Need Care Plan Help Please oh Please



My second day of clinicals at a nursing home facility. I have to complete three care plans. I have narrowed down my the three disease processes somewhat but I need help. A little background: 83Y F diagnosis: CVA, GERD, Anemia, Hypokalemia, osteoarthosis, HTN, diet controlled diabetes mellitus, colostomy due to bowel obstruction, hemiplegia on non dominant left side. She has had a hysterectomy and cholecystomy. Bp 136/75....all vitals WNL. creatinine 0.9 , potassium.....all labs are normal. I'm guessing our care plans have to be as if the patient is presented before treatment has been rendered? So my teacher suggested my care plans involve bowel obstruction (which I have to do a physiology and analysis of), CVA, and Diabetes. So here are my diagnosis in I hope the right priority order:

1. Ineffective cerebral tissue perfusion r/t interruption of blood flow aeb weakness in motor responses on Left side and hemiplegia

2. Dysfunctional gastrointestinal motility r/t hypokalemia aeb abdominal pain and vomiting. (this is where I'm lost, maybe because she receiving potassium meds and has a colostomy) or

Deficient electrolyte balance r/t vomiting aeb abdominal pain and distention.....

3. I'm lost as well, per one of my instructors we are not allowed to use Risk for Nanda diagnosis. So I'm stuck because my patient doesn't receive insulin because her diabetes is controlled by diet. She doesn't have an order for blood glucose monitoring either. Her skin is intact, no breakdowns. Even if so I still cant use risk for impaired skin integrity.

However, I'm working on my objective and subjective data, interventions, and rationales for what I do have. If anyone has any suggestions, insight, critiques please do so.

Thank you in advance!!!!


47 Posts

Specializes in Peds,Geri-Psych,Acute Care Rehab. Has 3 years experience.

Odd that you cant use Risk for dx....the main thing we do as nurses is identify potential problems and prevention...maybe she is trying to get you to focus on the main dx first because as soon as you add Risk for dx you have about a million possibilities.... How about Acute Pain/Chronic Pain, what meds is she on?, always a good dx, or is the hempilplegia r/to CVA? That opens even more doors for you, how about Impaired Physical Mobility related to Hempiplegia, loss of balance. Or depending on her ADL function how about Deficient Self Care related to (insert dx impairing her) How about Disturbed Body image related to colostomy, potential self care deficit related to the disturbed body image?

Think about all the psychosocial dx as well not just medical related ones. Remember we are nurses we worry about the WHOLE person.

Think holistic :)