New student-Need help with my Nursing Diagnosis!

lifesacomedy · Apr 11, 2009

First and foremost...her ABC's. Does her compromised situation affect her airway, breathing, or circulation? Is she on oxygen? Does her immobility affect her circulation, risk for DVT's, risk for skin breakdown, etc?

Secondly, what about safety? Fall risk, etc?

I think once you have gone through these, the self-care deficit is the thing that stuck out to me. There are many many measurable interventions you can implement (that you listed) that will aid in her self-care. These things will also keep her immobility from having as drastic of an affect on her circulation, safety, etc.

Just my thought. I'm only finishing my second semester of NS, but those were the things that came out to me.

Good luck!

Daytonite, BSN, RN · Apr 11, 2009

before i begin to break the information down into some diagnoses for you, i want to point out that this is a sticky thread that has information on how to care plan where you can see many more examples of what i am about to do for you: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

if you utilize the steps of the nursing process to keep you organized it will help you tremendously. the nursing process is a method of problem solving and a care plan is one big problem solving activity.

step 1 assessment - assessment consists of:

a health history (review of systems) - 90 year old lady with end stage alzheimer's with a history of uti's and slightly elevated cholesterol
performing a physical exam - any edema? heart, lung or skin problems? how is movement accomplished? does she have any contractures? is skin breakdown a concern? does she attempt any kind of communication at all? if she gets distressed how does the staff know? does she have difficulty sleeping?
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - it is not good enough to say that she is unable to do any adls. you have to specifically describe them. can she button things? tie her shoes? hold a washcloth and wash herself? would she wash herself if she wasn't directed to do so? would she get dressed or change clothes if someone didn't direct her to do so? would she even attempt to go to the bathroom or is she totally incontinent of bowel and bladder?
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - information about alzheimer's needs to be looked up and checked. how does the patient's symptoms compared to what the textbooks say?
- http://www.merck.com/mmpe/sec16/ch213/ch213c.html
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - other than her pureed diet, is she on any medications or ordered treatments?

before going on i just want to mention maslow's hierarchy of needs. the physiologic needs come first and they are broken down into priority as follows:

cells that need/require oxygen
- the airways where air gets into the body
- the cells of the brain
- the cells of the heart
- the cells of the lungs
- cells of the other organs
[*]need for water and fluid
[*]need for food/nutrients/electrolytes
[*]the need to eliminate and dispose of bodily wastes
[*]the need to control body temperature
[*]the need to move
[*]the need for rest
[*]the need for comfort

these are important to assess for in a patient who is not able to perform their own adls. always ask how these basic needs are being met in these patients because there are nursing diagnoses for every one of these needs.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is what you provided

90 years old
urinary and bowel incontinence
completely immobile - what does this mean?
unable to do any adl's (toileting, hygiene, feeding) - needs to be specified
doesn't speak - there are other ways of communicating

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. every nursing diagnosis has a definition, related factors (causes), and defining characteristics (signs and symptoms). this information can be found in care plan books, in the appendix of a copy of taber's cyclopedic medical dictionary and some can be found on these two websites:

these are the nursing diagnoses i can make from the data you supplied:

impaired physical mobility r/t neurological dysfunction secondary to alzheimer's disease aeb completely immobile
total incontinence r/t neurological dysfunction secondary to alzheimer's disease aeb urinary and bowel incontinence
bathing/hygiene self-care deficit r/t physical and neurological dysfunction secondary to alzheimer's disease aeb [needs to be specified]
dressing/grooming self-care deficit r/t physical and neurological dysfunction secondary to alzheimer's disease aeb [needs to be specified]
feeding self-care deficit r/t physical and neurological dysfunction secondary to alzheimer's disease aeb [needs to be specified]
impaired verbal communication r/t physiologic changes in the brain secondary to alzheimer's disease aeb doesn't speak
risk for impaired skin integrity r/t immobility, incontinence, and elderly age
risk for falls r/t age, incontinence and impaired physical mobility

step #3 planning (write measurable goals/outcomes and nursing interventions) - take each diagnosis and write goals and nursing interventions based upon the evidence that supports the problem. this is why your assessment data needs to be specific so your interventions will be targeting those things. if the patient, for example, can't move the right arm at all, then interventions for an impaired physical mobility diagnosis will target how to support that right arm in the performance of activities, won't it?

---------------------------------

having issues with the problem (nursing diagnosis) and the r/t (etiology) though

a nursing diagnostic statement is constructed following this format:

p

(problem)

- e

(etiology)

- s

(symptoms)

problem
- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of
taber's cyclopedic medical dictionary
has this information.
etiology
- also called the
related factor
by nanda, this is what is causing the problem and resulting in the symptoms. pathophysiologies of the patient's medical diagnosis or medical conditions need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
symptoms
- also called
defining characteristics
by nanda, these are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

MattiesMama · Apr 11, 2009

WOW, thanks Dayonite for taking the time to do that...I've actually printed out several of your posts to use for reference, you are a great teacher.

Lifesacomedy...thank you I totally forgot about the ABC's! So now I'm actually thinking that maybe I should use Impaired Physical Mobility as the primary diagnosis...because while her self-care deficit seems to be the most all-encompassing problem, her being bedridden and immobile could lead to problems with circulation and therefore would be a higher priority than hygiene, right? I did note that she flinched in pain when I touched her feet...and I wasn't even manipulating them, just from touching it, so I wonder if that could be a sign of a clot forming...

But if I use Impaired Physical Mobility as my diagnosis, should I include something about the risk for impaired circulation (not sure what the NANDA would be for that) in the primary diagnosis, or would that have to be a separate diagnosis?

Daytonite, BSN, RN · Apr 11, 2009

the symptoms of a dvt are not only flinching in pain:

redness
swelling
positive homan's sign
warm sensation when touching the leg
fever
chills

impaired circulation also has specific signs and symptoms. not being mean here, but your assessment data isn't the greatest, or at least you haven't listed much. how about going with what you know. . .acute pain. however, you need to research her medical history to determine what the pathophysiology of this might be in order to come up with the related factor for the diagnostic statement. it is, most likely, related to neurological dysfunction secondary to the ad if a physical reason cannot be found.

i gave you the diagnosis for impaired physical mobility as impaired physical mobility r/t neurological dysfunction secondary to alzheimer's disease aeb completely immobile. it has nothing to do with impaired circulation and everything to do with the alzheimer's disease. impaired circulation to the legs doesn't cause pain with immobility--that is a myth. if you are thinking of claudication you need to look it up because you have the wrong idea about it. it has to do with oxygenation of the tissues that causes muscle spasm when the patient walks. please read the merck manual weblink i gave you about dementia. you need to understand the underlying pathophysiology of alzheimer's disease in order to understand how this lady got to this point that she is at. in fact, someone else asked about doing a care plan on an ad patient this morning and i posted a whole bunch more websites which wouldn't hurt you to read:

http://www.medicinenet.com/alzheimers_disease/article.htm - alzheimer's disease
http://www.nlm.nih.gov/medlineplus/alzheimersdisease.html - alzheimer's disease weblinks at the nih
http://www.fpnotebook.com/neuro/cognitive/dmnt.htm - ad, thumbnail list of types/signs and symptoms/diagnostic tests
http://www.merck.com/mmpe/sec16/ch213/ch213c.html - dementia
http://www.webmd.com/alzheimers/default.htm - alzheimer's health center on webmd
http://www.medicinenet.com/alzheimers_disease_patient_caregiver_guide/article.htm - alzheimer's disease patient caregiver guide
http://www.medicinenet.com/alzheimers_disease_home_safety_information/article.htm - home safety for people with alzheimer's disease
http://www.fpnotebook.com/neuro/cognitive/wndrngbhvrindmnt.htm - management of wandering behavior

ad is a progressive degenerative disease of the brain. it is their brain that causes the patients to do what they end up doing as they regress to the stage of babylike behavior. their brains have checked out and left the building. it is sad to see the decline to total care. i worked in ltc where we had alzheimer units and saw this all too often. we had to get really good at observing these patients because they can't tell you when something is going wrong with them.

MattiesMama · Apr 11, 2009

Unfortunately being that this was my first clinical rotation my assessment data wasn't all that great...I was a nervous wreck and was concentrating so hard on doing the ADL's right that I kind of flaked on the head to toe assessment. I did read as much of her chart as I could though, and there really wasn't much in there except for the history of UTI's, and the Alzheimers. I only saw mention of the elevated cholesterol mentioned one time.

What I was getting at with the impaired circulation is that (from what I've read) immobility can LEAD to impaired circulation, clot formation, etc. So I was thinking that her most pressing issue would be the impaired physical mobility, since it can directly impact her circulation, and that has a higher priority than hygeine...does that make any sense?

Also, I've been reading the links on the pathophysiology of AD but so far I can't come up with a specific reason as to why it leads to complete immobility in the end stage...I found a great slideshow of how the disease progresses here: http://www.alz.org/brain/01.asp

so what I am gathering from this is that Alzheimers starts in the areas that impact thinking and memory and as it progresses, it begins to spread to the other areas of the brain untill the entire cortex is seriously damaged, and that is the point where they lose the ability to walk. Am I on the right track here?

Daytonite, BSN, RN · Apr 11, 2009

i've been reading the links on the pathophysiology of ad but so far i can't come up with a specific reason as to why it leads to complete immobility in the end stage...i found a great slideshow of how the disease progresses here: http://www.alz.org/brain/01.asp
so what i am gathering from this is that alzheimers starts in the areas that impact thinking and memory and as it progresses, it begins to spread to the other areas of the brain until the entire cortex is seriously damaged, and that is the point where they lose the ability to walk. am i on the right track here?

you got it!

getting all the assessment data is a learning curve. you get better at it with experience. take a look at the weblinks listed on posts #5, #11 and #13 of https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html - health assessment resources, techniques, and forms (the head to toe assessment information).

ad does a real number on people. the dementia really brings normal, healthy functioning people down in the space of about 10 to 15 years. the people who have done serious research on this (my neurologist is one of them) can cite some of the underlying causes: people who are engaged day after day in stressful work who do not take time to relax and years of sleep deprivation (no lie!). typically, ad patients are highly productive people whose brains go on the fritz. ad is at epidemic numbers in the industrialized civilizations. it does not seem to be a disease that occurs in the uncivilized world. there is also evidence that it can be genetic. many of our ad patients were professors, ceos who ran successful companies or were highly successful in the jobs they did. the people who did come in to visit them would tell us how they couldn't believe what had happened so that these patients ended up in the situation they were in.