Help With Nursing Care Plan


I am having a lot of trouble figuring out a diagnosis for my patient.

Here is her assessment:

Mrs. H, an 85 year old woman who lives in a nursing home.

Diagnosed with dementia, hypertension, depression, continence in bowels, requires the use of bladder pads, hearing aids in both ears, ambulates well with the assistance of a walker, skin intact, cognitive problems. Requires the use of laxatives and analgesics, antihypertensive medication, urinary incontinence once per day or less. Stress incontinence - leakage with cough, drops.

Experiences some dizziness and light-headedness

Temp 37 degrees C, pulse 62 bpm, respirations 18/min, BP 119/70, oximetry 94%, weight 152 lbs

Stage 2/7 depression - exhibits behaviors but participates in activities.

Cognitive performance 2/6 - mild impairment

Mental - slight reduction of mental function with ocassional brief periods of confusion.

Change in care needs - deteriorated as of 90 days ago.

She does not have Alzheimers, only dementia.

I her chart it says that she has decreasing cognitive function. However, she is able to hold a conversation and she can do everything herself (feeding, bathing, bathroom). She requires aid with perineal care.

My first diagnosis is "Stress urinary incontinence related to weak pelvic floor muscles". Should I add anything in my diagnosis about the use of incontinence pads?

What about adding "secondary to the processes of aging" after my diagnosis?

Short term: provide peri-care after toileting

Long term: maintain perineal skin integrity

My interventions would include: monitoring urinary elimination, observe skin moisture, coolour and temperature,

Some of my ideas for her second diagnosis is "Toileting self-care deficit related to cognitive deficits".

OR: "Toileting self-care deficit related to aging process"

OR: "Cognitive impairment related to disease process"

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

Random thoughts:

When you are stuck thinking of a nursing diagnosis, it's helpful to think about what nursing this patient needs. Does she need help with peri care? Why? What else would you monitor? Damp underwear or clothing? Odor?

Is it really stress incontinence? Have you assessed for the difference betw that, overflow incont, and reflex incont by looking at the defining characteristics in the NANDA-I 2012-2014?

Does she have a toileting self-care deficit, really? How do you know? Why does that happen? What might you do to compensate for that?

Think of your nsg dx in the form of, "I think my patient has ______________. This is because I see _____,________, and _______ (these are the dread "as evidenced by"). She has this problem because she has ____________. (that's the "related to") " That will help you formulate your plan of care and reassessment for that problem.


3 Posts

According to my patients chart she has had:

Change in care needs - deteriorated as of 90 days ago

Mental - slight reduction of mental function with occasional brief periods of confusion

Cognitive performance - 2/6 mild impairment

Independent in most ADL, requires supervision when getting set up for the day. Requires intermittent assistance with incontinent bladder pads.

She has intact skin and continent bowels.

She has dementia, hypertension and depression.

My diagnosis is: Cognitive impairment related to disease process as evidence by brief periods of confusion

Is this nursing diagnosis appropriate considering the assessments that were made?

Is my diagnosis properly worded?

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

However, just having the list like that will NOT be enough. You need the real book, NANDA-I 2012-2014 is the current edition, free two-day shipping from Amazon. Why? Because you will need the defining characteristics to make the diagnosis, and they are given in the book. This is THE definitive book on nursing diagnosis. Surprise the heck out of your faculty by having it and using it like a pro, even though they forgot to put it on your bookstore list.

You do know that nursing diagnoses are not dependent on medical ones, and you, the nursing clinician, need to assess for defining characteristics in order to make your nursing diagnosis, right? Guessing and then trying to cram the available facts into a sexy-sounding one (like the one you pulled out of the air) will not cut it.


566 Posts

IMHO due to her dementia, her increase in care needs, urinary and stress incontinence etc I would focus my diagnosis more on the risks for skin breakdown.

Esme12, ASN, BSN, RN

4 Articles; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience.

Welcome to AN! The largest online nursing community!

What nursing diagnosis book is your school using. These are not NANDA approved diagnosis. You need to have a nursing care plan or diagnosis book first before you can develop a care plan. Then the NANDA diagnosis have certain "characteristics" that your patient must fit into. Is this a real patient?

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 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.

pdf.gif 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