I need help for shelter mom

Nursing Students Student Assist

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Hi all,

I really need help on nursing care plan. Ok I have to write a paper form the interview I conducted and then make nursing care plan. I interview the woman who lives in the shelter. She has two children's that lives with her. This woman has been through a lot from the very young age. She has been abused sexually and mentally from her mom and stepdad. She does not have finical problems she get help from the government. Her Dx are COPD (emphysema), diabetics, and high blood pressure. She said her good BP reading is 174/100. And I ask her what the normal BP is and she does not know. She is obese for her age. She sleeps during day time (6:00am-2:30pm) so defiantly her sleeping patterns are disturbed. And I ask the reason, she is afraid not to wake up in the morning. Plus she hates the environment she lives in. finally I ask that one thing that concerns her. She side she doesn't want to die in that shelter. She side" I know it is coming soon but I do not want to die, I'm only 43" and she cried. This story broke my heart. I really want to help this woman to get out of from this situation.

So I have to come up with 3nursing diagnosis and 3interventions for each diagnosis that is appropriate for this woman. If the instructor likes the care plan she will give to the shelter social workers and use it for this lady. I don't want to do it just to get good grade. I really want to help her.

I did a concept map and most of her situations are tied with stress. So I come up with this nursing diagnosis.

Ineffective coping mechanism.

Sleep disturbance

Risk for nutritional imbalanced

So please help me..

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Specializes in ER, ICU, Medsurg.

How about also addressing her Dx? She prolly has impaired gas exchange from the COPD. She has insufficient knowledge r/t her BP. How about anticipatory grieving? Low self-esteem? How is her knowledge regarding her diabetes? Risk for impaired skin integrity?

As far as interventions, check out RNcentral.com. That is a great site for customizing care plans. Good Luck

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

this sounds like a lady who has a very complicated life with some very serious medical, physical, and psychosocial problems. a care plan is a listing of the person's nursing problems and the plan to do something about them. we use the nursing process as our tool to help us accomplish this:

step 1 assessment - you can see how important the collection of data is now, can't you? look how much you learned from just an interview! but keep in mind as you interact with clients that as nurses we are always thinking about what the person's responses are/have been to what has happened to them medically, and in this case, financially, personally and by society. while part of your assessment is done face-o-face with the client, some of your assessment activity for the writing of this care plan is a learning activity that you must engage in. assessment consists of:

  • a health history (review of systems) - that is what you have been doing while interviewing this lady--collecting information about her health history. she told you she was abused sexually and mentally. how did this affect her in her adult life, i wondered as i read your post. did she ever get counseling for it? does she worry about the effect it might have on her own children? she told you she sleeps during the day and she is afraid not to wake up in the morning. did she say what it was that might cause her not to wake up? she feels her death is coming soon. did she say what is was that was causing her death? she knows her 3 medical problems: copd (emphysema), diabetes and high blood pressure but there are some things she doesn't seem to understand about them. is her emphysema from smoking? does she still smoke? if so, where is she getting the money for cigarettes? what kind of diabetes does she have? is she aware that her obesity contributes to it? where is she eating in order to maintain her obesity? when she stated that she did not know what her normal b/p that was a flag that she had no understanding of the importance of hypertension and diabetes in relation to her health.
  • performing a physical exam - were you able to do any part of an exam other than vital signs and getting a b/p of 174/100
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you know of copd (emphysema), diabetes, high blood pressure and obesity. she also told you she was sexually abused. the copd (emphysema), diabetes and high blood pressure are chronic conditions. you need to look each of them up and learn about them. you can't help this patient if you don't know the recommended treatments and care for theses conditions.
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - i didn't notice any listed.

step #2 determination of the patient's problem(s)/nursing diagnosis - make a list of the abnormal data that was collected that will go forward into the problem solving. you may want to add more after making a more thorough assessment. we've done this before on another post of yours.

  • lives in the shelter
  • she hates the environment she lives in
  • she doesn't want to die in that shelter - "i know it is coming soon but i do not want to die, i'm only 43" and she cried.
  • has two children that live with her
  • was abused sexually and mentally by her mom and stepdad
  • gets help from the government
  • bp reading is 174/100 - i ask her what the normal bp is and she does not know
  • is obese for her age
  • sleeps during day time (6:00am-2:30pm) - she is afraid not to wake up in the morning
  • stress

from this evidence you must determine what your nursing diagnoses are.

  • imbalanced nutrition: more than body requirements r/t excessive intake aeb obese for her age
  • death anxiety r/t perception of closeness of own death aeb fear of dying in her sleep, worry that she doesn't want to die in a shelter, crying over this and her statement that "i know it is coming soon but i do not want to die, i'm only 43".
  • deficient knowledge, disease process emphysema, diabetes and hypertension r/t lack of information aeb unable to know what normal b/p is, worry about dying in her sleep, and obesity. - teaching is something that can be easily done in a shelter setting and there is a lot that she needs to learn to empower her about her illnesses. if she controls her diet, loses some weight, learns some breathing exercises she can keep some of her diseases under control. we can teach her that.

step #3 planning (write measurable goals/outcomes and nursing interventions) - now you can develop the 3 interventions for each diagnosis.

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Thank you so much..

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