Help with Care Plans - Page 11

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  1. Oct 29, '08 by
    yea you would want to assess their knowledge of the disease and their prescribed management because the only thing to really to is to yes maintain their condition because it will be hard for them to carry out their lifestyle modifications if they do not fully understand the effects of their condition. another priority would be to have routine bp checks
  2. Oct 30, '08 by
    I could use some help...my final care plan is due tomorrow from last nights patient. I need diagnoses for each system, as well as 4 priority diagnoses for her problems...I have a few in mind here, and am working on it..but this thing is worth 150 points out of 300 needed to pass!
    49 yr old female:
    Admitted for acute abd. pain, nausea, vomiting. Diagnostic laparoscopy performed on day 2 of hospitalization for partial bowel obstruction, lysis of adhesions...5 small incisions in abd.
    Surgical hx includes: 2006 gastric bypass
    Spring 2008:Hernia repair (5 areas) and cholecystectomy at that time.
    Summer 2008: Appendectomy
    Medical Hx: Hypertension, GERD, Migraine headaches, Depression. States she was told she had a slight "heart murmur"-but does not require SBE prophylaxis...nothing listed in her chart about this. Weight loss of 85 lbs since gastric bypass surgery, 6 lb weight loss since hospitalization (4 days)
    states she follows the Southbeach diet at home.
    Meds include Protonix, Zoloft, Norvasc, Multi vitamins at home. (hospitalization includes zofran, dilaudid q2h prn, heparin therapy)
    She requires and requests pain meds every 2 hours...
    Foley d/c'd today, voiding
    VS BP:135-69, Pulse: 64, Resp: 20, normal, lungs clear, Pulse ox 95% RA.
    She smokes 4-6 cig./day
    Labs:Abnormals only
    RBC: 3.75
    HGB: 10.4
    HCT: 31.0
    RdW: 15.8
    PLATELET: 235
    NEUT ABS: 6.9
    LYMPH ABS:0.8
    NEUT: 87.4
    LYMPH: 10.0
    Fasting Glucose: 132--only time it was elevated
    She was A&O xs 3--pain averaged 7-8, and after Dilaudid, 5 at best.
    Ambulating, voiding, BM day 2 post op
    nd: Acute Pain? Nutrition less than requirements r/t bypass, Body image disturbed? Readiness for enhanced nutrition? Anxiety? R/f unstable glucose? R/f Infection r/t incisions? Does smoking come into play here for lungs? what about ND's for systems w/ no problems! Interruption in family process? (married, 1 child) ugh! I gotta get working on this...will be good to see your responses and if I'm on the right track!
    Last edit by imac on Oct 30, '08 : Reason: typographical error
  3. Oct 30, '08 by
    tullosrn2010. . .would you please include a quote of the poster you are answering, please. I am getting confused and answering your posts when I just realized that you are answering someone else's posts. This is a sticky thread, so members post all kinds of questions here for help. If there are several questions posted at one time by different members it is difficult to keep track of who is responding to who or answering which questions.
    Last edit by Daytonite on Oct 30, '08
  4. Oct 30, '08 by
    Quote from imac
    i could use some help...my final care plan is due tomorrow from last nights patient. i need diagnoses for each system, as well as 4 priority diagnoses for her problems...i have a few in mind here, and am working on it..but this thing is worth 150 points out of 300 needed to pass!
    49 yr old female:
    admitted for acute abd. pain, nausea, vomiting. diagnostic laparoscopy performed on day 2 of hospitalization for partial bowel obstruction, lysis of adhesions...5 small incisions in abd.
    surgical hx includes: 2006 gastric bypass
    spring 2008:hernia repair (5 areas) and cholecystectomy at that time.
    summer 2008: appendectomy
    medical hx: hypertension, gerd, migraine headaches, depression. states she was told she had a slight "heart murmur"-but does not require sbe prophylaxis...nothing listed in her chart about this. weight loss of 85 lbs since gastric bypass surgery, 6 lb weight loss since hospitalization (4 days)
    states she follows the southbeach diet at home.
    meds include protonix, zoloft, norvasc, multi vitamins at home. (hospitalization includes zofran, dilaudid q2h prn, heparin therapy)
    she requires and requests pain meds every 2 hours...
    foley d/c'd today, voiding
    vs bp:135-69, pulse: 64, resp: 20, normal, lungs clear, pulse ox 95% ra.
    she smokes 4-6 cig./day
    labs:abnormals only
    rbc: 3.75
    hgb: 10.4
    hct: 31.0
    rdw: 15.8
    platelet: 235
    neut abs: 6.9
    lymph abs:0.8
    neut: 87.4
    lymph: 10.0
    fasting glucose: 132--only time it was elevated
    she was a&o xs 3--pain averaged 7-8, and after dilaudid, 5 at best.
    ambulating, voiding, bm day 2 post op
    nd: acute pain? nutrition less than requirements r/t bypass, body image disturbed? readiness for enhanced nutrition? anxiety? r/f unstable glucose? r/f infection r/t incisions? does smoking come into play here for lungs? what about nd's for systems w/ no problems! interruption in family process? (married, 1 child) ugh! i gotta get working on this...will be good to see your responses and if i'm on the right track!
    what are the "systems" you must address? are they just the physiological body systems, or are psychosocial items also included in there? i would then organize the evidence (signs and symptoms) that i have for each of those "systems" because you cannot have a diagnosis without proof to support it.

