Need someone to correct my careplan

dishes, BSN, RN · Mar 1, 2009

I have a few questions in regards to your careplan.

You believe that the client wouldn't go to bed if she had activities to distract her, but you do not give evidence that supports this. Does she indicate that she is bored and has nothing else to do? If so, add this to the assessment.

Is there anyway for you to include the patient's desires in the goal planning?

Does the patient experience other symptoms besides vomitting does she want to prevent them from recurring?

If she indicates she wants more activities, what activities does she enjoy? Does she need to be set up for the activities?

What alternative plan be implemented if the patient is tired and needs to go to bed after supper? Can her head be elevated when she is in bed? If so, indicate how will it be elevated and for how long.

Dishes

Daytonite, BSN, RN · Mar 2, 2009

nursing diagnosis

high risk for nutritional imbalance due to vomiting.

goal. within 30 days 2/28/09

patient will maintain fluid volume and sustain optimum levels of nutrition. - you have no nursing interventions that address how you will maintain her fluid volume or make sure she is eating enough food; nor do you address how anyone can assess she is eating enough.
client will learn and understand the importance of nutrition. - you have no teaching interventions that explain anything to the patient about nutrition or how important it is for her. vomiting is first a safety issue.
client will keep to a daily active routine after meals - how will you accomplish this?
client will maintain normal nutritional levels. - what are normal nutritional levels for her? you have no interventions that assess this for this patient or state how it will be monitored, so how can normal levels be maintained if they are not even defined?

nursing intervention

advise the client against going to bed after eating or drinking and explain and teach client the ramifications of imbalanced nutrition due to vomiting. - for a patient of limited cognitive ability i wouldn't advise, but make an order of the staff that she not be allowed to go to bed. vomiting is a safety issue and she could aspirate, choke and die.

provide a task or activity to occupy client after meals in order to lengthen time spent out of bed to prevent vomiting. - for a patient of limited cognitive ability i would specify the tasks or activities in this care plan.

patients with gerd should not be receiving any acid or foods with high fat content.

eating 2-4 hours before sleeping is an absolute no-no with these patients so her lying down after eating dinner needs to be stopped or her meals need to be adjusted with main meal at lunch and the evening meal being very small if the patient is unwilling or uncooperative in following a plan of care.

head of bed should be elevated or blocks should be placed under the head of her bed.

this patient has gerd, gastroesophagitis and gastritis. is she on medication for this? i would have an intervention that mentions that her medications be given as ordered.

rationale

client will have better understanding of how to maintain balance of nutrition. - this is not a rationale. a rationale is why you are doing something. the reason for teaching the patient why she needs to remain upright after eating is so the food has a chance to move on down her gi track and be fully digested.

client will be too occupied (diverted by) with activities or tasks to keep her from going to bed so early after eating.

outcome/evaluation

client understand the importance of nutrition.

met.

client is able to complete activities or tasks after meals.

met

client maintains normal nutritional levels.

met

Valerie Salva, BSN, RN · Mar 2, 2009

The pt could also be at high risk for aspiration if she is vomiting while lying down.

Perhaps her meals could be smaller and more frequent, plus the last meal of the day could be earlier- so she won't want to go to bed right away.

deemarys · Mar 2, 2009

My client is advised constantly by nursing staff to wait awhile after eating so she doesn't throw up. She throws up on a daily basis. She eats whatever she wants, if she doesn't like what is brought up by the kitchen she goes to the cafateria to pick out something she likes.

She is on several meds for her medical problems but as I am in week 5 of nursing school I am still learning alot. I thought it would be a good learning experience to right a real nursing care plan on actual events as my instructor advised us all we are welcome to make things up.

Here is my new care plan as follows:

High Risk for Imbalanced Nutrition less than body requirements related to inability to absorb nutrients

Because of vomiting

Within 30 days 2/28/09

Patient will demonstrate

Progressive weight

gain

Client will learn and understand the importance of nutrition.

Client will keep to a daily active routine after meals

To maintain normal nutritional levels.

-Assess cause of vomiting:

determine if client is

Lactose intolerant, or ask client and/or significant other what causes client to vomit

-Ascertain client's understanding of nutritional needs

-Assess drug interactions, disease effects

-Provide small frequent feedings, dietary supplements

-Encourage client to choose foods that are appealing

-Promote pleasant environment, including socialization

-Promote adequate /timely fluid intake

-Weigh weekly, caloric

count

-Develop exercises/ stress reduction program

-Assessing causative

Factor will determine

Proper intevention

-Inorder to determine what nutritional information the client needs

-These factors may be affecting appetite, food intake and absorption

-Avoid fatigue

-To stimulate appetite

-To enhance intake

-Limiting fluids 1 hour before meal decreases early satiety

-To monitor effectiveness of interventions

-Promote wellness

Goal met.

At the end of 30 days The client verbalized understanding on the importance of well balanced, nutritious intake.

Client is able to complete activities or tasks after meals.

dishes, BSN, RN · Mar 2, 2009

Deemarys

You doing great for only 5 weeks of nursing. Your patient's situation is challenging. I hope you can help this patient so that she stops lying down after eating.

Dishes

deemarys · Mar 2, 2009

Yes its difficult. I can't really do much about it because she refuses. I can't make her not go to bed. I have to find savy ways to occupy her so she doesn't think about going right to bed all the time. I am still working on the care plan. I hope I get it right. Thanks for everyones input and advice.

