Care plan help for patient with history of mental retardation!

Esme12, ASN, BSN, RN · Feb 25, 2013

Welcome to AN! The largest online nursing community!

No trolls allowed here.....

From what you tell me........

Patient is unable to provide history secondary to AMS (altered mental status). Per nursing home records, patient was sent to ER for evaluation of facial droop. In ER, patient was negative for following commands and responsiveness to questioning, mumbling only. Unsure of symptom onset time to present. CT of head performed in ER indicates multiple new infarcts since 2011. UA (urinalysis) positive for nitrates and leukocytes. Suspect mandibular dislocation and pneumonia of right lung on CT scan. Patient admitted to r/o CVA.
Lab: [Hospital standard for normal ranges are in brackets next to lab value]
BUN 28H [6-23]
CL: 109 [98-109]
CO2: 23.3L [24-32]
Calcium: 8.3L [8.6-10.4]
Albumin: 3.0L [3.5-5.5]
Bilirubin:
Nursing Diagnoses:
Imbalanced nutrition less than body requirements related to lack of oral intake.
Impaired gas exchange related to effects of alveolar-capillary membrane changes.
Ineffective airway clearance related to accumulation of secretions.
Activity intolerance as evidenced by verbalization of pain during physical therapy.

Nice work......I have a few questions. First....... Is this your priority order? Remember ABC's first. Are you to include any at risk for diagnosis? What semester are you? Do you have a care plan book? It appears that you do....which is good.

What are his vital signs? Is he febrile? what you your assessment? What do his lungs sound like? Why do they suspect a dislocation of the mandible?

leezee.loo · Feb 26, 2013

I'm going to put down my assessment first before I answer other questions since my assessment helps me with some issues with my diagnoses. It was difficult since he was unresponsive and therefore didn't comply to directions and such but I assessed what I could.

Assessment:

Respiratory

- Lungs clear bilaterally upon auscultation (didn't hear any rales despite his diagnosis of pneumonia)

- RR: 16

- O2 saturation: 97%

Cardiovascular

- Heart sounds regular

- Pulse: 61 (with machine) or 65 (manual for full minute)

- BP: 103/53

GU

- Positive for bowel sounds, normoactive

- Non-tender and not distended

GI

- Foley catheter output: 33 mLs (unsure of when foley was last emptied)

Other/Neuro

- Skin: intact and even in pigmentation, turgor

- Not alert, awake or oriented; very lethargic when awake and unresponsive unless physically stimulated (says "ow" or "that hurts" when moved for PT)

- Feet were cold and pedal pulses were difficult to feel/palpate (unable to locate in left foot, very weak pulse felt in right foot, not sure if pulse was weak or if I was feeling incorrect area); no edema present

- Temp: 98.0 degrees F

- Unable to assess six cardinal signs of gaze, PERRLA, and range of motion since pt. did/would not respond and follow directions given

- Submandibular lymph nodes were slightly swollen and palpable on which side but I forget which (didn't write it down in my note book :sorry: )

The nursing diagnoses I listed aren't in prioritized order yet. Sorry I should have mentioned that! So far I'm in my junior year, second semester and am currently nearing the end of my MedSurg clinical for which this care plan is for. I don't have a care plan book (been relying on the NANDA lists I can find online) but I have one ordered and it should be coming soon. As you can see my pt. isn't febrile and the other results of my assessment are listed above. And I'm unsure of why they suspected a dislocation of the mandible. I was able to confirm that he did have one and it was set back into place. The brother of my patient aided in my assessment a bit since the patient actually responded more so to him than any other person and we were able to get the patient to say "My head hurts". Also, while I was palpating the patient's left submandibular lymph nodes I had the brother ask the pt if he felt any pain in that area to which the pt said "Yes". Now I'm unsure if this is reliable information since I am unable to assess whether the pt. has a full understanding of the questions asked but it is all I have to go on.

Esme12, ASN, BSN, RN · Feb 26, 2013

Wow.....I am surprised that you have been able to do care plans without a care plan book. I use Ackley: Nursing Diagnosis Handbook, 9th Edition....I like that they have an online care plan constructor.

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.