    if you have looked at any of the replies i have made to questions on this thread, including the last one to one of your questions, you know that i always start by grouping the patient data. there is a difference between the data that is just informational and contributes to knowledge about the patient and what is going on and abnormal assessment data that is evidence of the nursing problems. i have no idea of which systems you have to come up with diagnoses for; i can only group the evidentiary data you did post by systems.

    step 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
    • diagnostic laparoscopy performed on day 2 of hospitalization for partial bowel obstruction, lysis of adhesions
    • gastric bypass in 2006 - 85 lbs weight loss since surgery
    • follows the south beach diet
    • hernia repair and cholecystectomy in 2008
    • appendectomy this past summer
    • hypertension
    • gerd - can there be loss of blood and anemia with this?
    • migraine headaches
    • depression
    • states she was told she had a slight "heart murmur"
    • smokes 4-6 cig./day
    • meds include (did you look each of these up and why they are given?):
      • protonix
      • zoloft
      • norvasc
      • multi vitamins - i know a lot about gastric bypass surgery and this is why she is getting the vitamins and will need to take them for the remainder of her life, but do you understand why?
    • hospital meds include:
      • zofran
      • dilaudid q2h prn - requests every 2 hours
      • heparin therapy + iv - why is she being anti-coagulated?
    • other treatment:
      • foley catheter which was d/c'd today
    step #2 determination of the patient's problem(s)/nursing diagnosis - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use –
    1. acute pain?
      • better: acute pain r/t abdominal distension
        • abdominal pain
        • last bm 2 days ago
        • pain averaged 7-8, and after dilaudid, 5 at best
    2. nutrition less than requirements r/t bypass
      • better: nutrition: less than body requirements r/t inability to ingest adequate amounts of food secondary to gastric bypass surgery
        • 6 lb weight loss in past 4 days
        • nausea
        • vomiting
    3. deficient fluid volume r/t fluid volume loss (these are symptoms of anemia)
      • rbc: 3.75
      • hgb: 10.4
      • hct: 31.0
    4. impaired tissue integrity r/t surgical intervention
      • 5 small incisions in abdomen
    5. r/f infection r/t incisions?
      • better: risk for infection r/t surgical intervention
      • neut abs: 6.9
      • lymph abs:0.8
      • neut: 87.4
      • lymph: 10.0
    6. risk for injury r/t anticoagulation (on heparin therapy)
    anxiety? - problem: where is the evidence of this?
    body image disturbed? - problem: where is the evidence of this?
    readiness for enhanced nutrition? problem: did the patient express a desire to learn more about her diet? most bypass patients follow very special diet needs (vitamins, protein) prescribed by their surgeons that the surgeons are pretty strict about. did you discuss this with her?
    r/f unstable glucose? - is this patient even a diabetic? could the elevated glucose have been due to iv fluids?
    does smoking come into play here for lungs? you can use a wellness diagnosis (readiness for enhanced. . .r?t desire to improve) to stop smoking
    what about nd's for systems w/ no problems! again, you use a wellness diagnosis (readiness for enhanced. . .) see http://allnurses.com/forums/1924722-post85.html for a list of them.
  5. Nov 1, '08 by
    Quote from daytonite
    step #2 determination of the patient's problem(s)/nursing diagnosis - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use –
    1. acute pain?
      • better: acute pain r/t abdominal distension
        • abdominal pain
        • last bm 2 days ago
        • pain averaged 7-8, and after dilaudid, 5 at best
    2. nutrition less than requirements r/t bypass
      • better: nutrition: less than body requirements r/t inability to ingest adequate amounts of food secondary to gastric bypass surgery
        • 6 lb weight loss in past 4 days
        • nausea
        • vomiting
    3. deficient fluid volume r/t fluid volume loss (these are symptoms of anemia)
      • rbc: 3.75
      • hgb: 10.4
      • hct: 31.0
    4. impaired tissue integrity r/t surgical intervention
      • 5 small incisions in abdomen
    5. r/f infection r/t incisions?
      • better: risk for infection r/t surgical intervention
      • neut abs: 6.9
      • lymph abs:0.8
      • neut: 87.4
      • lymph: 10.0
    6. risk for injury r/t anticoagulation (on heparin therapy)
    hi daytonite,
    i had a pt today who had gbp surgery 7 years ago. she was hospitalized b/c her primary care physician requested she get blood. her h&h levels were low.
    do you think i could use #2 or #3 from you list above ? i am having trouble because i have no s & s except her lab values for h& h. by the time i met her she already received blood and said she felt great. not sure how to go about a care plan for someone who does not seem to have any trouble. they wanted to run some more test on her for fibroids . she also had some gouty issues which is why she went to see he pcp in the first place. she says she eats well and has not had any problems since her gastric bypass. can i do a care plan for imbalanced nutrition even though i am not sure why she is anemic? anemia apparently "runs in her family" ??????
    help
    thanks
    chicagrl
    Last edit by chicagrl on Nov 1, '08 : Reason: used wrong item numbers
  6. Nov 1, '08 by
    Quote from chicagrl
    hi daytonite,
    i had a pt today who had gbp surgery 7 years ago. she was hospitalized b/c her primary care physician requested she get blood. her h&h levels were low.
    do you think i could use #2 or #3 from you list above ? i am having trouble because i have no s & s except her lab values for h& h. by the time i met her she already received blood and said she felt great. not sure how to go about a care plan for someone who does not seem to have any trouble. they wanted to run some more test on her for fibroids . she also had some gouty issues which is why she went to see he pcp in the first place. she says she eats well and has not had any problems since her gastric bypass. can i do a care plan for imbalanced nutrition even though i am not sure why she is anemic? anemia apparently "runs in her family" ??????
    help
    thanks
    chicagrl
    step #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
    • anemic - a blood transfusion doesn't fix the problem. the h&h is still low, so she is still anemic. do they know why yet? maybe it has something to do with the fibroids? (http://www.merck.com/mmpe/sec18/ch248/ch248a.html)
    • fibroids - is she having pain? is she having any problems urinating or with incontinency as a result of the fibroids? fibroids can also cause constipation. what tests are planned? perhaps some teaching related to fibroids and testing can be done
    • gouty issues which is why she went to see he pcp in the first place - same as above. . .pain? swelling? problems walking? need for education regarding gout and its treatment? (http://www.merck.com/mmpe/sec04/ch035/ch035b.html)
      • deficient fluid volume r/t fluid volume loss
      • impaired urinary elimination r/t obstruction by fibroids
      • impaired physical mobility
      • (acute or chronic) pain r/t inflammatory process in large joint of toe, inflammatory process in uterus
      • deficient knowledge, gout, uterine fibroids
  7. Nov 1, '08 by
    Thanks Daytonite!

