Need help with priorities in Care Plan

Editorial Team / Admin · Oct 31, 2011

Moved to its own thread.

dylansmom7 · Oct 31, 2011

You haven't really given any vital assessment/s? Pulse, blood pressure, RR, Temp???? What are her baseline vitals? What are they when/if she ambulates? Does she have pain? Fluid overload? Activity intolerance? I&O's...why dehydration? Risk for are collaborative, not nursing interventions. I wish I could help you ,but you haven't given enough information. Impaired walking? Pain? What are her labs?

xtxrn, ASN, RN · Oct 31, 2011

Agree with above poster re: need more information. :)

The syncope and cardiac issues need to be addressed.

Do you know if she's dehydrated?

Who's the caregiver that's strained?

Do you know the diagnosis for the Mellaril ?

Won't the risk of falls and risk of injury be in the same ND? Or do you not do goals for each ND (i.e. - Patient will be free of injury ..... the result of your interventions for the risk of falls???) (and depending on how you are instructed to write them, they may not be :) I'm just asking )

Think of ABCs, and Maslow's Hierarchy. :)

Max 555 · Oct 31, 2011

I am doing assignment and I am bit confused with priorities
77 years old lady, aortic valve replacement done in February and has a history of hypertension, hypothyroidism, diabetes and Cardiac heart failure. She had a fall due to syncopal episode. Assessment data: confusion, stiffness in all joints, tiredness, little exercise due to unsteady gait, wearing glasses and using walking frame. GCS-14, 3-4 hourly going to toilet. Medications such as Antipsychotic (Mellaril), antihypertensive (Hydralazine), Cardiac glycosides (Digoxin), Diuretic (Lasix), states tiredness. Old age, confused, increased short-term memory loss, GCS-14, taking Antipsychotic, Cardiac glycosides (Digoxin), denies existence of any health problems, forgetful of taking medications, poor attention span, requires assistance with most ADLs.
Sense of smell: Absent.
Sense of taste: Find it difficult to detect strong taste.
Hearing: both ear diminished.
1)Risk of falls 2) Impaired memory 3) Dehydration 4) Impaired social interaction 5) Ineffective health maintenance 6) Risk of for Injury 7) Risk for caregiver role strain
I need to choose three Nursing Diagnosis which one will appropiate. I am thinking of 1)Risk of falls 2) Impaired memory 3) Dehydration... Any suggestation
It would be great help......

History of aortic valve replacement, hypothyroidism, diabetes type 2, hypertension, 3-4 time hospitalized for CHF(aortic stenosis), AVR.

Last admission she fell following Syncopal episode.

Gerneral: Tiredness, wear glasses for reading, slight hearing loss.

Musculoskeletal: Stiffness in all joints and unsteady gait.

Neurologic: Unsteady, mild apraxia, GCS=14

Range of motion of Head/neck:- Limited range of movement.

Sense of smell: absent

Sense of taste: find difficult to detect strong taste.

Hearing : both ears diminished

Lab result: Rest is normal except for Glucose(fasting)14.2 mmol, Serum BUN- 9.1 mmol/L.

Medication: Regular insulin, Mellaril hydralazine, Thyroixine, digoxin, lasix, macrodantin, Metamucil

BP:® 100/70, BP(L) 100/70, Respiration-18, Temp-36.5, Apical- 108.

She is living alone, but due to memory deficits, occasional confusion, and unsteady gait. She deny the existence of any health problem.

I need to choose three Nursing Diagnosis which one will appropiate. I am thinking of 1)Risk of falls 2) Impaired memory 3) Dehydration... Any suggestation

xtxrn, ASN, RN · Nov 1, 2011

I still have the same questions.... :) You worded what you had fine- it just needs more information :)

My suggestions are to prioritize based on the ABCs, and Maslows :) Falls & memory are not related to airway or breathing; dehydration is related to circulation - but I don't see dehydration as a diagnosis.

If she's denying the existence of health issues, but is on those meds & has that medical/surgical history, she definitely needs memory issues addressed. She also needs falls addressed. Just not #s 1 & 2. :)

What type of apraxia?

LadyinScrubs, ASN, RN · Nov 1, 2011

It may be she has a hx of something else: "increased short-term memory loss" is thsi whyshe is given:

"Thioridazine (Melleril, Novoridazine, Thioril) is a typical antipsychotic drug belonging to the phenothiazine drug group and was previously widely used in the treatment of schizophrenia and psychosis. Due to concerns about cardiotoxicity and retinopathy at high doses this drug is not commonly prescribed, reserved for patients who have failed to respond to, or have contraindications for, more widely used antipsychotics. A serious side effect is the potentially fatal neuroleptic malignant syndrome."

xtxrn, ASN, RN · Nov 2, 2011

It may be she has a hx of something else: "increased short-term memory loss" is thsi whyshe is given:
"Thioridazine (Melleril, Novoridazine, Thioril) is a typical antipsychotic drug belonging to the phenothiazine drug group and was previously widely used in the treatment of schizophrenia and psychosis. Due to concerns about cardiotoxicity and retinopathy at high doses this drug is not commonly prescribed, reserved for patients who have failed to respond to, or have contraindications for, more widely used antipsychotics. A serious side effect is the potentially fatal neuroleptic malignant syndrome."

Agree w/ high (better be VERY high ) risk of psychiatric diagnosis- and that phenothiazines are not the 'go to' med for psychosis.... but impaired memory should never be an indication for starting psych meds. Impaired memory is a symptom. :) Phenothiazines also include Compazine (perchlorpromazine) and Phenergan (promethezine) - good to know if ordered post-op for patients (or any time) for nausea.

Just FWIW- there should never be a psychiatric med without a psychiatric diagnosis. In LTC, psych meds require a diagnosis, or it becomes an issue with state regulators. I know you're not in LTC- but the need for a true psych diagnosis is the same :up: