Nursing Care Plan - Brain Neoplasm

Daytonite, BSN, RN · Jun 21, 2009

diagnosis is based upon the abnormal symptoms that the patient has. these are found by assessment of the patient. i went through the data you posted and i have some questions since this patient is confined to bed and doesn't speak. it sounds as if there is a lot of care that needs to be provided for her, but your nursing diagnoses do not seem like they are going to provide that. i shuffled the data and listed it by maslow's hierarchy of needs:

incontinent - is she also incontinent of bowel?
bed bound - how much independent movement does she have? does she move at all? or does the nursing staff have to turn and reposition her? if the nursing staff has to do all her turning and repositioning, where is the nursing diagnosis for that?
right sided weakness
contractures - of what body parts?
sleepiness and weakness of body - are you sure this is because of the radiation therapy? could it be because of something else? side effect of pain medication? other medications? weakness is a term i would avoid--it is a subjective term and usually used by a patient as a descriptor.
reddened areas over the left buttock - due to pressure and what else? pressure ulcers are related to immobility. they are staged between i to iv and there are specific signs and symptoms that put a pressure ulcer in each stage. there are 2 nursing diagnoses for pressure ulcers and they depend on which stage the pressure ulcer is at. see http://www.nursingquality.org/ndnqipressureulcertraining/module1/default.aspx - pressure ulcer training tutorial
aphasic - we addressed this in your previous thread back in june
disoriented to time - this is not knowing what the time of day is

i will address your diagnostic statements next, but possible diagnoses you missed here are bowel incontinence, impaired bed mobility, impaired skin integrity, (acute or chronic) confusion and a number of the self-care deficits based on assessment information that is incomplete. most would come, in priority, before the diagnoses you did come up with:

impaired verbal communication r/t impaired cognitive ability as manifested by lack of speaking

problem (nursing diagnosis):

impaired verbal communication

etiology (cause of the problem):

impaired cognitive ability

is the brain tumor the reason the patient can no longer speak? did the brain tumor cause pressure on the speech center of the brain so that is the reason she can no longer speak? an impaired cognitive ability makes me think she is mentally retarded. that is not the reason is it? i would just say brain tumor or brain neoplasm because that is

why

she can no longer talk.

symptoms (evidence of the problem):

lack of speaking

it's not really lack of speaking, but unable to, or cannot speak. the wording you use is important.

fatigue r/t radiation therapy as manifested by constant sleepiness and weakness of body

problem (nursing diagnosis):

fatigue

this diagnosis is classified as one of "activity" and diagnoses involving physical activities are listed before

impaired verbal communication

which is a "safety" problem.

etiology (cause of the problem):

radiation therapy

i would research this as well as the type of brain tumor. radiation therapy is a local treatment, not a systemic one. while the fatigue is due to the radiation therapy be sure there is nothing else going on. fatigue is systemic and affects the entire body.

symptoms (evidence of the problem):

constant sleepiness and weakness of body

remember i said above that weakness is a subjective term used by patients. this patient doesn't speak, so where did this description of weakness of body come from? i also would not say

constant

sleepiness. it is not very scientific or measurable. to carry this further, your nursing interventions would need to address this sleepiness and weakness and goals would need to show some improvement of them. goals have to be measurable. you cannot have measurable goals when your initial assessment data identifying the problem doesn't give any kind of measurement of what is going on. symptoms cannot be too vague in description. for the diagnosis of

fatigue

, some of the acceptable defining characteristics (signs and symptoms) are patient verbalizations of what they are experiencing, but because this patient can't speak so you are going to miss having those as part of your evidence. see

fatigue

risk for impaired skin integrity r/t impaired mobility as manifested by blanching of skin

problem (nursing diagnosis):

risk for impaired skin integrity

after you read the pressure ulcer training tutorial you should understand why this should be impaired skin integrity and

not

a risk for impaired skin integrity

etiology (cause of the problem):

impaired mobility

and the first thing i said to myself was, "and where is the nursing diagnosis for

impaired physical mobility

?"

symptoms (evidence of the problem):

blanching of skin

potential, or anticipated, problems

never

have any symptoms because the problem does not yet exist.

what you should have done is an assessment that included:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
- http://www.cancer.gov/cancertopics/types/brain/ - brain tumor
  - http://www.cancer.gov/cancertopics/wyntk/brain - what you need to know about brain tumors
    - http://www.cancer.gov/cancertopics/wyntk/brain/page5 - symptoms
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
- http://www.cancer.gov/cancertopics/wyntk/brain/page7#g2 - radiation therapy

my suggestion is that a list of nursing diagnoses in priority order would look something like this:

bowel incontinence
impaired bed mobility
impaired skin integrity
fatigue
feeding self-care deficit
bathing/hygiene self-care deficit
grooming self-care deficit
acute confusion
impaired verbal communication

Tampanian · Jun 21, 2009

Thank you very much for the follow up. Our instructors want us to write our Nursing dx in the format of: Problem -- etiology -- secondary to -- as evidence by. I was a little confused on how i could use my diagnosis of impaired verbal communication as r/t to ? you clarified this greatly to me.

Her chart indicated that the tumor was over the corpus callosum and that the speech impairments only began in the past few months. She has had the tumor resected twice and underwent gamma knife tmt. The contractures are on her right arm and leg and she is completely dependent with ADL. She has limited used of her left arm as it seems very weak and she only uses it to scratch face or hold the rail when turning her. I also forgot to mention that she is on restricted fluid intake of 1500 cc and eats very limited amounts of food. Her urine was a tea color and her skin turgor was reduced ( possible dehydration?) She is both bowel and urinary incontinent as well.

Based on all the great information you gave me i have readjusted a few diagnosis to the best priorities (we are required 3 for this particular care plan)

Bowel incontinence r/t decreased functional ability as evidence by involuntary passage of stool ( i wasnt sure if impaired cognitive ability was an appropriate factor here after taking into consideration what you mentioned about mental status)

Impaired Bed Mobility r/t to decreased strength and endurance secondary to brain neoplasm as manifested by inability to move purposefully in bed (I'm not sure exactly how to word this)

Impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin

Any additional comments would be great !

Daytonite, BSN, RN · Jun 21, 2009

bowel incontinence r/t decreased functional ability as evidence by inability to pass stool ( i wasnt sure if impaired cognitive ability was an appropriate factor here after taking into consideration what you mentioned about mental status)

the inability to pass stool is

constipation

, so

bowel incontinence

would be the wrong diagnosis.

problem (nursing diagnosis):

constipation

etiology (cause of the problem):

dehydration and insufficient fluid and fiber intake

symptoms (evidence of the problem):

inability to pass stool

impaired bed mobility r/t to decreased strength and endurance secondary to brain neoplasm as manifested by inability to move purposefully in bed (i'm not sure exactly how to word this)

problem (nursing diagnosis):

impaired bed mobility

etiology (cause of the problem):

decreased strength and endurance secondary to brain neoplasm

the etiology is the cause, or why, the problem is happening.

decreased strength and endurance

is not why the

impaired bed mobility

is happening but one of the results of it. it is happening because the tumor is causing damage to the nerves that control the muscles. in medical terminology that is "neuromuscular impairment".

etiology (cause of the problem):
neuromuscular impairment secondary to tumor over the corpus callosum

symptoms (evidence of the problem):

inability to move purposefully in bed

a nursing diagnosis reference that contains the definitions, defining characteristics and related factors of the diagnoses (such as in the appendix of

taber's cyclopedic medical dictionary

) will give you suggestions. from page 123,

nanda international nursing diagnoses: definitions and classifications 2009-2011

:

impaired ability to move from supine to sitting
impaired ability to move from sitting to supine
impaired ability to move from supine to prone
impaired ability to move from prone to supine
impaired ability to move from supine to long sitting
impaired ability to move from long sitting to supine
impaired ability to "scoot" or reposition self in bed
impaired ability to turn from side to side

as i mentioned previously, if you cannot describe what is going on, you will have problems coming up with goals. since this lady has contractures she has some limbs she cannot move and cannot use in the process of turning one way or the other, correct? specify that in your ambs.

impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin

problem (nursing diagnosis):

impaired skin integrity

etiology (cause of the problem):

impaired mobility

read the tutorial and the related factors (etiologies) that are listed for this diagnosis on this page:

impaired skin integrity

. it is not just the immobility. this is the beginning of a

pressure

ulcer

.

hint:

pressure

. and what is her age? is she elderly? elderly skin is thin, frail and tears more easily than young skin. dehydrated and emaciated skin breaks easily over bony prominences. with tea colored urine and reduced skin turgor its a pretty good guess that she's pretty well dehydrated. did you give her a couple of drinks of water when you were caring for her? if not, its a pretty good guess that nobody else does either. how much you want a bet we could add "dry mouth" to her list of assessment data or "thirsty" if she could talk?

and since you mentioned this dehydration i think we ought to take a long hard look at her food and fluid status which trumps elimination (constipation and incontinence) on maslow's hierarchy of needs. did you assess adls? specifically, the eating one? it sounds like there may be some imbalanced nutrition going on here. was there a body weight done on admission and then one recently? it would be interesting to know what these are. we are nurses.

adls r us

. never underestimate what is (or isn't) going on with someone's adls, particularly someone who is confused or has a brain tumor and can't talk.

symptoms (evidence of the problem):

redness and blanching of skin

i am going to keep bring up the issue of measurement because it is an important assessment idea. we assess when we first meet the patient and when we evaluate them at many other times along the way when we are caring for them. the only way we have of proving our treatment methods are working is to compare our first assessments with subsequent ones. how does redness and blanching today compare with redness and blanching from last week? if i am nurse whoever coming along and reading your care plan for this patient and i see

impaired skin integrity r/t impaired mobility as evidence by redness and blanching of skin

i know absolutely nothing about this except somewhere on this person's body there is red, blanched skin. it could be on her shoulder or her nose and it could be the size of a penny or as big as a dinner plate. what kind of supplies should i take into the room to do her nursing care? the heck if i know. i'll have to go in the room and probably do a whole head-to-toe assessment myself to figure out what is going on. do you see why detail is important here? and then there will be the problems you are going to have as you delve further into the planning and writing of the nursing care for this.

impaired skin of any kind must be assessed for the following objective evidence:

location
size (length and width)
appearance - color, thickness or thinness, swelling
hot, cold, clammy or diaphoretic to touch including the surrounding skin
if a wound is present:
- give its measurements and depth
- describe the margins
- note if any necrotic tissue is present
- note if any odor is present
- note the amount, color and consistency of any drainage

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

a nursing diagnostic statement follows 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 medical diagnoses and 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.