I need help with a care plan

Daytonite, BSN, RN · Oct 12, 2009

ineffective health maintance related to depression as evidence by inability to focus and lack of self care needs

i don't think

depression

is an appropriate related factor to use for this diagnosis. it is generally felt to be a medical diagnosis and medical diagnoses are not used in nursing diagnostic statements. if her problem was that she was not taking or was misusing her medications that is a lack of ability to make appropriate judgments and that should be the related factor for this diagnosis. the evidence (aeb) is overdosing and not taking her medications as prescribed. that is what this diagnosis,

ineffective health maintenance

is about--failure to follow the medical plan of care. your interventions should be to assist the patient in following the doctor's orders and any other things that go along with the doctor's plan.

goals are what you predict will happen if your interventions are followed.

tlc2u · Oct 12, 2009

i am not great at writing nursing diagnosis so i can not tell you the exact ones to write. however our instructors taught us that for the nursing diagnosis we had to look at what our patients current concerns are and for the nursing interventions look at what things the nurse was doing or what we as a nursing student were doing to resolve their problem.

all i know about your patient is you stated: the client is bipolar, overdosed on her medication and they are wanting her to go to an alf. the client was very disheveled-(maybe nd of self care deficit for this) and even before the overdose was not taking meds well.

in your nursing diagnosis you stated: nursing diagnosis of "ineffective health maintance r/t (related to) depression aeb (as evidence by) inability to focus and lack of self care needs"

yet you stated her medical diagnosis was bipolar disorder.

ineffective health maintance r/t bipolar disorder-- for some instructors we were not allowed to use the exact medical diagnosis in our nursing diagnosis- we would have to say something like r/t cognitive impairment or something similar. if your instructor says it is ok to use the medical diagnosis, do so, it is easier that way.

ineffective health maintance r/t bipolar disorder (aeb -inability to focus and lack of self care needs?)

aeb as evidenced by should explain what your patient is doing that she is not maintaining her health. she is inneffective with her health maintenance when she is not taking her medication as prescribed and when she overdoses on her meds.

your nursing interventions should reflect that they will aid in improving your patients concerns and aid in improving the problem focused on in your nursing diagnosis. they should also be what actions you took to care for your patient the day you were the student nurse or at least the actions you would have taken if they were scheduled for your shift.

here is a simplified example (not related to your patient) just to get the idea.

ex. impaired skin integrity r/t physical immobilization aeb left hip decubitus ulcer (size, shape, depth etc.)

nursing interventions

1. applied (skin healing treatment) per doctors orders

2. changed bandages (however often) per doctors orders

3. applied wound vac per doctors orders.

4. turned and repositioned patient q2 hrs

5. positioned client with pillows to reduce pressure on left hip

6. provided high protein supplement with meal (if ordered) etc. etc.

2. risk for infection r/t left hip decubitus ulcer (there would be no aeb since this is only a risk for)

what would the nurse do to prevent or detect infection?

1. maintain clean dry dressing.

2. assess for signs of infection (list signs)

3. assess vs (however often per orders) elevated temperature for one thing may indicate infection.

4. manage wound care using clean or sterile technique per orders or hospital protocol.

6. wash hands before and after any patient contact.

7. wash hands before and wear gloves during dressing changes. etc. etc.

since i am not the greatest with nursing diagnosis if anyone else here can add to this i'd love to learn how to write them better as well. i welcome any corrections.

thanks in advance from tlc2u

and to the op (best of luck)