Think of the care plan as a recipe to caring for your patient.......your plan of 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. let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first. https://allnurses.com/nursing-student-assistance/care-plan-nursing-817414.html

You will have to assess patients even if they are non verbal and unable to respond. Did the brother say this was unusual for his brother? What about his skin? was his CBC normal? He didn't have an elevated WBC? What was the Differential?

Ok....care plans are all about the assessment. Without even seeing this patient I can see many

Activity intolerance
Ineffective Airway clearance
Risk for Aspiration
Ineffective Breathing pattern
Impaired verbal Communication
Constipation
Risk for compromised Human Dignity
Adult Failure to thrive
Risk for Falls
Deficient Fluid volume
Impaired Gas exchange
Delayed Growth and development
Hyperthermia
Risk for Infection
Impaired physical Mobility
Impaired Memory
Impaired Oral mucous membrane
Acute Pain
Chronic Pain
Risk for ineffective cerebral tissue Perfusion
Ineffective peripheral tissue Perfusion
Bathing Self-Care deficit
Disturbed Sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)
Impaired Skin integrity
Impaired Swallowing
Imbalanced Nutrition: less than body requirements

The question is now.....according to NANDA I.....does your patient fit into any of the above by using the NANDA definition, defining characteristics and reasons (related to) that have caused you to think the patient has these issues. What evidence do you have that proves the patient has these issues...according to the requirements of NANDA.......AND, according to Maslows.... which of these come first.

leezee.loo · Feb 26, 2013

Ooo I have a better understanding now. Thank you so much! I really appreciate it :)

I have one more quick question if you don't mind. There's another patient I need to write a care plan on (two patients in total). This one I have a better grasp on since she is easier to assess.

She was admitted for right thumb pain and swelling. She ended up getting diagnosed with cellulitis of the right thumb. There is weeping of the skin on the lateral aspect of the right thumb and no purulent drainage as of yet.

My biggest concern is the patient developing sepsis as a result of the cellulitis. I have pretty much all the interventions and rationale for this diagnosis but I'm unsure of how to phrase the actual nursing diagnoses. I'll write what I wrote as the diagnosis.

Risk for systemic infection r/t cellulitis.

Is this enough? It seems too simple to me but I have no clue how to make it any more specific.

Esme12, ASN, BSN, RN · Feb 26, 2013

Is risk for systemic infection an NANDA I Diagnosis?

A list of diagnosis can be found here......

https://allnurses.com/nursing-student-assistance/student-resources-nursing-424826-page2.html#post6007291

leezee.loo · Feb 26, 2013

Hmm I guess not. So I'll just leave it as

Risk for infection r/t cellulitis.

Esme12, ASN, BSN, RN · Feb 26, 2013

but if they already have an infection...it is not a risk right? Assessment.....Assessment. What is the patient assessment?

She was admitted for right thumb pain and swelling. She ended up getting diagnosed with cellulitis of the right thumb. There is weeping of the skin on the lateral aspect of the right thumb and no purulent drainage as of yet.

So your patient has ACUTE PAIN related to infection and swelling

They have Impaired Skin integrity or Impaired Tissue integrity .........do they have hyperthermia?

You are picking your diagnosis then trying to fit your patient into it. SEE what you patient NEEDS and give it to them.

leezee.loo · Feb 27, 2013

Mmm I understand your thinking. So even if the patient is at risk for sepsis (the reddening of the cellulitis of her thumb spread to around her wrist area in a direct line, in other works spreading up a vein in her arm, thus causing me to worry about the infection spreading systemically), that wouldn't take priority over acute pain? I'll list the nursing dx I have for this patient in descending priority order.

1. Risk for infection r/t cellulitis (this currently is my top priority for this patient since her cellulitis showed signs of spreading. Feel free to correct me if I'm wrong! I realize that I forgot to mention the part of my assessment where I saw signs of it spreading)

2. Acute pain s/t impaired skin integrity as evidenced by weeping of the skin on the lateral aspect of the R thumb

3. Risk for ineffective peripheral tissue perfusion r/t inflammatory response secondary to infection.

4. Impaired skin integrity r/t cellulitis as evidenced by swelling, redness and weeping of the skin on the lateral aspect of the R thumb.

5. Activity intolerance s/t immobilized digits as evidenced by patient stating "I can't bend my right thumb".

6. Disturbed sleep pattern r/t pain as evidenced by patient stating "I've hardly had a wink for the past two days because my thumb hurt so much".

