need a good start for my careplan

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my patient has late stage alzheimer's, hospitalized for malnutrition and is now recieving nutrition through a peg tube, she has dysphagia and prior to hospitalization had not ate or drank for about a month, she has leg contractures and does not get out of bed, she also has a stage 3 pressure ulcer on her sacral area and necrosis on both heels that are all recieving wound care, she also does not speak, but is alert and will make eye contact ok so i am not sure where to start running with all this, please!! help with a good start, a nursing diagnosis for starters :bowingpur:nurse:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

if you walked into a doctor's office and the first thing he did was open your chart and say, "let's get you a medical diagnosis for starters" without having done anything else, what kind of physician would you think he is? well, that sounds to me like the exact same thing you are doing!

were you in lecture the day the nursing process was discussed? you can't write a care plan without following the 5 steps of the nursing process in the sequence that they occur. and that is why you can't start out the writing of any care plan by picking nursing diagnoses out of the air, or worse, based on a medical diagnosis!

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

determination of nursing diagnoses doesn't occur until you have thoroughly assessed the patient and made a list of all their symptoms (abnormal data). every nursing diagnosis, just like every medical diagnosis, has a set of symptoms. before you start the process of choosing nursing diagnoses you need to know what your patient's symptoms are.

please read the information on this thread. after, if you have more specific questions post them here:

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I know malnutrition is her priority diagnosis thats why she is in the hospital and other than that and alzheimers and the pressure ulcers she is healthy, she only takes one pill per day for alzheimers and thats all the meds she is on, so do you think a malnutrition care plan or impaired skin integrity care plan would be better or would you go a different direction, i can do a great care plan once i get a good nursing diagnosis to start

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i guess you are not understanding how i m trying to guide you on this. i'm trying to help you critically think your way through this. what i think you may not be getting is that while a careplan seems to be about what you are going to do for the patient it is actually the written documentation of your critical thinking in solving one or more of the patient's nursing problems. the nursing process is the problem solving process that we nurses use, and it isn't just useful in doing careplans. doctors document their problem solving in the "physician's progress notes" section of the patient charts and use a number of different methods to do it (soap notes, straight narrative charting, etc.). nurses have to, by federal law, include a written careplan in every hospital and nursing home patient's chart which is one reason why you are being taught how to write a careplan. not only that, but from the first day on the job until the day you retire from nursing you will primarily be solving problems. i called it stamping out fires as they flared up. how do you know what to do? you rely on the steps of the nursing process to help you out. get that now, learn how to work them now, to save yourself a lot of grief later on down the road. because either here or later on during job situations when you are under stress to perform for wages you will have to learn this or you will slide through your career with your head in a fog. i don't want that for you or any other student. believe me, i am sincerely trying to help you out here.

first of all, malnutrition is a medical diagnosis and you and i are nurses, so that diagnosis isn't of much use to us in our writing of a care plan because there is no nursing diagnosis for malnutrition. and if you are thinking that imbalanced nutrition: less than body requirements is malnutrition, i'm going to suggest that you read the nanda definition, related factors, and defining characteristics for this nursing diagnosis. you will not see the word "malnutrition" used anywhere. secondly, malnutrition is a complication of alzheimer's disease which is also a medical diagnosis. however, as nurses, we are very interested in a patients reactions and responses to what is going on with their illnesses. that would include the symptoms of the diseases they have, problems accomplishing adls or statements by the patient of their negativity or doubts about their health status. this is all considered evidence (symptoms, nanda calls them defining characteristics) to us nurses and we need that specific information for the purpose of diagnosing their nursing problems. you find this evidence during your assessment activity. go back and look at what i posted about the steps of the nursing process for you. you must complete the activity in step #1 when you sit down to do the actual physical writing of this careplan before you can even start thinking about choosing any nursing diagnoses!

assessment

  1. collect data from medical record

  2. do a physical assessment of the patient

  3. assess adl's

  4. look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - in this case (1) alzheimer's disease (2) malnutrition, and (3) pressure ulcers (tissue destruction and healing)

what i'm telling you is that you need to look up the signs, symptoms and pathophysiology for alzheimer's disease. malnutrition and pressure ulcers (tissue destruction and healing) before you move on to step #2 of the nursing process and writing of this care plan and the choosing of any nursing diagnoses!

in this last post of yours you are choosing a nursing diagnosis (impaired skin integrity) with no evidence (symptoms) that i can find to back up this decision. here's some information you need to know about assessing pressure ulcers and choosing nursing diagnoses for them. . .pressure ulcers are rated as being stage i, ii, iii or iv depending on how deep the ulcer has invaded and destroyed skin and body tissue. this is part of learning the pathophysiology of pressure ulcers. there are actually two nursing diagnoses that are used in connection with pressure ulcers and you have to know the stage this patient's pressure ulcer is at in order to diagnose it correctly. if you can't find this information in your textbooks your will find it on the internet:

  • impaired skin integrity - used for stage i an ii pressure ulcers
  • impaired tissue integrity - used for stage ii and iv pressure ulcers

now, if you will post a specific listing of this patient's symptoms that you obtained from your assessment, and even any attempts you made at choosing nursing diagnoses based on those symptoms, i will critique them for you and help you correct any errors in them. however, i can't help you if you insist on not following the steps of the nursing process. i know it is slow at first, but so was learning to tie your shoes when you were a little kid--now you don't give it a second thought because it is a skill that you have mastered. well, so is using the nursing process. and if you have learned anything on the day you get you nursing degree/diploma, let it be how to successfully execute the nursing process.

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Impaired Tissue Integrity R/t immobility

I would not use impaired skin because it is a stage 3 pressure ulcer

Impaired immobility r/t leg contractures

Nutrition is no longer an issue because she is receiving nutrition via peg tube

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i suggest getting one of the nursing diagnosis and care plan books. It helps you get started. It has helped me get the point of it all. I am able to do them without any headaches now. The books are expensive but its worth it.

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