Need feedback on care plan

Daytonite, BSN, RN · Feb 18, 2009

i don't understand exactly what was going on with your patient, but i can tell what doesn't make rational sense. i think you are interpreting his blindness incorrectly. when blindness is a safety concern, as in falling and gait, it is a risk for falls and not a memory issue. i gave you two weblinks to chronic confusion websites where you can read diagnosis pages about this diagnosis, its definition, defining characteristics and related factors. find information on dementia and confusion. these patients, unless they are in early stages pf ad, do not know they are confused and do not ask for help. they regress into themselves and become progressive dependent on others for their needs to be met.

nursing

diagnosis: chronic confusion r/t alzheimer's disease

supportive data

(subjective & objective)

subj: pt stated nurse did not uncover his food but nurse did ask and he told her he wasn't ready. he says maybe he forgot.

obj: altered/disturbed personality (irritability) and altered response to visual stimuli due to blindness.

just say irritability. what were the "altered responses to visual stimuli"? describe them. then, in the nursing interventions below, give strategies to do something to solve them. see

chronic confusion

and

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=12

.

short term

goal/outcome

the patient will remain free from falls and/or injuries by next week's clinical visit.

falls have no relationship to this diagnosis. this diagnosis is about

manifestations of

disturbances

in memory, orientation and behavior.

falling is none of these. falling is a disturbance of balance (not person, place and time orientation). your goals should be what you anticipate will happen in the patient as a result of the nursing interventions being done. and, the nursing interventions target the supportive data for this diagnosis because they are the signs and symptoms of the problem (chronic confusion).

evaluation

of short term goal

the patient will report no falls or injuries due to confusion or altered visual stimuli on next weekly clinical visit.

as stated above, this has no relationship to this diagnosis. if the patient has a history of falling, then use the diagnosis of

risk for falls

.

date

nursing actions

scientific rationale

evaluations

modification of

plan of care

the nurse will assess the degree of cognitive impairment using cam. this will provide a baseline for further evaluation

the nurse will assist patient with memory activities.

this will motivate the client to reinforce usefulness and maintain cognitive ability.

the nurse will provide safety measures by mainting walkway and area free of clutter

this will decrease his risk for falls and injuries due to his confusion and altered response to visual stimuli.

there is no basis for this. he has memory problems and altered responses because of his blindness. those altered responses are meant to be "cognitive" meaning that what he see he interprets incorrectly because of his visual problems. if he is falling because of blindness then diagnose him with

risk for fall r/t diminished mental status and blindness

. see

risk for falls

the nurse will show the patient location of call light and make it easily accessible.

will provide safety for the patient; pt can easily and quickly call for assistance if needed due to confusion or altered vision; will reduce chance of pt wandering.

does the patient know when they are confused? if so, include that in your data above as supportive data.

the nurse will assist the patient for all activities that require ambulation.

same as above.

when did ambulation get to be a problem for this patient? if this patient has trouble walking then he has

impaired physical mobility

.

the nurse will approach the pt in a calm and slow manner and speak in a slower, lower voice.

this will avoid startling the patient, will increase comprehension; both which can help prevent an irritated response. aggravating the patient.

the nurse will monitor the patient's nutritional intake and assist with feeding if pt requests.

confused patient's may not be able to always remember to eat or the amount eaten; due altered visual stimuli, it may be difficult for pt to eat on his own.

patient has memory impairment. the evidence indicated they forgot whatever was going on with their food when they were asked. they are probably not going to request help with eating.

the nurse will evaluate diagnostic results of psychologic evaluation(s).

evaluating psychiatric diagnostic findings will allow the nurse to be

better informed regarding the ex-tent of the pt's alzheimer's and/or confusion.

this is the same as the first intervention.

the nurse will teach the patient simple exercises and activities paced to his abilities that he can perform on his own.

this will help the patient maintain mobility despite loss of vision and confusion even when nurse not available.

this patient is chronically confused. it is doubtful that he can perform any exercise routine on their own without regular prompting.

littley · Feb 18, 2009

Thank you Daytonite! This is what I wish our professor would do. Again, this has basically been me teaching myself. I misunderstood the defining characteristic of altered visual stimuli. As i went over it again I realized it didn't apply in the way I had understood it did. I'm going to revise my care plan using your suggestions. Your help was greatly appreciated!