7. Impaired comfort r/t fatigue s/t disturbed sleep pattern

8. Risk for decreased cardiac output r/t vasoconstriction (Pt. has a history of well managed hypertension. However upon admission she missed 1-2 of her medication for her hypertension so I figured she could still be at risk)

9. Risk for ineffective tissue perfusion r/t vasoconstriction. (Not sure if I can include this even though the relating factors are different than the first one. I figured I could since like I said before her HTN is well managed and therefore this is much less priority than the above dx)

10. Readiness for enhanced self-health management r/t expression of desire to manage the illness as evidenced by patient stating "Let me know what I can do to make this better. I want to get back on my feet as soon as possible".

As a quick overview, my patient is a 41 y.o. woman with a history of HTN that is currently well managed. She was admitted two days ago for pain and swelling of her right thumb. Later diagnosed to be cellulitis. She is currently on a 2g sodium diet. Her current medications include cefazolin (IV 1gm over 30 minutes q8 hrs), acetaminophen (600 mg PO prn q6hrs for pain 1-5), and Diovan HCT (160mg/12.5mg PO daily).

Esme12, ASN, BSN, RN · Feb 27, 2013

She HAS an infection of her thumb....AEB.....

the reddening of the cellulitis of her thumb spread to around her wrist area in a direct line

Therefore THAT part of her care is clear. I don't know about your school....but "at risk for" is usually NOT considered a priority....over existing problems the patient actually HAS symptoms.

For example....you have a patient that is Short of breath (SOB).....they are no longer "at risk" for impaired gas exchange because you have EVIDENCE that they have this as an active diagnosis.

So for your patient.....you have EVIDENCE that this patient has an infection...therefore they are NO LONGER "at risk".

This would be clearer if you had a nursing diagnosis book to look you the NANDA definition of Risk for infection........

NANDA-I Definition
At increased risk for being invaded by pathogenic organisms
Risk Factors
Chronic disease; inadequate acquired immunity; inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); inadequate secondary defenses (decreased hemoglobin, leukopenia, suppressed inflammatory response); increased environmental exposure to pathogens; immunosuppression; invasive procedures; insufficient knowledge to avoid exposure to pathogens; malnutrition; pharmaceutical agents (e.g., immunosuppressants); premature rupture of amniotic membranes; prolonged rupture of amniotic membranes; trauma; tissue destruction

does you patient fit this criteria? A patient with diabeties is at risk for infections but that doesn't mean they actively have one.

Risk for decreased cardiac output r/t vasoconstriction (Pt. has a history of well managed hypertension. However upon admission she missed 1-2 of her medication for her hypertension so I figured she could still be at risk)
Risk for ineffective tissue perfusion r/t vasoconstriction. (Not sure if I can include this even though the relating factors are different than the first one. I figured I could since like I said before her HTN is well managed and therefore this is much less priority than the above dx)

Vaso-constriction of what? The NANDA definition of decreased cardiac output is......

NANDA-I Definition
Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body
Defining Characteristics (as evidenced by....)
Altered Heart Rate/Rhythm
Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Altered Preload
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Altered Afterload
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
Altered Contractility
Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
Behavioral/Emotional
Anxiety; restlessness
Related Factors (r/t)
Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

Your patient has.......

Impaired comfort r/t fatigue s/t disturbed sleep pattern

What does s/t stand for?

according to NANDA.......

NANDA-I Definition
Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental and social dimensions
Defining Characteristics
Anxiety; crying; disturbed sleep pattern; fear; illness-related symptoms; inability to relax; insufficient resources (e.g., financial, social support); irritability; lack of environmental control; lack of privacy; lack of situational control; moaning; noxious environmental stimuli; reports being uncomfortable; reports being cold; reports being hot; reports distressing symptoms; reports hunger; reports itching; reports lack of contentment in situation; reports lack of ease in situation; restlessness; treatment-related side effects (e.g., medication, radiation)

According to the evidence you supplied...your patient has.....

Impaired comfort R/T pain AEB patient lack of sleep and complaints of pain.

Do you see???

leezee.loo · Feb 27, 2013

I see I see. It's much more clear to me now. Thank you so much for your help! I really appreciate it :]

Esme12, ASN, BSN, RN · Feb 27, 2013

YOu are welcome! :)