Daytonite, BSN, RN · Mar 2, 2009

a "risk for" problem means the situation (in this case, not getting enough nutrients) doesn't exit yet. with "risk for" problems the interventions need to be:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional

i thought a great deal about your post and care plan last evening. i think your diagnosis is wrong. there is a very definite and real problem here as opposed to an anticipated problem. this patient lies down too early in the evening after eating and she vomits putting herself at risk of aspirating and choking. i don't think nutrition is the major issue unless there is more information that you haven't disclosed. i can't think of any writing or research that would support vomiting an entire meal daily resulting in malnutrition unless it happens nightly and over a long period of time. people who are anorexic will loose weight because they deliberately vomit to empty their stomachs of all the food they eat regularly, but that is not the case here unless you haven't described this problem clearly. this patient compensates for her food loss by getting food from other sources. do you have evidence that she is losing weight because of this vomiting? i think your rationale of this is faulty. i'm more concerned about her breathing safety. gerd patients are told to stay upright for 2-4 hours after a full meal. this patient isn't cognitively able to comply with that because of her mental retardation. so, the nursing staff needs to step in. the nursing staff can "advise" her to wait after she eats all they want, but the patient obviously isn't going to do that, has demonstrated that, and other strategies need to be sought. this is a real problem and not an anticipated one as you are trying to make it. there are a number of ways this can be diagnosed. her cerebral palsy makes choking on her vomitus a real safety issue since her muscular tone is compromised. the fact that she doesn't speak indicates that she has muscular deficits in the mouth and throat. so, risk for aspiration is one way to go. however, i, personally, would diagnose ineffective health maintenance r/t cognitive impairment, inability to make appropriate judgments and unwillingness to follow instructions aeb consistently retiring to bed immediately after eating dinner resulting in the vomiting of the meal, not complying with the dietary plan of her physician and obtaining food insistent with her diet plan to eat elsewhere. you know what really bothers me about this? she's in a wheelchair, can't talk and depends on others. people are enabling her to some extent!

high risk for imbalanced nutrition less than body requirements related to inability to absorb nutrients b

ecause of vomiting

within 30 days 2/28/09 patient will demonstrate progressive weight gain - the primary goal for a "risk for" diagnosis is for the risk, or problem, not to occur. by putting a weight gain as a goal you are saying there is a nutritional problem that exists and that is wrong.

client will learn and understand the importance of nutrition. - the risk is because of vomiting and i don't see the importance of the client learning about nutrition having anything to do with vomiting.

client will keep to a daily active routine after meals - again, the risk is because of vomiting and i don't see the importance of the client keeping a daily active routine after meals having anything to do with vomiting.

to maintain normal nutritional levels. - we're back to the last plan, what are normal nutritional levels for her? state them. a dietician would specific state something like " ____ calorie low fat, low cholesterol diet, no fried foods".

-assess cause of vomiting:

determine if client is

lactose intolerant, or ask client and/or significant other what causes client to vomit

you really haven't described this vomiting problem and that is the first thing one does when problem solving--assess the problem.

monitor patient's behavior following last meal of the day with respect to the time she goes to bed and when and if she has any episodes of vomiting.

note color, consistency and amount of vomitus. how does it compare to the amount of food she just ate?

-ascertain client's understanding of nutritional needs - this is not going to prevent the problem from happening and has nothing to do with monitoring the problem.

-assess drug interactions, disease effects - how is this preventing the problem from happening or monitoring the problem?

-provide small frequent feedings, dietary supplements - this is treating a problem that already exists and that is not what this diagnosis is about. this diagnosis is about preventing a problem that doesn't exist.

-encourage client to choose foods that are appealing - this is treating a problem that already exists and that is not what this diagnosis is about. this diagnosis is about preventing a problem that doesn't exist.

-promote pleasant environment, including socialization - this is treating a problem that already exists and that is not what this diagnosis is about. this diagnosis is about preventing a problem that doesn't exist.

-promote adequate /timely fluid intake - this is treating a problem that already exists and that is not what this diagnosis is about. this diagnosis is about preventing a problem that doesn't exist.

-weigh weekly, caloric count

-develop exercises/ stress reduction program

deemarys · Mar 3, 2009

You are so right about this. The nursing staff does enable her, they don't want to upset her so they always do what she wants. Usually if she doesn't get what she wants she will report you to Administration. She was my patient for 4 days and all she would allow me to do is her vitals. I advised her to wait at least 30 minutes before going to bed and she just passed me and found a CNA to put her to bed. While I was caring for her room mate I heard her vomit as they were putting her to bed. My instructor came in and was about to yell at me for allowing her to go to bed but what am I supposed to do, she refused and the instructor said, you have to respect your clients wishes. Then she went over to the patient and chastised her for going to bed so soon. I did revise the care plan and I would love to email it to you.

Daytonite, BSN, RN · Mar 3, 2009

I do not take e-mail. I am not a tutor. I removed my email address from my profile some time ago. Any responses I make to the forums are at my choice and when I have time. Some responses take me a great deal of time and work to create. I do it to help you and others who read these posts.

deemarys · Mar 6, 2009

Ok, Well thanks anyway for your input.