Very first care plan - Need help

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ok so i've been reading the care plan threads and i've learned quite a bit, but i'm having problems with my very first care plan!

i've consulted the nic and noc books, and i've created a diagnosis, but i'm having problems making the outcomes measurable!

the patient is a 76 year old female, who is living at home. she has her bedroom and bathroom on the second floor. she has 5 steps at the back and front entrances of her home. she has piles of newspapers and magazines stacked on the floors downstairs. she has hardwood floors with throw rugs all over the house. she also occassionally gets diarrhea and has beginning cataracts.

these are the outcomes that i have so far but i don't really know what i can do with them?

patient will

1. immediately begin to use handrails as needed to assist patient in walking up the stairs.

2. immediately provide adequate lighting in all rooms.

3. immediately eliminate clutter from floors and remove throw rugs.

4. identify behaviors and factors that affect risk of falls.

please help! thanks

also

this is my nsg. dx, goal and data

priority nursing diagnosis: risk for falls r/t age 65 or over, female, visual difficulties, diarrhea, diuretic usage, throw / scatter rugs, cluttered environment.

data to support nsg. dx: patient is age 76, female, has beginning cataracts, reports occasionally having diarrhea, and uses diuretic hydrochlorothiazide 12.5 mg once daily. patient has hardwood floors with rugs throughout the house, and clutter with newspapers and magazines downstairs. patient has a recent diagnosis of osteoporosis, in which minimizing the risk for falls is part of treatment to avoid fractures.

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Specializes in Certified Diabetes Educator.

Risk for fall/injury is a good nursing dx. However, you are trying to include too much stuff in one nursing plan.

The problem is the rugs, newspapers, magazines etc. Call this household hazards. This is your evidence.

What are you going to do? You are going to remove the rugs and provide adequate lighting. You also want to instruct this patient on using handrails when using the stairs.

If you do those things, what do you want to happen?? You want her to remain safe and not fall. Patient will have no falls or injuries.

So, now why is this lady at risk? Lots of people have rugs and newspapers and magazines, but it puts this lady at risk because she has visual difficulties and medications that can cause diarrhea.

Put it all together.....

Risk For Injury r/t visual difficulties and medications that can cause diarrhea AEB household hazards.

Goal: Patient will remain free of falls and injuries

Interventions: Remove household hazards such as rugs, newspapers and magazines on the floors. Instruct Pt on the importance of using handrails when using the stairs. Add additional lighting.

Evaluation: Pt states that she understands importance of using the handrails on the stairs. Pt states that when she is having diarrhea, she will sleep on the couch downstairs near the bathroom to avoid the stairs. Pt has remained free of falls and injuries.

Safety is one of the most basic needs of a person----Maslow's hierarchy of needs.

Hope this helps.

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Thanks very much that helped a lot!!

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

as i was reading through your post i had a couple of questions. is this a real patient or a case study that is just on paper? the reason i ask is because you only listed one nursing diagnosis which is an anticipated one, not an existing problem. then, i see toward the end that the patient has osteoporosis and cataracts and a few bells went off. what led to this diagnosis of osteoporosis being discovered? patients with osteoporosis often have some kind of pain, especially in the low back or neck. over time they lose height due to kyphosis and progressive deformity of the spine. eventually, they develop spontaneous fractures in the vertebrae and it doesn't take a fall for these fractures to occur. they can just happen. another thing is that she is on a diuretic. why? does she have edema? do they know why? heart problem? kidney problem? circulation problem? seems to me like there are other things going on here that you may have missed, assuming this is a real patient. even if it is not, i believe you need to address the real problems of the osteoporosis and the cataracts as well as any risk for falls or injury. patients with cataracts often also have associated hypertension and arteriosclerosis.

you cannot get to the development of measurable outcomes until you have decided on some nursing diagnoses. let me also explain that outcomes are the predicted results of our independent nursing actions. until you have decided on some of the independent nursing actions you are going to take, you cannot start to list any outcomes. you have three things to consider when formulating outcomes. your patient's problem will either (1) improve (2) stabilize, or (3) deteriorate. your nursing interventions will focus on one of those three things. it is perfectly ok for nursing to support the deterioration of a patient's condition. when you word an outcome, you state it something like this: by december 25, 2006 there will be 10 presents under the christmas tree that will need to be unwrapped. the statement has a time frame and is specific.

not knowing any more than the information you have given, my suggestions for nursing diagnoses would be the following, in priority sequence, and i'm also giving you links to online information about those nursing diagnoses:

  1. disturbed sensory perception: vision r/t alteration in vision aeb [needs assessment data collected from the patient] http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=46 http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_062.php
  2. deficient knowledge r/t diet and exercise secondary to osteoporosis aeb [needs assessment data collected from the patient] http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=34 http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_044.php
  3. risk for injury r/t disturbed sensory perception, effects of medications, and degeneration of bone http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_043.php

here is a link to nursing diagnosis information on risk for falls

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_026.php

let me also say that the general formula for putting together a nursing diagnosis statement is pes.

p(problem)--e(etiology)--s(symptoms)

the problem is the nanda nursing diagnosis label that you choose based on the grouping of the symptoms that patient has. the etiology is what is causing the symptoms. the symptoms are the abnormal data you found in your assessment of the patient.

have you checked out the posts in these threads that apply to assessment and care planning?

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Specializes in OR, MS, Neuro, UC.

can't say it any better than Daytonite has but I want to stress ....

get familiar with Ackley. Know how to use the book and you will ace care planning. Good luck!

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thanks... this is a case study on paper so the missing information is data gaps that we are required to find

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

I see. Well, I think you should also focus on the osteoporosis, cataracts, and that diuretic. Look up the signs and symptoms of these two conditions and use them to come up with more symptoms that this patient will have. Go with real problems first rather than problems that don't already exist. I think you did well with determining the patient is at risk for falling at her home. However, she has some other serious health problems going on as well that you should also be considering, OK?

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very very thank you

this is also my case study & pt have the same diagnosis

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