Published Apr 21, 2014
I'm doing my peds' rotation now and our assignment is to create 5 nursing diagnoses for a mentally challenged patient. Then write interventions for 3 of them, 2 are medical and 1 is psychosocial. My problem is to come up with 5 nursing interventions for each of the diagnoses so I really could really use your input. Thank you!
PMH: 21 year-old female who was born at full term. When pt was a year old, she was assaulted by a caregiver and was diagnosed with Shaken Baby Syndrome with subsequent sever TBI, cerebral palsy with profound mental retardation, seizure disorder, spastic quadriparesis, scoliosis, Diabetes type 2, cortical blindness, anemia, atropic gastritis, history of GI bleeds, and disuse osteoporosis.
- Neuro: Pt is cognitive impaired, non-verbal.
- Resp: ineffective mucus clearance. Lungs are wheezes bilaterally.
- Cardiac: WNL
- GI/GU: WNL (bowel regimen)
- Nutrition: G-tube feed. Jevity 1cal@40ml/hr/tube for total of 105mlQid via pump
Prosauce 35ml per tube Qd
80ml free water flushes before and after feed.
75ml free water flushes before and after meds.
150ml of water flushes BID between tube feeds
4oz of fruit juice for BG
- Musculoskeletal: non-ambulatory. Passive ROM. 2 person scoop lift for bath and activities.
- Family structure: Pt has 2 siblings. Dad is not involved. Mom is unemployed and is looking for job.
- Labs: WNL
Nursing interventions: (this is where I'm stuck on)
1. Risk for aspiration related to ineffective airway clearance
2. Impaired growth and development related to cognitive dysfunction.
- Increase communication verbally and tactile stimulation. For ex: explain to client what step of care I'm about to perform.
- Establish trust with client according to Erickson's trust vs. mistrust stage.
- Encourage client to participate in group activities and school activities.
- Provide consistent nursing care.
- Assess client's non-verbal communication to pain and discomfort.
3. Interrupted family processes related to having a child with mental disadvantages. (This is my psychosocial diagnose)
- Family teaching about child development milestone.
- Encourage family to visit child frequently
- Refer to social worker for financial and other support needs.
If you can think of more stuff to add that would be really helpful. Thanks so much!
Esme12, ASN, BSN, RN
We are happy to help ....What semester are you? What care plan resource do you have?
Care plans are all about the patient assessment. Here is my standard speech.....
Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.
Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.
Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite
Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.
What I would suggest you do is to work the nursing process from step #1.
Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.
What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.
Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.
This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
Another member GrnTea say this best......
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__." "Related to" means "caused by," not something else.
While your patient has a risk of aspiration....her bigger priority problem is the infective airway clearance.
While there is a risk of injury ....she actually has impaired mobility that puts her at risk for skin integrity. Her seizures place her at risk of injury.
Her risk of aspiration in not only because she has difficulty with secretions......she is on tube feedings which increases her risk exponentially.
What NANDA I resource do you use?
KelRN215, BSN, RN
I wouldn't exactly say this patient's GI/GU assessments are WNL. She has a G-tube and is dependent on it for nutrition. Is she allowed to PO at all or is she NPO? It doesn't look like she's getting enough nutrition at all if she's not allowed to PO. She also has a history of GI bleeds and requires a bowel regimen. She is in no way WNL for a 21 yr old female. Is she incontinent? With all her issues, I'd be surprised if she weren't.
Thanks so much guys! I will get a chance to see her again this week so I will try to better assessing her again. It's been very hard for us as students to assess the kids because 5 of us are teamed up to take care of 3 other kids. And I picked this pt because I didn't know what Shaken Baby Syndrome is. I don't get much time to really see or taking care of her because we're not assigned to her.
But I think the 2 diagnoses: infective airway clearance, risk for injury are the major ones. I also need 1 psychosocial diagnose, so I'm thinking the "establishing trust between health care provider and pt".
KelRN215: I guess by saying WNL I wanted to say it's WNL for her, does that make sense? Maybe I should clarify that in my prep.
She is not PO at all and she is incontinence. I know she probably isn't getting enough nutrition for a 21-year-old but she's very small for her age. Also they've been successfully control her diabetes as well.
Esme12: I used http://www.amazon.com/Nurses-Pocket-Guide-Prioritized-Interventions/dp/0803627823/ref=sr_1_3?ie=UTF8&qid=1398130904&sr=8-3&keywords=NANDA
I'm in my 3rd semester of nursing school. I haven't had a pt who has so many problems at the same time before so I'm just trying to figure it all out and it's tough.
Thank you so much for all of your input! I really appreciate it.
WNL means "within normal limits." Normal limits for a 21 year old for a GI/GU assessment would NOT include a G-tube, NPO, enteral nutrition, a bowel regimen or incontinence. All of this should be noted in your assessment, because the patient is outside of realm of normal limits for her age.
This patient really only gets 105 mL of Jevity QID and that's the entirety of her nutrition? So she gets 420 calories per day and that's it? I'm having a hard time with this. It can't be right. 900 calories/day is a starvation diet.
Seems to me there's terrific advice here and one recurring theme is you need more assessment. I'm curious about the clinical assignment. You have 3 patients and she (this 21 year old) is not one of them? If she is not your patient, do you have the OK to do a physical assessment and read her chart? If the answer is "no" to any of the above, you're not in a position to do any sort of clinical reasoning about her.
This is not to say you can't imagine/intuit/suspect/speculate a care plan into existence. Of course you could. But is the learning objective to be able to search through a book and put together some coherent phrases?
I'm just curious. I'm not blaming you... but I'm confused about... I wouldn't let my students write a care plan on a patient to whom they were not assigned. Who made the clinical assignment? If you were given other patients, presumably the instructor considered those patients to be good learning opportunities for you at this level of competence and knowledge.
Here's the level of assessment I would expect of a 3rd semester student:
1. Stand at the door and just watch your patient for about 3-5 minutes. Close your eyes and ask yourself what you saw. (I have a "Walmart Test" I use with my students... it's basically "Why is this patient in that bed and not out shopping at Walmart).
2. Neuro: She's not shopping in Walmart because:
she has cognitive deficits. Someone damaged her cortex years ago. So describe your patient's level of consciousness. Does she respond to her name? Does she know you're there? Tell me everything you can about how she responds to and interacts with her environment. Does she have motor control? Which of her extremities does she move? Does she follow commands? Does she swat you away and move defensively? Which of her cranial nerves don't work? If I had to guess, glossopharyngeal, facial, trigemminal etc. any that involve reflexes that protect the airway (swallow, cough, gag.)
All of that is just one body system (CNS... ) If you were going to speak to her nutrition, I'd expect you to have looked at her labs and know what her BMI is, and what is in her feedings... If you are going to speak to airway clearance and aspiration, I'd wonder if you'd listened to her lungs. BTW: What are her vital signs? If you are worried about her skin... where is your assessment of it? What do her pressure points look like? Speaking of skin breakdown, how does she void... is she in briefs/diapers? Did you look at her perineum?
Again... I may be confused because I don't know what your clinical learning objectives are. But I don't think you will learn anything about care planning/clinical logic under the circumstances you described. And it probably isn't your fault. Make sure you clarify with your instructor what he/she wants and look in your syllabus at the objectives written there.
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