Quick Care Plan question

impaired physical mobility r/t dementia aeb altered mental status

the construction of the 3-part diagnostic statement follows this format:

• problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
  
• etiology - also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  
• symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
  

Ok, I see what your saying.. I dont have my plan in front of me... but I know I wanted to incorporate dementia into it... so I suppose a more appropriate dx would be impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremeties, pt states "My legs feel very weak when I stand".

right?

That's right.

could i have risk for infection r/t iv lock... or would i have to add more into that?

correct priority sequencing:

1. ineffective airway clearance r/t excessive mucous aeb inability to cough effectively.
   
2. activity intolerance r/t generalized weakness aeb pt states "i feel very weak all the time and don't get out of bed much".
   
   • this diagnosis is used when there are respiratory and cardiac symptoms when the patient attempts any activity and results in them having to stop the activity and sit down. weakness and not getting out of bed much is really a cause of this problem. you really haven't listed any respiratory or cardiac symptoms.
     

[*]impaired physical mobility r/t impaired balance aeb limited muscle strength in lower extremities, pt states "my legs feel very weak when i stand".

[*]impaired skin integrity r/t tissue breakdown aeb redness on sacral area.

• you should be more specific about the cause of the tissue breakdown. it would probably be due to pressure and immobility
  

[*]risk for deficient fluid volume r/t diarrhea.

[*]risk for infection r/t iv lock.

[*]risk for falls r/t diminished mental status.