavior toward self

Inappropriate use of defense mechanisms

High illness rate

or......Ineffective Health Maintenance as described by NANDA

NANDA-I Definition: Inability to identify, manage, and/or seek help to maintain health

with common related factors.....

Perceptual/cognitive impairment

Presence of physical disabilities or challenges

Presence of adverse personal habits:

Poor diet selection
Poor hygiene

Low income/lack of material resources

Lack of knowledge

Ineffective coping

Lack of support systems

Denial of need to change current habits

Defining Characteristics

Behavioral characteristics:

Demonstrated lack of knowledge
Failure to keep appointments
Failure to recognize or respond to important symptoms reflective of changing health state

Physical characteristics:

Body or mouth odor
Unusual skin color, pallor
Poor hygiene
Soiled clothing
Frequent infections (e.g., upper respiratory infection, urinary tract infection

or.......Impaired Home Maintenance as defined

NANDA-I Definition: Inability to independently maintain a safe growth-promoting immediate environment with Related Factors as

Cognitive, perceptual, or emotional disturbance

Low income

Inadequate or absent support systems

Lack of knowledge

with defining characteristicsa as..

Poor personal habits:

Soiled clothing
Frequent illness
Weight loss
Body odor
Poor fiscal management
Home visits reveal unsafe home environment or lack of basic hygiene measures (e.g., presence of vermin in the home, accumulation of waste, home in poor repair_

or.......Powerlessness

NANDA-I Definition: Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening

with commone related facotrs as.......

Acute or chronic illness

Dependence on others for activities of daily living

Inability to perform role responsibilities

Progressive debilitating disease

Terminal prognosis

Loss of control over life decisions

with defining characteristics as

Nonparticipation in care or decision making when opportunities are provided

Reluctance to express true feelings

Diminished patient-initiated interaction

Passivity, submissiveness, apathy

Withdrawal, depression

Feeling of hopelessness

Decreased participation in activities of daily living

Gulanick: Nursing Care Plans, 7th Edition

This should be more than a great lead for you.

Meganmomtotwo · Mar 30, 2012

Thank you so much for your help...

Esme12, ASN, BSN, RN · Mar 30, 2012

You're welcome!

LadyinScrubs, ASN, RN · Mar 30, 2012

Esme12, I like the Powerless NDX. The fact is this client values her independence. She lives by herself but continues to experience problems that will put her at risk for other problems. The original poster did not provide the client's age, but many independent elderly fear being dependent. If social services were to conduct an in home assessment, the result may reveal that she needs help and/or a conservator. This would be devastating to someone who is indepedent. If she does not have the funds to hire help or for some other reason a caretaker could not be obtained, the state will come in, liquidate her home and possessions, and place her in a long term facility--all without her permission because she would be under conservatorship. I doubt that the client is unaware of this possibility and is probably terrified of leaving her home, losing her possessions, and independence. Powerless would be appropriate for this client. Hospice is an option; while care if is free, a caregiver is not.

nurseprnRN, BSN, RN · Mar 30, 2012

you know what i think? i think that this lady has lived her life and knows perfectly well that she is nearing the end of it, and is not afraid of that. this is often impossible for younger people to understand, but just wait until you have seen your grandparents, parents, and contemporaries begin to leave this earth; i promise you that you will begin to consider how that works and feels. i think the nursing plan of care would serve her much better by working with her, not by trying to change her mind.

she likely meets criteria for hospice at this point. speak frankly; ask what she understands about her medical condition and what can be done to make her more comfortable. i'll bet she knows exactly how ill she is, and that she is not at all likely to improve much.

explain to her that there is such a thing as a nursing service that will help her manage her symptoms at no charge, it's called hospice, and that she doesn't have to have cancer to have the medicare hospice benefit (common misconception). tell her there is no charge to her for an aide to come by every day and help her out for an hour or so (she may be very worried about money) and that no one will do anything that she, herself, does not approve.

tell her there is no bother involved, it's strictly to help her be safer and more comfortable in her own home, at no charge to her. tell her hospice doesn't mean giving up hope, and that sometimes when we cannot hope for cure, we can hope for comfort. ask if she'd like to talk to someone about how this would work for her situation. have the phone number handy, and call for the nurse liaison to come in and speak with her asap-- certainly before they plop her into a snf against her will (and although we know people can refuse care, elders get coerced into this every day). you will sleep better at night, and so will she.

moonriseRN · Mar 30, 2012

I agree completely. More investigation is needed. She probably does know how ill she is but also wants to die with dignity (maybe in her own home for example). Many people choose to live in their home to the end and there are definitely programs such as the hospice benefit that has been mentioned and that can be given to home visits (if i'm not mistaken) as well.

inforthelonghaul · Mar 31, 2012

Can I ask what class this is for and how far it happens to be in your program. I was just accepted into the nursing program at my school and I'm trying to gain som insight as to what I'm really headded for. Thanks so much.