Nursing Care plan

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:

• https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
  

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

• directly from nanda in nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

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

[*]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:

• https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans

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

Urinary Incontinence r/t

dementia

limited mobility

impaired cognition

Impaired Physical Mobility r/t

use of a wheelchair

unable to ambulate w/o assistance

DVT

Impaired Memory r/t

?

?

?

Risk for Injury r/t

unsteady gait

disorientation

muscle incoordination