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NANDA nursing dx- unsure about "related to" part

LPN/LVN Students   (171 Views 1 Comments)
by FashionablyL8 FashionablyL8, CNA (Member) Member

FashionablyL8 has 15 years experience as a CNA.

2,724 Profile Views; 51 Posts

Hi Everyone,

I'll try to make this brief. I'm in the 2nd month of my LPN program and we are doing our 1st care plan on a case study. I'll try not to only write the important things but here's the basics:

Assessment at free health fair. 82yo male, 5'11", 152lbs. Vitals: T 98.3 oral, P 92 strong & regular, BP 168/92, R 14 normal. Skin- pale, dry. Mucous membranes- dry. Appears tired and needs haircut.

Hx-high cholesterol, hypertension, cataracts, arthritis.

Med Hx- Lipitor, Lopressor, Ibuprofen. Current issues reported- weight loss approx 10lbs, reduced appetite- eats less than 50% of meals, fatigue, insomnia, nocturia, occasional urinary incontinence, slight unsteadiness ambulating (uses cane).

Retired warehouse worker, married 60y- wife has increasing dementia. Has not seen MD in years but reports keeping up w/ wife's medical appts. When asked about current meds, fidgets and states,"I'm glad my blood pressure was good at the last health fair, those pills are so expensive."

What I came up with is (I have no idea of I can even use this so I appreciate any criticism including "that's all wrong"!):

Hypertension, related to knowledge deficit regarding condition and therapeutic regimen, as evidenced by not seeing HCP and not continuing medication. (AEB in my own words- ?)

Imbalanced nutrition, less than body requirements, related to ineffective health management OR ineffective coping (wife w/ dementia and obvious concerns over expense of meds as a stress factor).

I'm concerned if these are worded and laid out correctly- especially if using my own wording in the AEB is OK. I know I still need to do interventions and goals, but I'm going one step at a time and hoping I'll start getting the hang of it as I go along. But first I need to know if I'm even on the right track. 

Thanks for any guidance!

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