[slinkeecat]

what have you got so far?
ineffective tissue perfusion: cardiopulmonary/peripheral r/t arterial or venous flow exchange problems: sepsis...
Risk for injury: r/t sepsis resulting in mutiple organ failure , death
ineffective protection: r/t inadequately functioning immune system
imbalanced nutrition: less than body requirements r/t generalized weakness, anorexia

address air way... if she is gunky:
ineffective airway clearance: r/t poor cough, thick secretions...

hope this helps!!!
I remember care plans well and still hate them.

[Lisa8361]

So far I have come up with:

Decreased Cardiac Output R/t inadequate fluid volume AEB hypotension and Decreased Urinary output (< 30 mL/hr) Not sure about the R/t, kind of winging it.

Interventions:

Monitor vital signs with frequent monitoring of BP

Monitor urine output with Foley catheter.


Need three more therapeutic interventions? This is making my crazier than normal.

[Daytonite]

Hi, Lisa8361!

The reason you're having problems is because you are backing into a nursing diagnosis instead of looking at the evidence you collected from your assessment of this patient to help you determine the diagnosis. Once you determine the correct nursing diagnosis your nursing interventions will fall into place. Your nursing interventions will be aimed at the patient's abnormal symptoms or problems he/she is having. Sepsis is more of a medical diagnosis. What is more important for you to be concerned with is what signs and symptoms your patient was having. You say in your post that the patient has bacterial pneumonia that has become septic. Does your patient have any of these symptoms that are typical of patients with pneumonia?

• cough
• sputum production that might be purulent
• fever
• wheezing
• pleuritic chest pain
• dyspnea
• tachypnea
• tachycardia
• headache
• fatigue

These are all the defining symptoms of the medical diagnosis of pneumonia, in general. You need to be using them in picking a nursing diagnoses, not the sepsis. There is no nursing diagnosis of pneumonia. We nurses are going to take the medical symptoms of pneumonia and group them differently to come up with our nursing diagnoses. There are several nursing diagnoses that fit those symptoms. There are independent nursing actions that you can take for every single one of those symptoms that I have listed. Now, if your patient has any of the above symptoms, you need to look up those symptoms in the alphabetical listing of symptoms, problems, medical diagnoses and clinical states in the front section of your Mosby's Nursing Diagnosis Handbook, if that's the care plan book you have. You will find them listed there. Then, you will be guided to appropriate nursing diagnoses that you can use where you will find the nursing interventions for the symptoms listed with the nursing diagnosis.

Care plans are nothing more than the written nursing process. The nursing process is (1) collect data (2) Plan care (3) implement the plan of care (4) evaluate. All that data you collected from the chart and from doing the physical assessment of the patient is what you seem to have left hanging in limbo. From all that data you pull out those items that are not normal. Those abnormal symptoms are then grouped, or clustered, together to form nursing diagnoses. NANDA has clearly defined and described what symptoms make up each nursing diagnosis. Your care plan book should be able to help you make these determinations, particularly the care plan books written by Ackley and Lagwig. If you are still having problems understanding this concept, please read these threads in the nursing student assistant forums or PM (Private Message) me:
http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)

Welcome to allnurses!

[Lisa8361]

Thank you so much for taking the time to address my little problem. I finally decided that a Nursing Diagnosis of Decreased Cardiac Output more fit the symptoms this patient is having. So I kind of did what you suggested and addressed the symtoms, in a long, round about way. Unfortunately, at this point in our clinic experience, we review the charts the night before and can only visit our patient long enough to introduce ourselves. It is a little frustrating trying to come up with a care plan for a patient you have not yet assessed.

However, my guess is that the instructors are trying to get us used to how to go about creating a care plan. Somehow I know that sentence could make better sense, but I have just packed in the books for the night and am too tired to think straight.

Thank you again for your assistance.

[Daytonite]

Decreased Cardiac Output R/T decreased preload AEB hypotension and oliguria

(The definition of this nursing diagnosis is inadequate blood pumped by the heart to meet the metabolic demands of the body.)

Nursing Interventions/Rationales:

1. Monitor blood pressure (frequency?) (Maintaining normal parameters assures adequate perfusion of all body tissues with blood, oxygen and nutrients.)
2. Listen to heart and lung sounds, monitoring for symptoms of heart failure (Looking for dyspnea, 3rd and/or 4th heart sounds and crackles in lungs which indicate heart failure and need to be reported to the physician.)
3. Monitor intake and output (Decrease cardiac output causes decreased kidney perfusion resulting in a decrease in urinary output.)
4. Administer oxygen (Supplemental oxygen provides oxygen needed for the heart and other body tissues.)
5. Place patient in semi-Fowler's postion. (Helps to ease breathing and decreases venous return to the heart.)

[earle58]

so this lady is basically comfort care?
then she's not being vented, transfused, receiving drugs/fluids for circulatory failure?
then i would concentrate on her breathing.
i guess i'm not understanding how aggressive they're being.

if she was being aggressively managed, then interventions r/t her sepsis would be more critical.
is she receiving pressors?
are her organs being perfused?
is she managing w/o a vent?

are you looking for interventions for the sepsis or end of life care?

leslie

eta: i reread all the posts. i wonder if she's not receiving aggressive care, then what good is it to monitor bp, uo, etc., if nothing is going to be done about it? is she only receiving abx? are they trying to maintain her, even knowing that she's going to die? in the event that she is comfort care, then some of these interventions mentioned, would be a moot point. i guess i do need more info.

[RStudentRN]

I am trying to work up my careplan and need some help. My patient has constipation. He is 4 days postop but I contributing his constipation to all the medication that he is on and not because of the surgical anasthesia. 6 of his 13 medications main side effect is constipation. He said he has not had a BM in 5 days, and now has been ordered a fleets enema. My question is he has some abdomen distension above his umbilicus. Would this be a subjective sign of constipation or could this be something else. I was not sure with constipation where the abdomen distension should be. Thanks R

[NurseyBaby'05]

What kind of surgery did your patient have? The distention could be from constipation. It could also be from gas or an ileus. How active has this patient been post-op? How much fluid has he taken in? Increasing activity and encouraging fluids and high fiber foods can be non-pharmacological interventions used alongside the medications. The other reason I wanted to know what kind of surgery your pt had is if it was anywhere in the abd or was a laproscopic surgery, he could be having some gas pain in addition to incisional pain. It's important that the pt be taught to differentiate between the two types of pain so he does not slow his gut down further by taking pain meds for gas pain. Just my .02. Hope it helps.

[Daytonite]

Yes, this is an objective (because you can see and observe it), not a subjective, sign of constipation and flatus build up. 5 days with no BM + air in the bowel from him being under anesthetic = abdominal distension and constipation. As the distension builds up, where's all this air and feces going to go if the patient isn't passing stool or gas? Up and pushing upward on the structures lying under the diaphragm. Even if a patient is NPO the body still makes a few grams of stool every day. The peristalsis of the GI tract is slowed immensely by anesthetic agents and narcotics that are given during OR. An empty inactive bowel fills with air. This is generally the cause of postop abdominal cramping. Give the Fleets enema to relieve the patient of the constipation and flatus. Just as a nursing action I might do an abdominal girth measurement with a tape measure before the enema and again afterward to empirically confirm if the abdominal distension were improved by the enema. Male abdomen's are capable of wondrous stretching. Their signs of bloating aren't quite the same as for females. When they bloat, they will get swelling all throughout the midriff and up to their xiphoid area.

[slinkeecat]

airway

observe and provide oral care Q __ hrs

I hate it when staff neglects the mouth...