Need help with careplan

rob4546, ADN, BSN, MSN · Jun 22, 2014

Maybe look at things a little differently, if you walked in the room and saw this patient without any subjective information what would your nursing diagnosis be? I don't think you care what caused which, you want to care for your patient the best you can. We never used "manifested by" in our diagnosis, only R/T and AEB.

Esme12, ASN, BSN, RN · Jun 22, 2014

When did you graduate school originally? How long did you practice?> What was your specialty? What NANDA reference are you using? How extensive does it need to be?

I agree with Rob....look at this from a nurses eyes

Male 69 yo with admitting DX of dehydration and pressure ulcer over a fractured R hip. He reported that he fell at home where he remained on the for for 30+ hours before he was discovered and admitted to the hospital.
Admission nursing assessment T 36.5; BP 80/50; pulse 98;respirations 24: wt 116 height 5' 8".
Clothes are dirty with urine . Pt grasps your arms and pulls at the bedrails yelling," Let me up, my cat is out there!" he cannot tell you where he is or why his hip hurts. When you ask him to tell you today's date, he again wants to get up and feed the cat that is in the other room.

I see a dehydrated, HYPOTENSIVE, slightly HYPOTHERMIC, confused male with an elevated heart rate and respiratory rate.

la_chica_suerte85, BSN, RN · Jun 22, 2014

I agree with Esme. We are told constantly in our program that when it comes to the older pts, dehydration is very likely the culprit for the confused mental status, especially since he was down for so long without any fluids or lytes. If the dehydration is addressed, it is likely his confusion will be ameliorated. So, the interventions for this Dx can be evaluated for their effectiveness based on whether or not his confusion is alleviated by having his F&E back in balance.

dovelove · Jun 22, 2014

Graduated in 1995 worked 3 years in Peds/NICU----- yes I see all those things as well and I believe I have addressed them, if not please advise- I have 4 full care plans addressing his confusion, dehydration, pain, risk for infection. It is the etiology, goals and interventions that are throwing me on his nutrition status ---- Should I do a diagnosis on nutrition? I think immobility, peripheral perfusion and the skin break down are also important... it could go on and on really--- I was told to be thorough. I am using two text books: Nursing care plans, :Gulanick,meyers, Nursing diagnosis: application to clinical practice and lots of internet stuff. But it is the individualization to this patient that I struggle with.

dovelove · Jun 22, 2014

Yes fluid volume deficit was the first care plan I wrote with him----then I addressed the confusion next as well as this poses a risk to his safety ---then i went with pain as this can aggravate confusion and then the infection risk related to his very compromised state and active tissue trauma. It is the nutritinal status that stumps . This will affect his healing process and confusion.

la_chica_suerte85, BSN, RN · Jun 23, 2014

Well, he definitely is on the "less than body requirements" end of an imbalanced nutrition Dx. You would want a positive nitrogen balance in order to encourage his pressure ulcer and hip fx to heal. For interventions, a nutritional consult may help you navigate this tricky situation and make sure that when he can eat, he is getting the proper meals. His confusion may be r/t more to the dehydration and trauma from the fall so dealing with the F&E and pain management may help with getting him to eat. If he's NPO, then you want to ask for the order to be changed as soon you as you assess he can tolerate CLRS and progress to regular diet (i.e. assess bowel sounds q4h). Also, if he isn't NPO, see if you can delegate feeding assistance to a NAP.

You're right...these interventions are pretty tricky. :yes:

As far as clearing up his confusion, I would put more emphasis on mantaining F&E balance than getting him to eat. I had a dementia pt NPO for 7 days (don't ask -- he was extra special) and it did not make him any more or less confused, just grumpy that he couldn't eat until his swallow study was completed.

Guest 360983 · Jun 23, 2014

A nurse who is much smarter than me told me that the elderly are like babies--neither group compensates well and both have initial presentations that are very different from the healthy young adult. If you had a neonate who was hypothermic, hypotensive, tachycardic, tachypenic and inconsolably fussy, what would you be concerned about?

You need the NANDA book, not a care plan book. Look on Amazon or in GrnTea's posts for the exact name. Look at the defining characteristics for each diagnosis to make sure you have the appropriate one selected.

Always prioritize based on Maslow's pyramid. Your priority should be things that can kill the patient. I would also recommend looking at SIRS criteria.

Esme12, ASN, BSN, RN · Jun 23, 2014

Graduated in 1995 worked 3 years in Peds/NICU----- yes I see all those things as well and I believe I have addressed them, if not please advise- I have 4 full care plans addressing his confusion, dehydration, pain, risk for infection. It is the etiology, goals and interventions that are throwing me on his nutrition status ---- Should I do a diagnosis on nutrition? I think immobility, peripheral perfusion and the skin break down are also important... it could go on and on really--- I was told to be thorough. I am using two text books: Nursing care plans, :Gulanick,meyers, Nursing diagnosis: application to clinical practice and lots of internet stuff. But it is the individualization to this patient that I struggle with.

