Please Help Care Plan Making Me CRAZZZY

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Here's my issue, I currently have a client with a med diagnosis of Mild AD,COPD,Dementia and GERD. Upon meeting her I had a pleasant conversation and was able to do a pretty thorough assessment. Only repeated herself 1-2 times, other than that, very mild symtoms of her AD. Doesn't use inhaler much for COPD and only recently had elevation changes made for hs with bed for GERD. gait is fine, participates in all assisted-home activites and performs all ADL's. Having trouble with appropriate carn plan. Any ideas?

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what semester are you in?

does she have edema? poor labs? acivity intolerance, do you notice a change in v/s after she participates in care? does she use accessory muscles to breathe? go through your nursing dx book and look at all the diagnosis im sure you will come up with on. we're not medical doctors, we're nurses so we dont diagnose them per say..we just find a way to CARE for them.

how is her skin turgor, mucous membranes. etc.

List alllllllllllllllllllllllllllllll her data, then cluster them to a diagnosis

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Specializes in med/surg, telemetry, IV therapy, mgmt.

mild ad. . very mild symptoms. . .are you referring to alzheimer's disease? what are these symptoms? is that what her dementia is about? what are her symptoms of the dementia? nursing diagnoses, which are actually labels that name nursing problems are based upon the abnormal data (signs and symptoms) that you discover in your assessment of the patient which you say in your post was "pretty thorough". you mention that "elevation changes made for hs with bed for gerd". this is a treatment for a problem that the patient has, but what were the symptoms that led to this treatment being done? those symptoms will be evidence supporting a nursing diagnosis. however, without you listing any of this patient's abnormal data from your assessment i cannot help you write this care plan from just your listing of her medical diagnoses. there is information on how to construct care plans on this sticky thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

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