[Daytonite]

Originally Posted by homieboi

I have a patient a 63 years old woman conscious, coherent, cold and clammy, with a temperature of 95 deg.F. She had a foley catheter in place with concentrated urine of 25cc per hour, and an IV of 5% dextrose in water. Her lips were cracked and her skin was dry and scaling. She has a pneumonia and she had already been in the hospital for 9 days. She also refused to eat for the past 2 days and had not a bowel movement for 5 days. Can somebody help me to make a Nursing Care Plan for this problem? I'm really having a hard time to make a NCP for this one. Thanks.

To write any care plan you MUST follow the nursing process (the problem solving process that nurses use). They are:

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

So, based on the information you have given. . .

Step #1 (Assessment). . .I have a patient a 63 years old woman conscious, coherent, cold and clammy, with a temperature of 95 deg.F. She had a foley catheter in place with concentrated urine of 25cc per hour, and an IV of 5% dextrose in water. Her lips were cracked and her skin was dry and scaling. She has a pneumonia and she had already been in the hospital for 9 days. She also refused to eat for the past 2 days and had not a bowel movement for 5 days.

The bolded pink items are what was found during the physical assessment. The bolded blue is the patient's medical diagnosis.

I don't see much in the way of an ADL assessment, so I don't know anything about how the patient is able to perform their bathing, dressing, transferring from bed to chair, walking, eating, use of the toilet or grooming and whether they can do them independently, require some degree of assistance or is unable to perform any of them at all. So, after you read this you need to think about the ADLs and which ones the patient could and couldn't do independently. The ADLs that she needed assistance with or couldn't perform by herself at all are patient problems that need to become part of this care plan.

The patient has a medical diagnosis of pneumonia. You need to look up the signs and symptoms of pneumonia as well as the pathophysiology of this disease (http://allnurses.com/forums/f205/pulmonary-tuberculosis-pneumonia-pathophysio-273191.html and http://allnurses.com/forums/f50/histamine-effect-244836.html). Reason: (1) for you to learn about the disease of pneumonia. This is one of the major illnesses that you are going to see people hospitalized for. You need to know about it, what it is, how doctors diagnose it, how they treat it. As a nurse, you're going to see a lot of patients over the years with pneumonia. (2) You need to know how you, as a nurse, must anticipate what the doctors are going to order and expect you to do to take care of these patients. And, (3) as a student, you need to double-check the signs and symptoms of this disease to see if you missed seeing any of them in this patient. It happens when you are a student because students are not proficient or experienced in assessment and knowledge of diseases yet, but this is how you get there.

The signs and symptoms of pneumonia are (you might find some of this information in the doctor's history and physical exam which is why you should be reviewing the patient's medical records):

• a fever, sometimes the fever will be more on the low grade side
• chills
• cough with sputum production - sputum may be purulent (pus-like or even rust colored)
• pleuritic chest pain
• breath sounds
  • will be diminished
  • you'll hear crackles, rales, rhonchi and/or wheezing
• patient may use accessory muscles to breathe
• tachypnea
• dyspnea
• dullness to percussion
• tactile fremitus
• egophony

Other information to be on the lookout for in the chart is:

• an x-ray will show patchy or lobar infiltrates or consolidations
• pulse oximetry will show decreased oxygen saturation
• WBCs on the blood counts will most likely be elevated
• sputum cultures and gram stain/smear will indicate the infective organism
• blood cultures, if they have been done, may be positive for the invading organism
• ABGs, if done, will indicate varying degrees of hypoxemia

Your study of pneumonia should also reveal to you that the complications of this illness are (any of these, depending on your patient's risk of developing them could become anticipatory nursing problems to be addressed on the care plan):

• the infection becoming septic and the patient going into septic shock (isn't this how Jim Henson, the creator of the Muppets died?)
• bacteremia
• hypoxemia
• respiratory failure
• empyema
• endocarditis
• pericarditis
• meningitis
• lung abscess
• pleural effusion

Now, what you need to do is go through the list of signs and symptoms and determine if you missed any of them in your patient. For example, in the information you posted you didn't mention anything about the patient's breath sounds and whether or not she had a cough. Most patients with pneumonia have rales or rhonchi. They may not cough because they don't want to, but their lungs are usually loaded with gunk. And, if they don't cough and get the gunk out (one of your nursing interventions) their condition gets worse. Think about all that pus sitting around down in her alveoli. Yuck!

With all this information, you are now ready to move on to. . .

Step #2 (Determination of the patient's problem(s)/Nursing diagnosis). . .and the first thing you want to do is make a list of your patient's abnormal data that you collected during your assessment. Now, I only have what you posted to work from although I suspect there is a lot more that you missed. That is something you will need to look at after reading this. However, this is the abnormal assessment data that you did provide:

• cold, clammy skin
• temperature of 95 degrees F (low grade fever)
• foley catheter in place
• concentrated urine of 25cc per hour
• lips were cracked and her skin was dry and scaling
• refused to eat for the past 2 days
• no bowel movement for 5 days

This becomes the patient's list of symptoms that you will work with for the remainder of the care plan. ADL assessment is missing and I believe there should be more signs and symptoms here as well that are missing. You will have to correct that. Step #2 of the nursing process tells you that after you develop this list of your patient's symptoms you match your symptoms (abnormal assessment data) to likely nursing diagnoses. This is very important: every nursing diagnosis has a set of symptoms which NANDA calls defining characteristics. A nursing diagnosis expresses a patient's problem; a nursing diagnosis is merely a label for the actual patient problem; the most accurate description of the patient problem is in the definition of the nursing diagnosis. The definitions for each nursing diagnosis are included in the information the NANDA publishes about the nursing diagnoses. However, NANDA does not provide this information for free. The information is sold to care plan authors as well as published in a book that NANDA sells. In order to diagnose correctly you need to have access to this NANDA information to make sure you are diagnosing correctly. Here is where you can find it:

