[mkcrturner]

yup, I got the careplan concept mastered.... Piece of cake....review patients problems- check,
work backwards- check.
I was quite proud of myself.. Now comes the wrench.
I need to do nursing diagnosis and interventions on an imaginary pediatric patient with otitis and one with tonsillitis. I need 3 for each disease. I froze up and went blank, this is HARD. I have no m/b or AEB cuz there is no patient. 20 months of doing this based on what I am seeing, now I need to fake it??!! I LOVE nursing school! LOL

Anyway, I tried to be thoughtful, and I did not want to pull the 2 out of the book that I know most people in the class will use. We needed 3 FULL diagnoses with the r/t and m/b. Then we needed goals and interventions...

I muddled through tonsillitis, and for otitis I came up with:
1- Acute Pain R/T infectious disease process M/B patient complaints of pain in both ears (this is a gimme)
2- Anxiety, mild r/t hospitalization m/b decreased pulse and sleep disturbance.
3- Disturbed Sensory Perception: Auditory, r/t chronic otitis, m/b head tilting, pt cups ears with hands, pt cannot walk straight and states his “head is spinning”, pt states his ear hurts.
Be gentle, I know I do not have exact things like "pain is 8/10" but the instructor said to be real generic and include things that COULD be a symptom. This is what is throwing me for a loop. I cannot do a pretend person! LOL
Will these suffice? And if you have advice for interventions for the disturbed sensory perception I would love to hear them.

TIA~
Kelly the student who needs a real patient with real S&S to dignose them! LOL


I

[Daytonite]

Originally Posted by mkcrturner

yup, I got the careplan concept mastered.... Piece of cake....review patients problems- check,
work backwards- check.
I was quite proud of myself.. Now comes the wrench.
I need to do nursing diagnosis and interventions on an imaginary pediatric patient with otitis and one with tonsillitis. I need 3 for each disease. I froze up and went blank, this is HARD. I have no m/b or AEB cuz there is no patient. 20 months of doing this based on what I am seeing, now I need to fake it??!! I LOVE nursing school! LOL

Anyway, I tried to be thoughtful, and I did not want to pull the 2 out of the book that I know most people in the class will use. We needed 3 FULL diagnoses with the r/t and m/b. Then we needed goals and interventions...

I muddled through tonsillitis, and for otitis I came up with:
1- Acute Pain R/T infectious disease process M/B patient complaints of pain in both ears (this is a gimme)
2- Anxiety, mild r/t hospitalization m/b decreased pulse and sleep disturbance.
3- Disturbed Sensory Perception: Auditory, r/t chronic otitis, m/b head tilting, pt cups ears with hands, pt cannot walk straight and states his “head is spinning”, pt states his ear hurts.
Be gentle, I know I do not have exact things like "pain is 8/10" but the instructor said to be real generic and include things that COULD be a symptom. This is what is throwing me for a loop. I cannot do a pretend person! LOL
Will these suffice? And if you have advice for interventions for the disturbed sensory perception I would love to hear them.

TIA~
Kelly the student who needs a real patient with real S&S to dignose them! LOL

Kelly, you are almost there. You actually have all the information you need-->a patient with a medical diagnosis so you can look up the signs and symptoms of that disease or medical condition in order to determine their nursing problems.

Your two patients have otitis (did they specify which type of otitis?) and tonsillitis. You need to look up the signs and symptoms of these two medical conditions and how the doctors diagnose and treat them. From that information you abstract how we nurses are going to deal with the situation. Many of the signs and symptoms of these conditions are the same signs and symptoms that we would also pick up when we do our assessment at the patient. You can also "imagine" what ADL problems might be involved.

Some time ago I posted a whole bunch of websites to help students find information about Medical Disease Information/Treatment/Procedures/Tests (http://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html). Please use them in putting these care plans together. http://www.baptistonline.org/health/library/child.asp - information about earache and tonsillitis in children can be found here

I would suggest that after looking at the S/S and medical treatment of these conditions that you will find different nursing problems of a higher priority than Anxiety, especially in a child. Children handle separation from their parents differently than adults, if they need to be hospitalized. They also have magical thinking about what happens during hospitalization or surgery, so their teaching needs are approached differently from adults.

