I need help with a care plan for an Alzheimer's patient with secondary med diagnosis of hip fracture. The patient it total dependence of care, sits in a chair, and incontinence. Non-verbal but used some sounds, cannot move body on command, skin issues, dsyphagia, contractures, and general muscle weakness, wears compression stockings but did not see edema. No vs abnormals. I need to list the nursing diagnosis for the above and then chose a priority diagnosis.
Here were my thoughts:
Feeding, bathing, dressing self care deficit
Impaired physical ability
Risk for powerlessness
Impaired verbal communication
Risk for peripheral neurovascular dysfunction
Impaired skin integrity
impaired physical mobility
Risk for lonliness
Originally, I was going to use chronic confusion for my priority but realized that I need to think about ABC. Would my priority diagnosis then be Impaired swallowing since he does not have actually airway/breathing issues.
We also need to look at a teaching need. Since I cannot teach this person directly can use a teaching need for the nursing staff?
Any help is appreciated!
Oct 1, '08
impaired swallowing r/t neuromuscular impairment aeb soft diet order and difficulty swallowing foods and liquids.
the patient will demonstrate effective swallowing without choking or aspiration.
aeb items are your evidence (symptoms, abnormal assessment data) that prove the existence of the problem (impaired swallowing). a "soft diet order" is a treatment and does not belong here. "difficulty swallowing foods and liquids" is your evidence. there may be other signs that you may have missed. see what they might have been from the list on this webpage: [color=#3366ff]impaired swallowing
since you have mentioned choking and aspiration, were these occurring? was choking a symptom?intervention
the nurse will monitor swallowing ability for choking.
the nurse will assess patient's month for food pockets.
the nurse will instruct the patient to swallow frequently.
please give feedback on deficient knowledge diagnosis. do you i use a caregiver teaching & deficient knowledge since he does not speak and has dementia? i am really stuck on the deficient knowledge diagnosis and teaching need.
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)
there is not one actual patient care intervention there. how are the caregivers going to feed this patient and avoid choking and aspiration (your two goals) without giving the patient any direct care? didn't you say above that this patient was confused? below you say the patient has dementia. "instruction" of the patient may be the wrong word to use--perhaps "prompt the patient to swallow" would be a better choice of words. what other things can be done when feeding patients that are at a risk of choking?
deficient knowledge of feeding r/t unfamiliarity of feeding process aeb feeding patients quickly.
deficient knowledge, specify focuses on a specific topic(s) such as a medical condition, its prognosis, treatment, self-care, or discharge needs. the care plan always focuses on the patient and his needs. if the caregiver is the one who needs the teaching in order for the patient to receive the needed care, then that is what must be done, but the patient is the focus. the focus of this diagnosis is "absence or deficiency of cognitive information related to a specific topic"
(page 130, nanda-i nursing diagnoses: definitions & classification 2007-2008
). the etiology of this problem is a cognitive lack. that simply means that the patient lacks the knowledge of the targeted subject for several reasons (these are listed in the taxonomy):
- cognitive limitation (in other words, not the brightest light bulb)
- information misinterpretation
- lack of exposure (to information sources)
- lack of interest in learning (apathy)
- lack of recall (bad memory)
- unfamiliarity with information resources/lack of information (doesn't know where to look)
better construction: deficient knowledge, feeding r/t lack of information aeb patient stuffs large amounts of food into mouth too rapidly. this indicates what the patient is doing wrong.
the caregivers will measure small amounts of food and alternate between solids and liquids
the caregivers would be family members. if these are geared toward the nursing staff these interventions should be included under the impaired swallowing diagnosis.
it is very difficult to have a specific teaching need for a patient who is confused and has dementia. these needs must be extremely simplistic because of their impaired memory. frankly, based on what you've listed about this patient, i'd try a bladder re-training program first to address the urinary incontinence.
Last edit by Daytonite on Oct 1, '08