Help me please!!

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i have to submit a care plan of a 90 yr old female with UTI and vasculitis. she has hx of HTN, cor pulmonae, osteoporosis, arthritis and pressure ulcers on BLE.impaired ROM. Bed ridden. she is on antibiotics & anti HTN drugs with lasix & k+. she has no dypnea. has foley. cultures show G+ bacteria. has poor appetite. not diabetic but has high sugar sometimes. runs high BPand uses NC for sleep apnea. :thnkg:

what would be some of the diagnosis that i can use? thank you

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How about infection, acute pain, risk for ineffective therapuetic regimen management, risk for impaired nutrition.... ummm that's all I can think of right now. Hope it at least helped you start :)

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Specializes in L & D, Med-Surge, Dialysis.
i have to submit a care plan of a 90 yr old female with UTI and vasculitis. she has hx of HTN, cor pulmonae, osteoporosis, arthritis and pressure ulcers on BLE.impaired ROM. Bed ridden. she is on antibiotics & anti HTN drugs with lasix & k+. she has no dypnea. has foley. cultures show G+ bacteria. has poor appetite. not diabetic but has high sugar sometimes. runs high BPand uses NC for sleep apnea. :thnkg:

what would be some of the diagnosis that i can use? thank you

Hope these will help

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

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Specializes in med/surg, telemetry, IV therapy, mgmt.

what you have posted in a rundown of this patient's medical diagnoses, the results of her medically ordered labs and medical treatments. a nursing care plan is about determining her nursing problems. that requires implementing the steps of the nursing process. the medical information you have is incorporated into that, but it is not enough which is why you are not coming up with the nursing problems, the names for them called nursing diagnoses. to do that there are some assessments that you need to consider that you have not included in all this data you have posted:

  • your physical exam of this patient - all you the information you included was that she runs a high bp, sometimes has high sugar, has a poor appetite and has impaired rom. it's not specific enough. physical exam information, especially when it is physiological, needs to be measurable. it gets important later when goal and evaluation issues come up. this lady has a uti and vasculitis. there is no assessment of these conditions. she's bedridden and there is no skin assessment. she has impaired rom and there is no specific description of the deficits. the arthritis has a part in this. is she in pain? the htn and cor pulmonale are related + she has sleep apnea. there is no pulmonary assessment. she has a serious heart condition, is on antihypertensives and a powerful diuretic and i don't see a cardiovascular assessment. does she have any edema--anywhere?
  • your assessment of her ability to perform her adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) -just how much do the nurses have to do for her? how much can she do for herself? if she was left in the bed and no one did anything for her, could she live for very long?
  • reviewing the pathophysiology, signs and symptoms and complications of her medical diseases/conditions -primarily you need to look up the uti and vasculitis if that is why she was admitted. the pathophysiologies of these conditions are needed for the etiologies ("related to" part) of some of your nursing diagnostic statements.
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that she is taking - she's on lasix which is a diuretic and potassium which is given for replacement of this electrolyte. lasix causes losses of potassium. what other meds is she on? they can give you other clues as to what is going on medically with her. side effects of medications need to be considered as well. we help patients deal with some of the side effects of medications--that's a very nursing thing that we do. she has a foley. there are potential complications to having a foley catheter. care for a catheter needs to be care planned for under a nursing diagnosis. there are also side effects to the atbs she is on. are they being given iv? why would she be on iv fluids? cultures were positive--were these urine cultures or blood cultures? it makes a difference. a positive blood culture means the infection is septic and we have a nursing diagnosis to cover the potential symptoms for that.

from that information you are looking for the data that is abnormal. it is the abnormal stuff that forms the foundation of any nursing problems (they form the foundation of medical diagnoses as well which is how doctors find medical disease--a&p that has gone wrong). once you have a list of this abnormal data, then you look for nursing diagnoses that match them. every nursing diagnosis has sets of defining characteristics (signs and symptoms) just as every medical diagnosis does. there is no guesswork to diagnosing. it is all sound and logical reasoning.

i can't help you any further from this point until you post more specific and customized data about this patient. see some of the posts on https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans for how i use the nursing process to diagnosis when you get more specific information together.

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