My first care plan, need your advice

[futuredream]

Hi everyone!

I know it's not good to ask help doing homework, but this is my first care plan , and i would like to make sure I'm on the right way.

My pt is 96 y.o/f, on wheelchair(not able to walk), with multiple diagnosis ( Depressive disorder unspecified, osteoporosis, history of falls,atheresclerosis, aspiration pneumonia, CHF, and compression Fx T12-L4 with back pain, OA( I am not sure what it is, but suspecting it's some kind of fall due to osteoporosis). Abnormal labs are creatinine high, urea nitrogen high. Needs assistance with ADL.

Mu job is prioritize medical and nursing diagnosis and come up with two nursing interventions(primary, secondary)

I think my prim would be CHF, and secondary would be osteoporosis

My nursing diagnosis are Activity intolerance r/t immobility, and High risk of falls. What do you experienced nurses think?

Thank you very much for taking your time and reading my post. Any of your advice is greatly appreciated.

[Daytonite, BSN, RN]

oa is the abbreviation for osteoarthritis.\

i think your medical diagnoses are probably sequenced correctly although the compression fractures of the back would be important too and are why the patient is unable to ambulate or stand. however, you really haven't provided much physical assessment data for me to determine if your nursing diagnoses are correct. activity intolerance is outright incorrect. the definition of this diagnosis is insufficient physiological or psychological energy to endure or complete required or desired daily activities (page 134, nanda international nursing diagnoses: definitions and classifications 2009-2011). it specifically has to do with respiratory and cardiac systems. dyspnea is one of the outstanding symptoms of this diagnosis and having to stop activities because of the dyspnea and sit down is another symptom. there must also be elevated pulse and respiratory rates. unless this lady is exhibiting these kinds of symptoms then she doesn't have activity intolerance. if there are signs and symptoms of chf which is why it is important to have physical assessment data (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, unexplained confusion or lethargy, fatigue, lower extremity edema due to venous insufficiency and lymphedema, hepatic engorgement and/or ascites, s3 gallop, jugular vein distension, pulsatile liver, rales, pulsus alternans and tachycardia, poor capillary refill, cool distal extremities, altered mental status, non-productive cough, crackles in lungs, hemoptysis, tachycardia) then there would be decreased cardiac output. the official nanda diagnosis for falling is risk for falls not high risk for falls and this is a potential problem. since this patient has osteoporosis as a priority medical diagnosis and already has spinal fractures i think it would be prudent to have impaired physical mobility or impaired bed mobility as a diagnosis.

[futuredream]

You're always there for help. I read all of the threads on nursing care plans, and found many useful info, and your guides, but still am confused. The reason i did not pick "impaired mobilty" is that the intervention would be to assist pt with ambulation. But my pt is VERY weak, and is not even able to stand on her own, how can I help her to walk? Her recent v/s are normal, but she does not consume all the given food,usually about 30-40%.So i maybe should try something like- Nutrition: altered, less than body requirements?

Thank you very much for your indispensible aid.

[Daytonite, BSN, RN]

it doesn't make sense to list two priority medical diseases and then not address nursing problems (nursing diagnoses) connected with them.

i also suggested impaired bed mobility - definition: limitation of independent movement from one bed position to another (page 123, nanda international nursing diagnoses: definitions and classifications 2009-2011). the related factor would be musculoskeletal impairment (the compression fractures). defining characteristics (symptoms) that nanda lists for this diagnosis are:

• impaired ability to move from supine to sitting
  
• impaired ability to move from sitting to supine
  
• impaired ability to move from supine to prone
  
• impaired ability to move from prone to supine
  
• impaired ability to move from supine to long sitting
  
• impaired ability to move from long sitting to supine
  
• impaired ability to reposition self in bed
  
• impaired ability to turn from side to side
  

[rachelgeorgina]

I might want to focus on investigating what's going on with her kidney function, since her BUN and creatinine aren't crash hot.

[futuredream]

Yes, I need to focus on impaired bed mobility, you're right!

Cannot wait till next week when I will do my Physical assesment on that patient since that particular facility's nurses do it once in a while( most recent 3 month ago), and then I can list abnormal musculosceletal functions or like you said find more on cardiac and lung assesments. Thanks

[Daytonite, BSN, RN]

I might want to focus on investigating what's going on with her kidney function, since her BUN and creatinine aren't crash hot.

It is not uncommon for the elderly, particularly someone who is 96, to have elevated BUN and creatinine levels.