Nursing Diagnosis/care plan help!

hodgieRN · Oct 30, 2012

Does the PICC and PEG tube put her at risk for anything? .... maybe Infection?

She got A-fib....A-FIB! What are some risk factors? Is blood circulating well b/c of the fibrillation.

Or, has something with breathing (wink wink)

She was found on the ground after laying there for two days. What happens to pt when they lay in the same spot for a long time. The ground can cause a lot of pressure to an area, right.

Esme12, ASN, BSN, RN · Oct 30, 2012

I am having the same problem with my care plan. I usually do not struggle this much but my resident has several issues. Her history is that she is 81 y/o and was found by her son in the fetal position under the kitchen table, covered in urine, feces, and coffee ground emesis. It is speculated she had been there about 2 days. She now has a PICC line and a peg tube. She is diagnosed with fall hx, protein-calorie malnutrition, and atrial fibrillation. She is very afraid of falling again and does not want to leave her bed. This only amplifies her incontinence and muscle atrophy (I believe the family said she was not eating well for some time before). What I have so far is
Anxiety r/t history of fall.
Risk of fall d/t weakness from protein-calorie malnutrition.
Impaired oral mucous membrane d/t NPO diet
I need two more. My question is would impaired skin integrity or imbalanced nutritrion: less than body requirements be good here. I feel the impaired skin integrity would be but have not idea how to word what it results from. I'm not sure about the imbalanced nutrition since she is on a feeding tube but I know they were having issues with residual feeding. How would that be assessed? Thank you in advance for any assistance you can give me!

What is your assessment of this patient? Why does she have the PEG tube? Why is she NPO? What caused her fall? Did she have a CVA? can she swallow? or is she a failure to thrive and that is why they are feeding her through the tube? (https://allnurses.com/nursing-student-assistance/adult-failure-thrive-684544.html#post6238248 information for failure to thrive)

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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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. From what you posted I do not have the information necessary to make a nursing diagnosis.

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

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

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.

So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? This givens me no information about what your patient needs, what brought them to the hospital...what is their complaint? What is their history?

kansasredneckwomen · Oct 30, 2012

I think my biggest problem is that I do not meet the patient before developing the care plan. We are given our "assignment" on Monday afternoons and told to read the H&P, labs, progress notes, etc. for our client and then develop a care plan that is due the next morning. Is this typical of nursing care plans or will we have some time to talk to the client to find out better what he/she needs?

nurseprnRN, BSN, RN · Oct 30, 2012

I need two more. My question is would impaired skin integrity or imbalanced nutritrion: less than body requirements be good here. I feel the impaired skin integrity would be but have not idea how to word what it results from. I'm not sure about the imbalanced nutrition since she is on a feeding tube but I know they were having issues with residual feeding. How would that be assessed? Thank you in advance for any assistance you can give me!

You are definitely on the right track. If you look in your NANDA-I 2012-2014 under impaired skin integrity (page 436), you will find a pretty good list of defining characteristics and internal and external causes (also called "related (to) factors"). I would bet you dollars to doughnuts that you will find several that apply to your patient that you have already identified in your assessment, or could verify pretty quickly.

Daily caloric intake is properly ordered by a dietitian or nutritionist, and you can find out whether that's being accomplished by looking at her I&O-- how many ccs is she getting (not how many ccs ordered, how many actually going into her and staying there), and how many calories per cc in the formula? Also look at what lab studies indicate nutritional status-- hint: think albumin and prealbumin. Look 'em up.

Don't have the NANDA-I 2012-2014? Free two-day delivery for students from Amazon, and save yourself a world of confusion and a lot of time. I mean it. Do not delay. Every student should have one, whether or not the faculty remembered to put it on the bookstore list. Get in the habit of expanding your reference collection, because if you have any sense (and you definitely sound like a sensible student, thank YOU!) you will not stop buying books when you graduate. :)

Esme12, ASN, BSN, RN · Oct 31, 2012

I think my biggest problem is that I do not meet the patient before developing the care plan. We are given our "assignment" on Monday afternoons and told to read the H&P, labs, progress notes, etc. for our client and then develop a care plan that is due the next morning. Is this typical of nursing care plans or will we have some time to talk to the client to find out better what he/she needs?

I think this is where students have so much trouble with care plans.....sigh. But is the H&P there is a main complaint and the patients complaints in the nurses notes. So, you need to learn what information you need.

So....your patient has a

Her history is that she is 81 y/o and was found by her son in the fetal position under the kitchen table, covered in urine, feces, and coffee ground emesis. It is speculated she had been there about 2 days. She now has a PICC line and a peg tube. She is diagnosed with fall hx, protein-calorie malnutrition, and atrial fibrillation. She is very afraid of falling again and does not want to leave her bed. This only amplifies her incontinence and muscle atrophy (I believe the family said she was not eating well for some time before). What I have so far is

So from this what can you assume.......what she may need.....kind of........

First what is A Fib? What complications does it cause? Is this patient on anti-coagulants? Does she have Activity intolerance? Anxiety? Does she have Adult Failure to thrive that she cannot care for her self at home and cause Self Neglect and Bathing Self-Care deficit? Does this make her at Risk for Falls? Make her Fearful?

Does the protien-calorie malnutrition cause Imbalanced Nutrition: less than body requirements? Does she need the PEG related to Impaired Swallowing?

What nursing diagnosis book do you have? What defining characteristics does she exhibit?

Do you see where I am going?