1st year nursing student

jpRN84, BSN, RN · Mar 30, 2009

Pt. will provide as much self-care as possible by end of discharge. Make the goals reasonable. Make interventions like, provide assistance with grooming toileting, teach ways to improve self grooming, dressing, etc...doing easier tasks first and saving the harder ones for last. People with dementia need cues to help them remember what they are doing. People with breathing problems or CV problems need to plan ahead of time to take their time and not run out of energy or breath, and should plan small breaks in their routine to rest and catch their breath. Make the interventions personalized too. Good Luck to you!

TalldiNY · Mar 30, 2009

Hello,

As a rehab nurse specialist, I would advise to approach your total care pt from the education of the caregiver viewpoint. Create your goals in family/caregiver teaching..ex: caregiver(s) will do bolus tube feedings and g tube site care independently within 3 days. caregiver(s) will be able to verbalize understanding of dementia process, caregiver(s) will be able to demonstrate proper body mechanics in turns and transfers (skin care, etc )

Even families who place their loved ones in LTC often have one or two members who wish to be able to care for Mom or Dad while they are visiting. They need to understand the why and the how.

In that respect a goal could be emotional support for their grieving process.

Daytonite, BSN, RN · Mar 30, 2009

hi, harmony5! before i begin, i would encourage you for future posts, especially care plan questions, to post on the nursing student assistance forum.

there is a thread on allnurses that gives a general outline on how to construct a care plan: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. care plan organization and construction follows the step-by-step procedure of the nursing process. if you follow it and diligently do everything that goes on in each step you will be able to complete your care plan.

the problem i have with assisting you is that outcomes and interventions for your self care deficit dressing, bathing, grooming, toileting nursing diagnosis must be based upon assessment data that you have not provided. this would be the specific and customized information that makes the care plan unique for that patient. i tell all students when they begin a care plan that their assessment information is the most important aspect of the entire work because everything else that follows (the diagnoses, the outcomes and goals, and the nursing interventions) is all based upon the abnormal data (signs and symptoms) that you discovered. every patient's nursing problem (nursing diagnosis) has signs and symptoms and until you find them to prove and say "here's the problem!" you will have a lot of trouble making outcomes and interventions fit in.

let me start you off. the first thing you need to do is go back and assess. some of this information you may have from the chart and seeing the patient, but not all. assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - in your aebs (symptoms) for your diagnosis you list "inability to perform adl's". that is not what you observed. that is an analysis. what did you observe? what, exactly, was the inability to participate with bathing? was the patient able to hold the washcloth and scrub, or not? was the patient unable to reach certain body areas only? how was mobility a problem? could the patient walk alone or need the help of one or two people? was the patient incontinent? or, if prompted would they go to the bathroom? you really need to describe the exact deficits because there are hundreds of ways to have an "inability to perform adl's".
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - i saw mention that this patient had a cva and dementia. you need to look up information about these two medical conditions, their signs and symptoms and compare what a textbook says with what symptoms you actually observed in your patient. did they match? did you miss some symptoms that you now remember after reading about these conditions?
- http://www.merck.com/mmpe/sec16/ch211/ch211a.html - stroke
- http://www.merck.com/mmpe/sec16/ch213/ch213a.html - dilirium and dementia
- http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a.jsp - dementia in the elderly - includes symptoms and nursing home care
[*]reviewing the signs, symptoms and side effects of the medications they are taking - what medications is the patient on and how may any potential side effects affect them? also, it is not mentioned here, but are there any treatments that were ordered that may have some potential side effects?

next, make a list of everything that is not normal. use what you do in your daily life as normal, if that helps you. think of why someone like this patient needs a nurse's help and you don't and start making a list.

--------------------------------

self care deficit dresssing, bathing, grooming, toileting related to musculoskeletal impairment, hemiplegia, cva, dementia amb inability to perform adl's

i do not know what your instructors allow for diagnoses. i am aware that many nursing schools are very liberal in this. however, i do know that

self care deficit dresssing, bathing, grooming, toileting

is not an official nanda approved nursing diagnosis the way you have worded it. the related factor, which is the etiology or cause of the problem (the self care deficits), cannot be a medical diagnosis like

hemiplegia, cva,

or

dementia.

and, as i already mentioned above your manifestations, or evidence, of the problem (the self care deficits) need to be more specific than

inability to perform adl's.

here is an example of an acceptable self-care deficit diagnosis:

dressing/grooming self-care deficit r/t cognitive impairment secondary to dementia amb forgetting to change into pajamas at bedtime, failing to change into a clean pair of underwear daily, inability to match buttons/buttonholes of shirts, inability to match socks and shoes and inability to tie shoelaces

. you can see how the patient's cognitive impairment, a fancy way of saying forgetful, is the cause of their dressing problem. but to clarify it further, the medical diagnosis of dementia was cleverly worked into the statement by saying it is "secondary to" to, or responsible for, the cognitive impairment. the symptoms of this are elaborated in the ambs, and boy can you get a pretty good picture of what is going on, can't you? when someone reads a diagnostic statement they should get a visual picture of what is going on with the patient.

Harmony5 · Mar 30, 2009

Thank You soooo much. This is the type of feedback that I've been trying to pry out of my instructor. Thanks for responding in such detail. It really helps me to understand what I'm doing wrong. I'm thankful for this wonderful site!. I've been a member for about three weeks now and this is my first post. I honestly thought no one would respond to me. THANKS a million.

Harmony5 · Mar 30, 2009

Thank you so much this really helps the pieces of the puzzle to come together. I'm sure I'll be on this page at least three times a week, My instructor is not very informative and I'm gonna need all the assitance that you all out there are willing to give.

Thanks Again!

Daytonite, BSN, RN · Mar 31, 2009

please post your care plan/nursing diagnosis questions on the nursing student assistance forum (https://allnurses.com/nursing-student-assistance/) where i will find them. i do not often come onto this forum looking for student's questions.