Need help w/ careplan....

[CocoChanel]

Hey everyone. I need some help writing a care plan for this particular patient. My patient is a 72 yr old white female that was admitted to the hospital from the nursing home with fever, dehydration, UTI, and hypotension (90/52). She was diagnosed with Alzheimer's about 10 years ago. She's somewhat oriented. She recognizes family members but does not recognize nurses/doctors, doesn't know who she is and doesn't know where she is or what day it is. She's a high fall risk because she tends to get out of bed on her own when no one is around and the muscles in her arms and legs are slightly contracted. She has a Foley. She's NPO (and will not be receiving a feeding tube) b/c she has recently developed swallowing difficulty and as the nurse described it "she has funky stuff in her blood". The doctor's believe that she may have MRSA and E. Coli was found in her urine. She's on Vancomyocin and Levaquin. She's DNR and her family is setting her up for hospice care.

My instructor wants me to write 3 nursing diagnosis and a careplan for this patient. None of the DX can be "risks" (ex. Risk for skin integrity, etc.). Any help would be greatly appreciated.

[Daytonite, BSN, RN]

the first thing you need to do in trying to decide on nursing diagnoses is to take a look at your abnormal data. based on what you posted, this is the list i come up with.

• fever
  
• hypotension (90/52)
  
• doesn't know who she is
  
• doesn't know where she is or what day it is
  
• tends to get out of bed on her own when no one is around
  
• the muscles in her arms and legs are slightly contracted
  
• has a foley
  
• swallowing difficulty

if you have a care plan book you can look up potential nursing diagnoses by the medical problems/disease that the patient has. with a nursing diagnosis book you look for nursing diagnoses that have defining characteristics listed with them that are similar to or the same as some of the abnormal data you collected on your patient. these are nursing diagnoses that you can use sequenced in priority order and i am including links to online nursing diagnosis pages from the ackley/ladwig and gulanick/myers careplan online companion websites for you to investigate for nursing interventions.

1. impaired swallowing r/t neuromuscular impairment secondary to alzheimer's disease aeb difficulty swallowing [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_068.php
   
2. hyperthermia r/t infectious process aeb elevated temperature [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_039.php
   
3. impaired physical mobility r/t contractures in arms and legs aeb [you need to supply assessment data] http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=35 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_047.php
   
4. chronic confusion r/t alzheimer's disease aeb disorientation to person, place and time that has been increasing over time http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=12 [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_018.php

i would like to have used deficient fluid volume as a nursing diagnosis because of her dehydration and swallowing problems, but you have provided no symptoms of the dehydration in order to use it. since they are going to allow the patient to pass away, i don't think a diagnosis of imbalanced nutrition: less than body requirements is necessary. other nursing diagnoses that might apply here (but you need to have the assessment data to back them up) are impaired memory, disturbed sleep pattern, any of the self-care deficits, and fear.

[CocoChanel]

Thank you Daytonite. This was a really big help. For the symptoms of dehydration, I read her chart thoroughly and they listed no symptoms of it. It just said that she was brought to the ER from the nursing home with low BP, dehydration and fever. I wasn't able to get a full assessment on her b/c we were only giving bed baths that day (it was our first clinical day). I asked her nurse about her situation and she said she didn't know because she was a new patient. She didn't even know why she was NPO. The information in her chart was kind of vague. THere were no signs or symptoms listed just direct diagnosis. and the only reason I found out that she had difficulty swallowing is that her sister told me. I also forgot to mention that she is starting to go into renal failure.

[Daytonite, BSN, RN]

You work with what you have. This is a first attempt, right? Based on the information you did have I was able to come up with four nursing diagnoses for real problems. That is one more than what you needed. The patient was made NPO because of the risk of aspiration if she was having swallowing problems. If I were you, I'd go with these:

1. Impaired Swallowing R/T neuromuscular impairment secondary to Alzheimer's disease AEB difficulty swallowing [i would address this from the situation as it is just being discovered and the patient is being kept NPO. Although you know that a gastric tube hasn't been inserted, I would care plan for the likelihood of IV fluids and perhaps even some diagnostic tests, especially since you don't know much more about what is going on with the patient. Hospice hadn't been ordered yet, so no definitive medical treatment is yet known. So, I would approach this as strictly a patient with a swallowing problem, what are we gonna do about it, what can we anticipate might be done about it]
   
2. Impaired Physical Mobility R/T contractures in arms and legs AEB [bedridden? can only walk with assistance?]
   
3. Chronic Confusion R/T Alzheimer's disease AEB disorientation to person, place and time that has been increasing over time

By talking to the sister you got some good information and that was excellent. You did good, Grasshopper!

As for the renal failure. . .she's going to have that and other organ failures as she begins the process of dying. End-of-life care is a little new for some people and somewhat emotional too. We used to do code blues and keep people alive on life support until there was just nothing left of them. It was, however, at the end of it all, fruitless. The newer thinking is to do what is going to be done for this patient--allow her to die with only comfort measures. Eventually all her various body systems will break down and go into failure and she will pass away. The care plans for patients like this are mostly involving comfort care, self-care deficits and coping strategies for the patient and family. Books and articles about hospice and end-of-life address these issues. It seems to be contrary to what the health professions promise to patients, but it really isn't. We are just honoring their wish not to prolong the breakdown of their body, but to provide comfort as it proceeds.

[pkapple]

Daytonite--you are awesome! I've been doing this for over 20 years and your concise yet thorough answer to the OP was outstanding!!!!

Keep up the "mentoring". Every student,new grad and old fogey will appreciate it and I am sure many patients will benefit. Kudos to you.

[CocoChanel]

Thanks again Daytonite. This was really a BIG help! I'm still trying to get the hang of this careplan thing (this is my first year of nursing). In fact my Ethics instructor was discussing this earlier today. She said that sometimes she feels that careplans are just another burden put on nursing students

[Daytonite, BSN, RN]

Don't be too hard on your instructors. Written care plans have to be done on acute hospital inpatients by RNs by any facilities accepting reimbursement from Medicare or Medicaid for any patient services they render. This is mandated by Title 42 of the federal law and pretty much applies to all acute hospitals in this country unless there are still some private hospitals that do not accept any Medicare or Medicaid patients at all. So, you have to learn how to do them if you are going to be an RN.

Some instructors know the nursing process and care planning so very well, that they also expect to see students able to play around with these nursing diagnoses. Some of it is mostly playing around with words a bit. It was like this in my BSN program. The problem is that some of these instructors are really not very good at explaining and getting across to students how this whole process works which leaves a lot of students stranded in midstream wondering just what is going on and breathing a sigh of relief when they get it right, but still not really knowing exactly what they did do that was right. That's sad.