Let me add another website where you can see samples of actual postop generic care plans for all kinds of surgeries and these are two cases of potential surgical outcomes:

• http://www.pana.org/ - generic care plans for all kinds of surgeries – to access the care plan bank, click on the "Student Activities" link at the left side of the home page. When the PANA Student Resources page comes up, scroll down and click on the "Care Plan Bank" link. These are intraoperative care plans.
  

By the way, the care plan concept is to assess the patient, analyze the abnormal data and determine what their nursing problems are and then to develop goals and interventions that are focused upon the abnormal data to:

• improve the patient's condition
• stabilize the patient's condition
• support the deterioration of the patient's condition

I hope that is what you were referring to by working backwards! Be aware that sometimes the patient's nursing problem can't be fixed. Sometimes the best we can do is support the deterioration of the patient's condition, and that is Ok.

[mkcrturner]

Originally Posted by Daytonite

the care plan concept is to assess the patient, analyze the abnormal data and determine what their nursing problems are and then to develop goals and interventions that are focused upon the abnormal data to:

• improve the patient's condition
• stabilize the patient's condition
• support the deterioration of the patient's condition

I hope that is what you were referring to by working backwards! Be aware that sometimes the patient's nursing problem can't be fixed. Sometimes the best we can do is support the deterioration of the patient's condition, and that is Ok.

That is exactly what I meant. I am used to having some actual 'abnormals' to evaluate to lead me to the nursing diagnosis. Thanks to this board I never made the common beginning error of thinking- this patient has COPD, so they must be having some air exchange issues....
I knew to assess the patient and work off their abnormals to lead me to a diagnosis.

I am not used to "pretend your patient has otitis (not specified) and come up with 3 diagnoses and some interventions"
There are sooo many things that could need to be addressed there is no way to address them all.

Thanks for the links, I am on my way now to look further into symptoms to create a patients condition then redo the diagnosis.

[RLynn39]

I am trying to come up with a nursing care plan for a woman, SR, after an interview based on "Health-Perception/Health-Maintenance."

My patient has just recently been diagnosed with hyperparathyroid disease. She is complaining of pain in her bones (specifically her feet), inability to sleep/fatigue, headaches, "foggy thinking," and overall irritability.

My initial attempts at creating a PES nursing diagnoses are giving me serious trouble!

Here is what I have come up with: (and I need to select just ONE)

Impaired physical mobility related to pain and discomfort secondary to joint stiffness as evidenced by instability during performance of routine ADL.

Chronic pain related to joint stiffness as evidenced by client's self report of pain intensity of 8 on scale of 1 to 10.

OBVIOUSLY I am having trouble verbalizing these things. I know I cannot use HPT disease as part of my diagnoses.

I feel fairly confident in building my nursing nterventions and outcomes, but cannot come up with a proper diagnoses.

ANY suggestions would be GREATLY appreciated!
R

[Daytonite]

Originally Posted by RLynn39

I am trying to come up with a nursing care plan for a woman, SR, after an interview based on "Health-Perception/Health-Maintenance."

My patient has just recently been diagnosed with hyperparathyroid disease. She is complaining of pain in her bones (specifically her feet), inability to sleep/fatigue, headaches, "foggy thinking," and overall irritability.

My initial attempts at creating a PES nursing diagnoses are giving me serious trouble!

Here is what I have come up with: (and I need to select just ONE)

Impaired physical mobility related to pain and discomfort secondary to joint stiffness as evidenced by instability during performance of routine ADL.

Chronic pain related to joint stiffness as evidenced by client's self report of pain intensity of 8 on scale of 1 to 10.

OBVIOUSLY I am having trouble verbalizing these things. I know I cannot use HPT disease as part of my diagnoses.

I feel fairly confident in building my nursing interventions and outcomes, but cannot come up with a proper diagnoses.

ANY suggestions would be GREATLY appreciated!
R

Care planning starts with an assessment from which you list out your patient's abnormal data:

• pain in her bones (specifically her feet) intensity of 8 on scale of 1 to 10
• headaches
• joint stiffness
• instability during performance of routine ADL
• inability to sleep/fatigue
• "foggy thinking"
• overall irritability

These items become the basis for the nursing diagnoses, goals and nursing interventions. They are, specifically, the defining characteristics (AEB items or symptoms) that are used to determine what the patient's nursing problems, or nursing diagnoses, are.

