Looking for some feedback on careplan

[mistiffy]

Ok, bear w/ me, Im still fairly new at this- here's what I've come up with and Im open to suggestions!

I have a 73 year old female pt that has just had a stroke in february, she suffers from senile dementia, dysphagia, and hypertension. She has scartches all over her arms which she said was from her scratching herself because she is nervous and wants to go home. She is oriented to person, but not place or time. She is also pretty confused, she has a hard time answering questions (the speech therapist asked her what things she likes to eat and she said "arms," :nuke:), She is also paralyzed on her rt. side and wears briefs, however she points to the bathroom when she needs to go. she has smoked since she was 14yo, and wanted me to take her out to have a cigarette at least 6 times while I was with her, which was only about 2h (she kept going to all kinds of therapy). She is WC bound and requires assistance with all of her ADL's. She also was very SOB as me and the CNA were getting her up and dresses, and also once when I took her outside, to which she told me she was not out of breath, but it was pretty obvious she was.

NDX 1-Impaired Physical mobility

Intervention 1-perform passive ROM of affected limbs

Intervention 2-teach pt to perform active ROM of unaffected limbs @ least 3 times a day

Intervention 3-Increase independence in ADL's by encouraging self-efficacy & discouraging helplessness as the pt gets stronger

NDX2-Anxiety

Intervention 1-provide backrubs/massages for the pt to decrease anxiety

-for the 3rd NDX I was thinking of using activity intolerance or acute confusion, I think they all could work, but I'm wondering what the BEST 3 would be. Im finding that the most trouble Im having is with the interventions and outcomes, any tips? Oh, by the way, in level one we are not required to do the r/t AEB so that's why I didn't include it, in case anyone was wonderin, lol.

[ladyinred667]

I don't have a book open in front of me or anything, but off the top of my head you might want to consider something related to breathing like Impaired Gas Exchange.

What you have so far sounds good to me. Make sure that your interventions are what the nurse will do and your goals are what the patient will do.

[casi, ASN, RN]

It looks like there are tons of diagnosises and interventions you could do with her. What about risk for injury r/t dementia and physical mobility. It might work well for her since I'm sure her anxiety is related to the confusion.

With confusion and risk of injury there are tons of things you could do for interventions

injury:

Have staff monitor pt. when smoking.

Keep room clean and clear of clutter.

Use a tabs alarm.

Do comfort checks and toileting every 2 hours.

Things that would keep her safe. If she is someone who may get confused and try to get up on her own and fall address that. If she has trouble with smoking address that. If she has bad judgement (i/e wandering outside in the middle of winter in a t-shirt and pants) address that.

For confusion don't look to keep her from being confused, but for things that alievate confusion and make the patient less anxious.

Instruct staff to use validation therapy

Instruct staff to keep a strict routine.

When pt. asks about going home, redirect her to reminise about her past home/s

Reminise with patient

If pt. is a sundowner engage pt in quiet activity during the evening

Keep the pt out of an overstimulating environment.

[Daytonite, BSN, RN]

do you read any of my posts on care plans? i get that you don't have to write out complete 3-part nursing diagnostic statements, but that doesn't relieve you of the responsibility of following the steps of the nursing process to write your care plan. you still have to know what the patient's symptoms are (the aeb stuff) because your outcomes and interventions are based upon them!

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, 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)

this is a list of her symptoms that i came up with as part of step #2 of the nursing process. when you look at them listed this way do you think maybe you missed a few important problems that this patient has?

• very sob as me and the cna were getting her up and dresses
  
• dysphagia
  
• wears briefs (does this mean she is incontinent at times?)
  
• scratches all over her arms from her scratching herself
  
• paralyzed on her right side
  
• wc bound
  
• requires assistance with all of her adl's
  
• not oriented to place or time
  
• pretty confused
  
• the speech therapist asked her what things she likes to eat and she said "arms,"
  
• smoker - altered health maint

first off, there's a whole bunch of symptoms for the nursing diagnosis of anxiety. check the list of defining characteristics for anxiety on this webpage: [color=#3366ff]anxiety. any outcomes and nursing interventions you develop for this anxiety should address her individual symptoms of it. her sob could be a symptom of the anxiety as well as her nervousness.

impaired swallowing [r/t neuromuscular impairment secondary to stroke aeb dysphagia] - focus of outcomes and nursing interventions should be on treating the dysphagia

impaired skin integrity [r/t abrasion forces aeb scratches all over arms] - focus of outcomes and nursing interventions should be on treating the scratches on her arms

impaired physical mobility [r/t neuromuscular impairment secondary to stroke aeb right sided paralysis and wc bound]

bathing/hygiene self-care deficit

dressing/grooming self-care deficit

feeding self-care deficit

toileting self-care deficit

chronic confusion [r/t dementia and cerebrovascular attack aeb disorientation to place and time and altered cognitive impairment]

[mistiffy]

Sorry, it's taken me a little while to post back here, but I just wanted to tell you all thank you for your assistance!!!

Daytonite-I have spent a lot of time reading over your many many many care plan posts and cannot even begin to tell you how much they have helped me! So I just wanted to say THANK YOU!