• many currently published care plan books have nursing diagnoses in them
  • Nursing Care Plans: Nursing Diagnosis and Intervention, by Meg Gulanick and Judith L. Myers
  • Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, by Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr
• nursing diagnosis books
  • Nursing Diagnosis Handbook: A Guide to Planning Care, by Betty J. Ackley and Gail B. Ladwig
• NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008published by NANDA International
• websites
  • http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/ - approximately 75 of the most commonly used nursing diagnoses
  • http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm - about 50+ of the most commonly used nursing diagnoses

Nursing diagnoses, and later in step #3, goals and nursing interventions, are based upon the list of symptoms that you come up with. So, what you learn from your assessment activities in Step #1 of the nursing process is extremely important. This is how you go about picking nursing diagnoses. . .

Cold, clammy skin and a temperature of 95 degrees F (a low grade fever) are symptoms (or defining characteristics) of the nursing diagnosis of Hypothermia whose NANDA definition is "body temperature below normal range." Yes, that describes this patient's problem. Now, the etiology, or related factor connected with this is her infection and that related factor is also listed in the NANDA information for this particular diagnosis. So, to write the 3-part nursing diagnostic statement, which most students are required to do, it will look like this: Hypothermia related to acute illness [NOTE: you cannot use the words "infection" or "pneumonia" as related factors because they would be medical diagnoses in this particular case and you can't use medical diagnoses in nursing diagnostic statements.] as evidenced by low grade temperatures of 95 degrees F and cold, clammy skin.

Concentrated urine of 25cc per hour and cracked lips and dry, scaling skin suggest to me that this lady is pretty dehydrated. Now, dehydration is a medical diagnosis which we cannot use in a written care plan, but we do have a nursing diagnosis that includes these symptoms and focuses on this problem: Deficient Fluid Volume. The definition of this diagnosis is "decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium." While the NANDA taxonomy only lists fluid volume loss and failure of regulatory mechanism as the etiological factors for this diagnosis, they don't really describe the real reason for the dehydration here which is the patient not taking in any food or fluid. The reason is that she's just not ingesting food or fluid. I looked at the defining characteristics of Imbalanced Nutrition: less than body requirements. This probably would be a good diagnosis to use, but these symptoms of the low urine output and dry, cracked skin are not symptoms of it. So, the nursing diagnostic statement here would be Deficient Fluid Volume related to refusal to ingest fluids as evidenced by urine output less than 25cc per hour, cracked lips, and dry scaling skin.

Refusing to eat for 2 days is Imbalanced Nutrition: less than body requirements related to inability to ingest food as evidenced by refusing to eat for 2 days.

The definition of the nursing diagnosis of Constipation is "decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool." If this were my patient and I had learned she had not had a BM in 5 days I would be checking her nursing admission information to see if she had a constipation problem. Is she on a stool softener or prn laxative? Did someone do a manual check for an impaction? Does she have bowel sounds? Abdominal pain or cramps? A distended abdomen? Nausea? After that, my best guess would be that this lady is constipated because even when we don't eat, the bowel does generate solid waste product. So, I would tag this as a constipation problem and give her the diagnosis of Constipation related to insufficient fluid and fiber intake and change in eating pattern as evidenced by no BM for 5 days.

Now, I was asking myself why this foley catheter was in place. Incontinence? To accurately measure output? There is always a danger of a UTI with a catheter because it is an invasive measure. It is up to you if you want to address that. If the patient is constantly pulling on the catheter I would probably want to address it as a Risk for Injury due to the danger of her pulling it out. I leave it up to you as to whether you want to do a nursing diagnosis involving the foley catheter.

That completes Step #2 of the nursing process in doing this care plan. However, for a pneumonia patient, there is a lot missing here. There should be symptoms of coughing, shortness of breath and congested lungs, ABGs, and pulse ox readings which would lead to nursing diagnoses of Impaired Gas Exchange and Ineffective Airway Clearance. So, you need to review your patient's assessment data again to see what you missed. If the patient didn't have any cough or congested lungs, like maybe these had cleared up after a number of days on antibiotics, then they are no longer problems for this patient.




Step #3 (Planning). . .in this step you take each nursing diagnosis one by one and focus on each symptom to develop goals and nursing interventions. Like this. . .

Hypothermia related to acute illness as evidenced by low grade temperatures of 95 degrees F and cold, clammy skin.

Long term goal: By discharge patient will maintain a body temperature within a normal range of 97 to 98 degrees F orally.
Short term goal: Patient will state she is comfortable and feels warm.

Nursing Interventions:

• Monitor patient for symptoms of hypothermia: chills, pale skin, shallow respirations
• Take temperature q2hours when hypothermia is present (temp 95 degrees F or below)
• Keep patient warm with blankets
• Maintain room temperature at 78 degrees F.
• Notify physician if temperature continues to show a trend of dropping

Now, you do this with each nursing diagnosis. Your nursing interventions address the "AEB" items in the nursing diagnostic statements which are, in actuality, the patient's symptoms. We treat treat the symptoms. Your goals are what you expect to happen as a result of performing your nursing interventions.

That should help get you started. You have a lot of work to do to complete this care plan. And, from what you have posted, a care plan about pneumonia wouldn't have been of any help to you at all because this patient has other problems beside the pneumonia.