Would this NDS be correct for a care plan? Need guidance.

  1. Scenario:

    PT has primary medical diagnosis of respiratory failure. Secondary include GERD, brain damage, depression, and hypertension.
    PT weighs 240 lbs.
    PT cannot move around and ambulatory needs include wheel chair.
    PT has edema near legs.
    PT's BP is within normal range.
    PT has no pain, has no shortness of breath, and is oriented.
    PT repeatedly requests for coffee or tea because of dehydration, but is restricted by RN from taking any more fluids. (probably not cognitive impairment, I assume.)

    Primary NDS: Risk for skin breakdown r/t immobility AEB edema on legs. (Is this the correct format?)

    Other NDS for consideration: Risk for falls r/t immobility AEB lying in wheel chair
    Cognitive impairment r/t chronic confusion AEB repeatedly asking for fluids (Probably won't work..)
    Hypertension r/t altered cardiac output (HTN) AEB higher blood pressure (Not priority)

    Any pointers are appreciated!
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    About J-Swish

    Joined: Jan '11; Posts: 81; Likes: 45


  3. by   Freedom42
    Look at your primary medical diagnosis. What is your priority, given that diagnosis?
  4. by   srobb11
    Exactly. Remember ABC (airway, breathing, circulation), these need to be addressed first.
  5. by   Esme12
    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:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. 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)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)

  6. by   J-Swish
    Helped alot. Thanks guys.