need help for first care plan

[carlarenee02]

I have started clinical/fundamental and we are to do a careplan on client. My client is 74 in wheelchair due to neuropathy in feet due to diabetes. He also needs assistance with adl's. Any suggestions on what nursing dx to use. He is also at risk for falls (one main reason he is in nursing home) His mind is quite good and he is very verbal. He also has hypertension

Thank you.

[Daytonite, BSN, RN]

medical diagnoses are not enough information to write a care plan for this patient. diagnosing is based upon what you find during your assessment of the patient that is not normal. neuropathy in the feet is a medical condition. what is the result of this neuropathy? pain in the feet? difficulty walking? can't feel? what specific assistance does he need with adls? there are other risk factors for risk for falls and living in a nursing home is not one of them. post his abnormal assessment information so i can help you.

assessment consists of:

• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
• reviewing the signs, symptoms and side effects of the medications they are taking
  

also see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

[Koyaanisqatsi-RN]

Isn't it bad to mention this much about our patients? What are we allowed to post on here regarding that? Sorry for the derail, I've just always wondered.

[Daytonite, BSN, RN]

Isn't it bad to mention this much about our patients? What are we allowed to post on here regarding that? Sorry for the derail, I've just always wondered.

No. I can't help anyone write a care plan or diagnose without that information. All that is needed for care planning is the abnormal information not the person's life history.