The patient's medical diagnosis and/or conditions, in this case, her hyperparathyroidism, is important in determining what the etiology or cause of some of her symptoms are. So, you need to know the pathophysiology of hyperthyroidism in order to help understand and explain why some of the above symptoms are occurring, or look for other things that might be contributing to the cause of this patient's nursing problems which could be anything from a medical condition to a psychosocial or financial one. This becomes important in the formation of your nursing diagnostic statements--the "E" part of the PES diagnostic statement.

With hyperparathyroidism there is often enlargement of one or more of the parathyroid glands which results in increased PTH (parathyroid hormone) secretion and elevated calcium levels. This is what causes the manifestations of the disease. There is primary and secondary hyperparathyroidism. Secondary hyperparathyroidism results in renal failure and eventually hypercalcemia. There are many pathologic changes in the bones (pathologic fractures, kyphosis of the spine, compression fractures of the vertebrae of the spine). It is more common in women, particularly postmenopause, than men. Symptoms include muscle weakness and atrophy, psychomotor disturbances, stupor that can lead to coma, skin necrosis and subcutaneous calcification. Complications include nephrolithiasis (kidney stones), polyuria, hematuria, chronic lower back pain, easy fracturing of the bones, osteoporosis, constant and severe epigastric pain that radiates to the back, abdominal pain, anorexia with nausea and vomiting, constipation, polydipsia, muscle weakness especially in the legs, lethargy, personality disturbances, depression, psychosis, cataracts and anemia. (page 394-395, Nurse's 5-Minute Clinical Consult: Diseases from Lippincott Williams & Wilkins) And, it sounds like your patient has some of these symptoms and complications already

The 3-part nursing diagnosis statement has this structural format:

P - E - S

P= Problem
E= Etiology
S = Symptoms

or

Problem - Etiology(ies) - Symptoms

these are, in NANDA language,

Nursing Diagnosis - Related Factor(s) - Defining Characteristic(s)

in a care plan they look like this:

PROBLEM [related to]ETIOLOGY(IES)[as evidenced by]SYMPTOM(S)

or

NURSING DIAGNOSIS [related to] RELATED FACTOR(S) [as evidenced by] DEFINING CHARACTERISTIC(S)

Impaired physical mobility related to pain and discomfort secondary to joint stiffness as evidenced by instability during performance of routine ADL. Change to: Impaired Physical Mobility related to pain and discomfort secondary to effects of hyperthyroidism as evidenced by instability during performance of routine ADL.

The P (problem) and E (etiology) are correct. The joint stiffness is a symptom of the bone problems of hyperthyroidism. The symptom is OK, but it could be stated in a more specific way, such as, "unable to maintain hold on utensils when eating", "jerky" or "shaky movements". In other words, what specifically is limiting or causing problems with her movement so it isn't as physically purposeful as yours. Are her fingers stiff? Her movements just s-l-o-w? Does she loose her balance? To give you an idea. . .I have shakiness and muscle spasms in my fingers that cause me to lose my grip on things and drop objects; I also stay close to walls and furniture when I walk so I can lean against or grab onto them when I move so I don't lose my balance and fall. That is my nursing impairment with mobility and it specifies the S (symptoms) or defining characteristics. My nursing diagnosis would be Impaired Mobility R/T neural impairment due to effects of chemotherapy, radiation therapy and carpal tunnel syndrome AEB shakiness and muscle spasms in the fingers when holding or gripping objects, dropping objects, and leaning against walls or grabbing onto furniture to maintain balance while ambulating.

Chronic pain related to joint stiffness as evidenced by client's self report of pain intensity of 8 on scale of 1 to 10.

The etiology, or cause, of chronic pain has to be from some kind of tissue damage or something abnormal in the tissues that is the cause of a physical or psychosocial disability. The pain this patient has is "in her bones (specifically her feet)". So what is the cause of the pain in the bone? That is where knowing about her disease of hyperparathyroidism is going to help. The pain in the joints is due to deposits of calcium in the tissues of the joints. And, my pathophysiology book (Pathophysiology: The Biologic Basis for Disease in Adults and Children, third edition, by Kathryn L. McCance and Sue E. Heuther) says that gout and pseudogout as a result of hyperuricemia and chronic renal failure due to high excretion of calcium and phosphates is also a cause of this arthritic type of pain and arthralgia. Arthritis is inflamed joints. The symptoms of inflammation are redness, heat, swelling and pain.

