need help writing care plan on non compliant pt!!

[dezclay]

so i need to come up with 2 or 3 nursing diagnosis, outcomes, and interventions. some of my pts are simple. but i am stumped on this one guy. hes young, 32 and non-compliant with his meds. his admitted for ischemic stroke, was having rt sided weakness, but that has since cleared up. hes not one i can use the usual diagnosis for, ex. acute pain, etc. would he be a good one for fall risk even though hes not having any weakness at this point? he is diabetic. he is now on anticoagulants, so i thought maybe a risk for bleeding one may work. has a hx of HTN, afib, EF of 5-10%. im just having trouble figuring out which direction to go with him. any help would be much appreciated! i have to have this turned in right away so please respond quickly and point me in the right direction! if you need any more info about the pt let me know. everything else seems to be WNL. also is there a knowledge deficit one or something related to his non compliance with meds at home i could use?? thanks!!

[mssjez]

First off... what have you come up with? It sounds like nothing and you're just asking for help, but I think it's important to tell us what you think.

I think if you're stumped you should make a list of each system. Take the data you have: past medical hx, abnormal labs, abnormal vital signs, on O2 or not, meds needed, etc. Whichever system has the most data (i.e. cardio, respiratory, neuro, etc.) is the system you should start with. As far as the med compliance, why is he non-compliant? If he doesn't take his meds, what else is he at risk for (based on what meds they are)? Good luck!

[BSN-to-MSN, ADN, BSN, RN]

Ask yourself : " Why does this patient need a nurse?" to come up w/ most important reason, then #2 and #3. It works for me.

[phuretrotr]

Ask yourself, with the information you have on this patient, how could he die or have the most complications in your care? What is going to kill him if you do not do specific assessments and interventions?

[Esme12, ASN, BSN, RN]

We are happy to help but I need some information before I can help....what semester are you?

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...WHAT DO THEY NEED?

also is there a knowledge deficit one or something related to his non compliance with meds at home i could use?? thanks!!

What care plan book do you use? Where have you gotten your nursing diagnosis before today?

[nurseprnRN, BSN, RN]

Hint: We don't use the word "noncompliant" anymore. People are always free to decline treatment; "compliance" has connotations of following orders. "Adherence," as in, "the patient adheres to the medical and nursing plans of care" is a better way to describe it and to think about it. How might that give you a hint as to things a nurse would assess and put into a nursing plan of care?