    The problem is , I don't have any answers. I was only with her for about 5 hours this am. She had just finished the blood transfusion and SAID she felt better - they drew blood to check her levels but I don't have the results.

    She had a painful swollen ankle previously, her uric acid levels are in normal range but I guess she good still have gout - they don't really know. She does not currently have and S&S for gout.

    She was going for some type of gyne stuff to see if there were fibroids. She did not complain of any symptoms, has not had any S&S either but they are trying to rule everything out.

    Vitals, all within normal ranges.

    Don't really know where to go with this....
  8. Nov 1, '08 by
    Quote from chicagrl
    thanks daytonite!

    the problem is , i don't have any answers. i was only with her for about 5 hours this am. she had just finished the blood transfusion and said she felt better - they drew blood to check her levels but i don't have the results.

    she had a painful swollen ankle previously, her uric acid levels are in normal range but i guess she good still have gout - they don't really know. she does not currently have and s&s for gout.

    she was going for some type of gyne stuff to see if there were fibroids. she did not complain of any symptoms, has not had any s&s either but they are trying to rule everything out.

    vitals, all within normal ranges.

    don't really know where to go with this....
    work with what you have. you know she is anemic. that is one thing you can care plan. you know she has swollen ankles. do some investigation of why people might get swollen ankles and work up some interventions to care for them. that is a second thing you can care plan. a third thing would be to educate her about fibroids and how they are diagnosed. i wouldn't be surprised to discover that her anemia is secondary to them.
    chicagrl likes this.
  9. Nov 1, '08 by
    Thanks so much for your insight and analagy. I'm a student nurse, care planning for months now and this was better than the explainations that my instructors have given!
  10. Nov 3, '08 by
    I Have An Extremely Helpful Book That Has Gotten Me Through Care Plans Called "nurse's Pocket Guide-diagnoses, Interventions, And Rationales" The Ninth Edition, I'm Sure There Is A More Recent Edition. Hope This Helps!!! Good Luck