The bone pain is most likely the result of calcium deposits in the soft tissues around the joints because of the hypercalcemia of hyperparathyroidism. The general term for inflammation of the joints is arthritis. Joint stiffness (that you mentioned back in Impaired Physical Mobility) is a common symptom of arthritis and osteoarthritis. But, with an etiology of a bone disease as a cause of the chronic pain, you have to word the E (Etiology) part of the diagnostic statement so that it doesn't contain medical disease language but still states the physical disability that has caused the tissue damage that is now resulting in her chronic pain. So, I would rewrite this as Chronic Pain R/T inflamed joints secondary to hyperparathyroidism AEB statement of the patient of "pain in her bones", specifically her feet, with an intensity of 8 on scale of 1 to 10.

FYI. . .your nursing interventions and outcomes are based upon the S (symptoms) that support the P (problem) which you now proceed to treat by developing interventions to either (these are your overall outcomes)

• improve and/or remedy
• stabilize
• support the deterioration

of the P (problem) or the E (etiology) or cause. In general, nursing interventions, much like medical interventions treat the symptoms.

Do you want to do anything about her headaches, inability to sleep, fatigue, "foggy thinking" or overall irritability?

[RLynn39]

My goodness! THANK YOU for all the time and thought you put into your response! Very elucidating!

I've put a lot of work into this assignment since last night, and I think that I have a better grasp on the material. Your thorough explanation sure is helpful!

Yes, I would like to do something "about her headaches, inability to sleep, fatigue, "foggy thinking" or overall irritability." I am assuming these symptoms are related to the pain, though, no? If we alleviate her pain, won't her sleeping improve, thus decreasing her fatigue, headaches, and/or irritability? How would I incorporate these symptoms into only one nursing diagnoses (as the assignment dictates)? Is that possible?

Can't thank you enough! What a valuable resource you and this forum is!
Rm

[RLynn39]

Arg. Forgive me if I sent a duplicate. Computer is having trouble.

THANK YOU so much for all the time and thought you put in to this post!

I have spent a good deal of time on this assignment since my post, but definitely have not had the clarity I received from you!

Yes, yes I definitely want to do something about her symptoms of headache, fatigue, irritability, etc. How do I incorporate those symptoms into this ONE diagnosis (as dictated by my assignment)? Would they go under an additional diagnosis? Wouldn't alleviating her pain enable her to sleep and subsequently alleviate headaches, fatigue, irritability, etc?

THANK YOU again. What a valuable and incredibly knowledgeable resource you are!
Rm

[Daytonite]

Originally Posted by RLynn39

Yes, I would like to do something "about her headaches, inability to sleep, fatigue, "foggy thinking" or overall irritability." I am assuming these symptoms are related to the pain, though, no? If we alleviate her pain, won't her sleeping improve, thus decreasing her fatigue, headaches, and/or irritability? How would I incorporate these symptoms into only one nursing diagnoses (as the assignment dictates)? Is that possible?

That's why I asked about them. Keep in mind that every diagnosis describes a problem and has a set of symptoms that characterizes it (as in defining characteristics).

• Anxiety R/T physiological stress secondary to electrolyte imbalance AEB irritability, inability to sleep, and "foggy thinking".

The electrolyte imbalance is the calcium. It would be nice if there was some labwork to support that.

If her headaches are chronic, include them with the diagnosis for Chronic Pain. I wasn't sure when I was originally answering your question if they were related to the hyperparathyroidism or they were due to something else. If they are due to something else, you have to add that related factor to the diagnostic statement. If the headaches are something new, then the diagnosis for them should rightfully be Acute Pain.

[bailey88]

I need help with care plan for a schizophrenic (disorganized type )and nephropathy, has history of swallowing metal objects . Have done care plans on med-surg patients , but never on mental illness .
Any info would help . Thanks

[Daytonite]

Originally Posted by bailey88

I need help with care plan for a schizophrenic (disorganized type )and nephropathy, has history of swallowing metal objects . Have done care plans on med-surg patients , but never on mental illness .
Any info would help . Thanks

All care planning begins with doing a thorough assessment of the patient. Assessment includes:

• collecting data from medical record
• doing a physical assessment of the patient
• assessing ADL's
• looking up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology--in this instance you need to look up information about
  • schizophrenia (a link to the pathophysiology is on http://allnurses.com/forums/2634117-post49.html)
  • nephropathy
  • ingestion of foreign objects

You want to isolate and make a list of the abnormal data that you discover during your assessment. That list of abnormal data is what you use to

• choose nursing diagnoses
  • determine goals
  • develop nursing interventions