Thank it helps me gear my answer. Be sure that your Gulanick: Nursing Care Plans, 7th Edition book is current. It has an online care plan constructor. What you really NEED to make your life easier is the real resourse....NANDA I it has EVERYTHING you need including interventions and outcomes. It still amazes me that schools don't recommend this book. It's cheap and informative.

Nursing Diagnoses: Definitions and Classification 2012-14

For example....for volume deficit it is now Deficient Fluid Volume each ND must contain characteristics from the definition/taxotomy

NANDA taxotomy states....

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Older patients are more likely to develop fluid imbalances.
Common Related Factors
Inadequate fluid intake
Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
Failure of regulatory mechanisms
Electrolyte and acid-base imbalances
Increased metabolic rate (fever, infection)
Fluid shifts (edema or effusions)
Defining Characteristics
Decreased urine output (less than 30 mL/hr)
Concentrated urine
Output greater than intake
Sudden weight loss
Decreased venous filling pressures (preload)
Hemoconcentration
Increased serum sodium
Hypotension/orthostasis
Thirst
Tachycardia/weak, rapid heart rate
Decreased skin turgor
Dry mucous membranes
Weakness
Changes in level of consciousness

I have both but I prefer Ackley: Nursing Diagnosis Handbook, 10th Edition

Deficient fluid volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level.

Defining characteristics: Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

related to: Active fluid volume loss; failure of regulatory mechanisms; inadequate intake.

You have "evidence" of this in your scenario

1) he remained on the floor for 30+ hours before he was discovered

2) BP 80/50; pulse 98

So your patient has deficient fluid volume related to insufficient intake as evidenced by on the floor for 30+ hours before he was discovered, hypotension, altered mental status (he cannot tell you where he is) and tachycardia (BP 80/50; pulse 98).

Your Gulanick...if it is the new one should have NOC/NIC outcomes interventions

Esme12, ASN, BSN, RN · Jun 23, 2014

pain: Pain r/t tissue trauma manifested by report of pain and restless behavior

ACUTE PAIN: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

common related to factors:

Pain resulting from medical problems

Pain resulting from diagnostic procedures or medical treatments

Pain resulting from trauma

Pain resulting from emotional, psychological, spiritual, or cultural distress

Defining characteristics:

Patient reports pain

Guarding behavior, protecting body part

Self-focused

Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)

Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)

Facial mask of pain

Alteration in muscle tone: listlessness or flaccidness; rigidity or tension

Autonomic responses (e.g., diaphoresis; change in blood pressure [bP], pulse rate; pupillary dilation; change in *respiratory rate; pallor; nausea)

Your patient has..... Acute pain related to trauma from a fall as evidenced by feature of the hip, patient reports pain, restlessness and tachycardia and tachypnea (pulse 98;respirations 24)

Do you see where I am going with this?

Esme12, ASN, BSN, RN · Jun 23, 2014

Interventions...what do you look for with a fluid volume deficit? You administer fluid, watch I/O to be at least 30cc/hr normalization of vitals.

Pain: administer analgesics, position for comfort...patient reports relief of pain, is less agitated/restless

From your scenario here is what can apply from the current NANDA 2012/2014

Decreased Cardiac Output

Anxiety

Impaired Comfort

Acute Confusion

Deficient Fluid Volume

Hypothermia

Impaired Memory

Impaired physical Mobility

Imbalanced Nutrition: less than body requirements

Acute Pain

Self-Neglect

Impaired Skin Integrity

Impaired Tissue Integrity

Risk for Shock

Risk for Electrolyte Imbalance

Risk for Falls

Risk for Infection

Risk for Injury

nurseprnRN, BSN, RN · Jun 23, 2014

Risk for ... diagnoses don't have "evidenced by"/"manifested by"-- they have risk factors. For example, your old fella is at risk for infection, from multiple causes, and yes, you must use the NANDA-I 2012-2014, because it's the only authoritative source for validated nursing diagnoses. Looking at the risk factors for infection, I see (page 417):

* Chronic diseases- DM, obesity

* Deficient knowledge to avoid exposure to pathogens

* Inadequate primary defenses

altered peristalsis

broken skin, e.g., iv catheter placement, invasive procedures

changes in pH of secretions

decrease in ciliary action

premature or prolonged rupture of amniotic membranes

smoking

stasis of body fluids

traumatized tissue, e.g., tissue destruction

*Inadequate secondary defenses

decreased hgb

immunosuppression, (e.g., inadequate acquired immunity, pharmaceutical agents including immunosupporessants, steroids, monoclonal antibodies, immunomodulators)

leukopenia

suppressed inflammatory response

* Inadequate vaccination

* Increased environmental exposure to pathogens -- outbreaks

* Invasive procedures

* Malnutrition

Seems to me that he meets a few of those.

You would make the nursing diagnosis statement like this:

Risk for infection, related to malnutrition, tissue damage, IV access, surgical procedure (hip nailing) (or whatever he had done to him), urinary catheter ... and whatever else you see that fits, though this is plenty to make this diagnosis.

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