Priority

Daytonite, BSN, RN · Apr 14, 2007

these are the changes i would make in the wording of your nursing diagnoses and their sequencing:

activity intolerance r/t bed rest and immobility secondary to surgery aeb tiring easily with activity
impaired physical mobility r/t atrophy of muscles and cognitive impairment secondary to alzheimer's disease and dementia aeb instability, requires support, coaching and assistance with physical activities, uncoordinated and limited movement, and requires help to turn, change position. or sit up.
total self-care deficit r/t perceptual and cognitive impairment secondary to alzheimer's disease and dementia aeb unable to dress/undress without help, unable to cut food and feed self, unable to bathe, and unable to get to bathroom unless assisted.
impaired verbal communication r/t
risk for peripheral neurovascular dysfunction r/t orthopedic surgery and immobility [physiological need for oxygen to the tissues]
risk for infection r/t surgery [physiological need for oxygen, nutrition and homeostasis]
risk for injury [safety need]. why not risk for falls r/t advanced age, mental disorientation [i assume] and impaired postoperative physical mobility?

the patient's muscle atrophy is an etiology for her impaired physical mobility and belongs with the related factors not the symptoms. think about it, what nursing interventions can you do for muscle atrophy? it is what it is. similar to contractures. not much you can do about them once you've got them. instability and requiring support and assistance are symptoms that i feel belong with the diagnosis of impaired physical mobility, not with activity intolerance. activity intolerance has to do with not having the energy to perform daily activities and instability just doesn't fit as a symptom that leads to someone being pooped out. that energy is related to oxygenation and circulation so it has to be positioned before the other diagnoses. on the total self-care deficit i would change the related factor to perceptual (watch your spelling) and cognitive impairment since they both exist. using the conjunction or between these two words implies ambiguity that it is one or it is the other. remember you are working with facts here, not suppositions (guesses). then, change the wording on your defining characteristics so it sounds more active voice. if you could be any more specific with those as well, that would be good too. what's going on with the impaired verbal communication? there's a list of the defining characteristics and related factors on this webpage: http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_015.php. remember that your "risk for" diagnoses are anticipatory problems and are always listed last after the actual problems. i think you could safely leave a diagnosis for acute pain out of this care plan since the patient isn't complaining of pain and you don't indicate that she has any other physical symptoms of pain. sometimes dementia is a blessing in that way. what injuries were you worried about the patient getting? with a history of falling, i was surprised you aren't including a diagnosis of risk for falls r/t advanced age, mental disorientation [i assume] and impaired postoperative physical mobility.

all in all--some good critical thinking on your part here! by george, i think you are getting it!

crystalcoastlvr, BSN · Apr 21, 2007

Ok, my latest patient, 84, fell and broke her hip and had hemiarthroplasty. She also has advanced Alzheimers and dementia. She needed help with most all ADL's and could'nt walk without assistance unless we coached her what to do and used walker. She never complained about pain, but was given a pain med every 4-5 hours. This is what I believe my diagnosises should be in order:
1. Impaired physical mobility r/t cognitive impairment sec. to alzheimers and dementia AEB atrophy of muscles, uncoorinated and limited movement, requires help to turn, change pos. or sit up.
2. Total self care deficit r/t perceptional or cognitive imp. sec. to alzheimers and dementia AEB req. ass. to dress/undress, cut food and feed self, bathe, go to bathroom without assistance.
3. Activity intolerance r/t bed rest and immobility sec. to surgery AEB unstable, requires support, needs assistance, tires easily, ect.
4. Risk for infection r/t...
5. Risk for peripheral neurovascular dysfunction
6. Impaired verbal communication
7. Risk for injury
Am I on the right track? Should I have musculoskeletal impairment for the r/t for imp. physical mobility instead of cog. imp. or have them both? I realize I could break up the total self care deficits to the bed, toilet, ect., but she has most all of them. I could also have alt. sensory perception or delayed surgery recovery in there. I also did my last care plan on acute pain, so we have to do it on something else for this one, but would it still be in the top 7? I'm thinking about no.4 or should I leave it out if it should be no. 1 or 2? I hate to keep asking for assistance, but hopefully I'm getting better at these and only a couple more to do.

If she is in the hospital because she broke her hip and had hemiarthroplasty, those would be her main problems she's dealing with right now. Here is my suggestion:

1. Risk for infection

2. Risk for injury (is she on heparin/lovenox or coumadin? if so risk for bleed)-she has impaired mobility and she just had surgery she is definitely at risk for thrombus formation. However she is also at risk for injury due to mobility issues, so I would put mobility under risk for falls maybe.

3. Risk for impaired tissue perfusion/impaired gas exchange/electrolye or fluid imbalance? She's elderly, immobilized, has dementia and as a result of the aging process has organs that have decreased perfusion.

5. Pain (she's getting a pain med)

6. Anxiety?/Knowledge Deficit?/

I think everything is important, but the problems that should be addressed first are the ones she is in the hospital for, the ones you would have the most impact on. Can she survive with impaired mobility? yes. Can she survive with an infection or thrombus forever? NO.

hope that helps,

jules

Daytonite, BSN, RN · Apr 21, 2007

if she is in the hospital because she broke her hip and had hemiarthroplasty, those would be her main problems she's dealing with right now. here is my suggestion:
1. risk for infection
2. risk for injury (is she on heparin/lovenox or coumadin? if so risk for bleed)-she has impaired mobility and she just had surgery she is definitely at risk for thrombus formation. however she is also at risk for injury due to mobility issues, so i would put mobility under risk for falls maybe.
3. risk for impaired tissue perfusion/impaired gas exchange/electrolye or fluid imbalance? she's elderly, immobilized, has dementia and as a result of the aging process has organs that have decreased perfusion.
5. pain (she's getting a pain med)
6. anxiety?/knowledge deficit?/
i think everything is important, but the problems that should be addressed first are the ones she is in the hospital for, the ones you would have the most impact on. can she survive with impaired mobility? yes. can she survive with an infection or thrombus forever? no.
hope that helps,
jules

what are you saying!!! you are correct in that the problems that should be addressed first are the ones she is in the hospital for. did this patient even have an infection or thrombus? no!

"risk for" diagnoses are not real problems and should never be sequenced first--ever! they are listed at the very end of the real patient problems. something that a patient is "at risk" for doesn't exist. while it may be important to plan for them not to occur, you need to use common sense and take care of the problems that are prevailing first. it would make no sense whatsoever to plan and carry out treatments for something that may never happen before addressing the patient's real problems. how would you explain that you let a patient get worse from her real problems while you were busy fooling around and planning for things that never happened? the state would call it malpractice and you should start waving because your license is going bye-bye.