nursing care plan

[daisyblue]

Please help! ok im trying to finsh my care plan but i am a little stuck. heres the info on my client;

85 yr old male in nursing home. Peg tube hx of depression, malnutrition dx of: dysphagia, copd, cva,htn, adb aortic aneurysm, cad, gout anemia, pheipheral neuropathy, debility, arthrisis......

WEll here wha ti feel is the most important diagnosis:

1) risk of aspiration r/t__?__ sec. to cva.

2) risk for impaired skin integrity r/t decreased o2 & nutrients and urinary excretions sec. to immobility and incontinence.

3) impaired physical mobility r/t musculoskeletal and neuromusclar impairments sec to cva.

Ok now for my questions: are these written correctly and if not how can i improve the structure, and secondly how do i correlate the third one to patho or psyco-physiology?

[ljeanmarielouise]

Your diagnosis are stated correctly but you need to be more specific regarding the "related to" component and the "as evidenced by" components (what specifically makes the patient a risk for aspirating). For example 1. risk for aspiration related to ineffective airway clearance and difficulty swallowing as evidenced by pooling of oral secretions in back of throat and coughing after eating or drinking.

Each nursing diagnosis should clearly spell out the problem, etiology of the problem, and the evidences of the problem so anyone caring for the patient can read you careplan and know exactly what needs to be done for the patient. This is true for the goals and interventions too. They should be specific for each patient, measurable, and realistic. www.nanda.org is a great web site for all things related to the Nursing Process. I hope this helps.

[gymnut]

Is this an actual patient you are seeing or is this a fictional scenario given to you in order to create your care plans? Because if this patient exists I feel very sorry for him. Talk about having almost everything under the sun!

Also as I was reading through your list and trying to decipher everything (not because you wrote it wrong. I'm just trying to learn all the medical abbreviations!) I couldn't find the WEll acronym and was getting frustrated until I realized it really was just the word well.

Time for bed.