how to make nursing care plan (nanda)

[tucker2008]

help! help! help! hoping someone will help me.

My teacher hand us a case study and NCP form and i dont know how to start a nursing care plan using nanda approved nursing diagnoses. this is the case study. and at the bottom NCP form.

Mary is doing a clinical rotation in anursing home. This morning, part of his assignment is to care for Mrs. York, a newly admitted, 82 yrs old pt.

Mrs. York came to the skilled nursing home facility after a short hospitalizationfor malnutrition. She is a retired piano teacher who has been living independently since her husband's death 10 yrs. ago. Three months ago, after her bout with "flu," her appetite and strength diminished. She lost 20 Lbs., w/c led to her hospitalization.

Mrs. York has three sons who visit regularly and are supportive of her returning to her home when her strength improves and her nutritional intake is stable. She is a pleasant woman who is cooperative and agreeable with the current plan for her recovery. Her sons describe her as extremely sociable; she enjoys numerous activities and interactions with others. The nurse, however, have observed her interacting very little with other residents and spending much time in he room alone. When aked about this apparent change in her socialization pattern, Mrs. York says she just doesn't want to bother people by asking them tp repeat things she can't hear. She is very hard of hearing. She admits that her hearing has gotten worse since the flu and that she should have it checked. However, she assumed she would have wait until she got home to make an appointment with an ear specialist.

Mrs. York is alert and oriented. her medical diagnoses are Osteoarthritis and Malnutrition. Her current medications are ibuprofen 200 mg qid and multivitamins 1 qd. She wears glasses for reading and has her own teeth. Her vital signs this morning were: B/P= 106/78; Pulse= 76; Respiration= 18; Temp= 98.7F. She has no edema or shortness of breath and no history of smoking or alcohol abuse. Her present weight was 95 lbs. with a height of 5'4", her ideal body weight is 120 lbs +- 10%. Before the flu, her weight was 112 lbs. Although she gained 3 lbs. since arriving at the nursing home, her appitite is still poor to fair. She consumes 50% to 75% of meals. She is continent of bowel and bladder and denies problems with constipation. She had a lot of diarrhea during the "flu" and for 1 week thereafter. Mrs. York continues to experience decreased strength and stamina since the flu. but is improving with physical therapy five times per week and increased food intake. Her gait is unsteady and her balance is poor during transfer from wheelchair to bed. She is able to bathe and dress herself with moderate assistance. Her skin is intact but fragile.

This is the NCP form.

Patient's Problem:

Nursing Diagnosis:

Goals/outcomes:

Inervention:

Evaluation: