Nursing Care plan

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I am a first year nursing student and just had my first clinical this week. We are supposed to come up with care plans for our patients. My patient's primary medical diagnoses is senile dementia alzheimer's type with co morbidities of renal insufficiency, carotid stenosis, kidney stones, dysphagia, CVA, and UTI w/ sepsis. I am really confused on the whole care plan itself. We are to have at least six NANDA dx and from what I have found out about him I have come up with....

Risk for Injury

Impaired memory

Impaired swallowing

Impaired physical mobility

Urinary incontinence

Ineffective health maintenance

I am having trouble coming up with three related to's under each one of them and am about ready to slam my head against a brick wall!!! If anybody could help me with my problem and try to set me in the right direction I would greatly appreciate it...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

hi! welcome to allnurses.

care planning is good old fashioned problem solving. we use the nursing process to help us in problem solving. it is particularly useful for care planning. the nursing process has 5 steps and if you follow them in their sequence and do specific activities at each step along the way, it becomes so much easier to get through the development of a written care plan for any one patient. it all begins with assessment which is much more than just doing a physical examination.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you also need to know the usual tests that are likely to be ordered and the medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. you can use the weblinks on this thread to find some of that information:

this patient has:

  • senile dementia alzheimer's type
  • cva (stroke)
  • renal insufficiency
  • dysphagia
  • carotid stenosis
  • a history of kidney stones
  • a history of uti w/ sepsis

you need to look up information at least about the alzheimer's disease, dementia, cva, renal insufficiency, dysphagia and carotid stenosis. the diagnosis of alzheimer's is not good. the patient's memory, swallowing and physical mobility problems at the least are likely to be tied to the pathophysiology of those conditions. alzheimer's dementia and cva (stroke) leave patients with many deficits and disabilities that are the basis of many of their nursing problems. it would be unfair to just give you those answers without asking that you attempt to find them first. you saw this patient, so as you read about the signs and symptoms of dementia and visualize this patient while you read, light switches are going to turn on all over the place for you. i don't want to deny you that thrill of discovery.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - because you have no specific data about this patient listed, i can't really do much else to help you with your diagnoses. diagnoses are always based upon evidence that has been gathered and i have no idea what evidence you have to support the diagnoses you have listed. i can tell you that every diagnosis has a list of defining characteristics (signs and symptoms). these can be found in a nursing diagnosis reference and some care plan books have this information as well. this information, the nanda taxonomy, can be obtained

if you give some thought to diagnosing, doctors do not put a diagnosis on a patient's condition until they have done an examination and often some testing. the abnormal information that "shakes out" is their evidence of the disease process going on. we do the same except we do not diagnose diseases; we diagnose nursing problems.

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 - once you have a clear picture of the patient's abnormal data/signs and symptoms/evidence you can then begin to draw some conclusions about what nursing problems they have. that's when you can start to put a label, or nursing diagnosis, to them. other professions that do something similar: car mechanics diagnose problems with people's cars; plumbers diagnose problems with the pipes and toilets in people's homes; police detectives diagnose who did crimes after they conduct an investigation. they all use a process very similar to the nursing process to solve problems.

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem.

  • goals have this overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

with those three steps completed, the majority of the written care plan is done.

step #4 implementation (initiate the care plan)

step #5 evaluation (determine if goals/outcomes have been met)

i can tell you a few things about your diagnoses:

  1. they are sequenced incorrectly. using maslow as a guide, i would sequence them this way:

    1. impaired swallowing (physiological need for food/also a safety need)
    2. urinary incontinence (physiological need for elimination)
      • there are several diagnoses of urinary incontinence, so you must be more specific about this

      3. [*]impaired physical mobility (physiological need for movement)

      [*]impaired memory (safety need for protection)

      [*]ineffective health maintenance (safety need for stability)

      [*]risk for injury (an anticipated safety need)

      [*]i would question the use of ineffective health maintenance for a patient with dementia.

      • this particular diagnosis is defined by nanda as the inability to identify, manage, and/or seek out help to maintain health. (page 103, nanda-i nursing diagnoses: definitions & classification 2007-2008). the fact that this patient is in a nursing home (i'm assuming that this is where the patient is from the diagnoses) means that the patient was unable/incapable of caring for themself. it's kind of a foregone conclusion. this diagnosis is often used for patients who are a bit on the non-compliant side for some reason or another, but there is still hope for them to put in some effort. that doesn't fit a patient with alzheimer's disease.

      [*]i believe there could be some self-care deficit diagnoses here with the patient having had a cva. how does this patient get dressed? comb their hair? brush their teeth? clean their eyeglasses? get to the bathroom for bms, or is the patient incontinent of stool as well? shower? part of assessing the patient back in step #1 activities also involves assessment of the patient's ability and assistance they need to accomplish their adls (activities of daily living). this is what we do and where we shine as professionals. we are the experts in how people accomplish their adls. always remember that.

      once you have your assessment information organized if you still need some assistance with choices in nursing diagnoses or putting diagnostic statements together, list the patient's abnormal data and anything else you think pertinent and i will help you with it. have patience. first efforts at care plan writing goes slow and can be frustrating. it is a skill that you will master through practice (writing many more care plans).

      there is also a sticky thread with care planning information on it:

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Thanks for all the useful information. I think I might be getting the hang of it...Im just still unsure of the related to's. I have to have three under each diagnoses. Let me know what you think about these:

Risk for Injury r/t

unsteady gait

disorientation

muscle incoordination

Impaired Physical Mobility r/t

use of a wheelchair

unable to ambulate w/o assistance

DVT

Urinary Incontinence r/t

dementia

limited mobility

impaired cognition

Impaired Swallowing r/t

muscle weakness

slurred speech

stroke

Impaired Memory r/t

?

?

?

And I am yet to find one more nursing diagnoses. I don't have them in any particular order, but was just wondering if I am on the right track with this. Any advice would be great! Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

The related factors, cause of the problem, are often based upon what the pathophysiology of the disease process is that is going on when a physical problem is involved. The NANDA taxonomy lists possible etiologies for each of the nursing diagnoses.

Impaired Swallowing r/t

muscle weakness

slurred speech

stroke

The patient's inability to swallow is probably a deficit due to the stroke. However, in writing nursing diagnoses we are not allowed to use medical diagnoses. We have to use different wording. I can see muscle weakness as a cause for a problem swallowing, but not slurred speech. Slurred speech is a symptom of Impaired Verbal Communication, a different nursing diagnosis. So, what you are left with is a nursing diagnostic statement that starts out with
Impaired Swallowing related to neurological impairment and muscle weakness.

Urinary Incontinence r/t

dementia

limited mobility

impaired cognition

These are OK. They are all risk factors of a patient's urinary incontinence.

Impaired Physical Mobility r/t

use of a wheelchair

unable to ambulate w/o assistance

DVT

Ask yourself, what is causing the immobility? Using a wheelchair is not a cause of immobility. It is the result of it. Not being able to ambulate w/o assistance is not a cause of immobility either. It is also a result of it. And, a DVT is a medical diagnosis. Is the blood clot causing the patient to be unable to move, or is it the pain as a result of the blood clot?

Impaired Memory r/t

?

?

?

The patient has senile dementia Alzheimer's type. This is the reason for the memory problems. The NANDA taxonomy gives us the related factor for this
: Impaired Memory R/T neurological disturbance.

Risk for Injury r/t

unsteady gait

disorientation

muscle incoordination

These are OK.

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ok....but I am kind of getting the hang of it? I now found chronic confusion for his last nursing dx and changed self care deficit to impaired transfer ability. This is my first ever care plan so I know it's going to take a while for me to get the hang of it and hopefully (fingers crossed) i will eventually. Thank you for your time. I really appreciate it.

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