Help with Care Plans

First of all, thank you very much for your informative post.

After reviewing the chart I would say the PEG tube was placed due to this patient's inability to swallow. And that was interesting about not administering water through the tubes. I honestly wouldn't have thought to do that, it's not taught either. Thanks for that.

The abdominal distention was relieved, however the diarrhea was almost constantly flowing throughout my shift. He did have a foley in place, but that was probably due to his immobility. Speaking of which, this patient was bedridden, and after doing some research I believe he had what is called decorticate posturing. We had to pry his arms away from his body to assess him. He would move his limbs sometimes when asked but it took him a while to do so and was not consistent.

The nurse for this patient told me that the ulcer was unstageable. I asked her why and she told me it was due to some yellowing tissue at the base of the sore. I did not understand that.

The symptoms for dementia, other than not speaking, were unassessable (if that's possible). How do you assess memory deficit or impaired thinking if the patient won't speak? I think this is where most of the confusion is coming from on my end. Towards the end of my shift he was making incomprehensible sounds, when asked if he needed something he would just stare at me. He had a flat affect the entire time. I don't know how his needs are met, it seemed as though the nurse only came in when she was scheduled to give meds.

The way I got these diagnoses was from my nursing diagnosis handbook. Those diagnoses were listed under dementia. "Impaired Verbal Communication" isn't in there, but that is basically what I was trying to get at. FTT was also in his chart; it didn't make sense to me (which started the cycle of confusion), but I thought that if it was in the chart I should have it on my concept map.

Thank you again for your post, I really do appreciate it a lot.

Daytonite,
First, Just want to say thank you for the teaching on care plans. I've learned more from these threads than in the couple of class I've had at school.
Still, I seem to be confused and if you've already addressed this, please send me to the correct post.

pt. is 76 yo hx of dementia found unresponsive at home
pulse ox in the ambulance 72% improved after 02 admin to92%
Cxr in the ER showed Rll infiltrate consistent with pneumonia
UA=UTI
Admitting diagnosis is Mental Status Change, Pneumonia, UTI, Early sepsis.
My question is: Whats the priority diagnosis? I think hypoxemia r/t pnuemonia caused the mental status change. but older adults also suffer mental status changes from UTIs. What should my care plan focus on? I read where you said to focus on the signs and symptoms presented. I took care of this patient on her 5th hospital day and 02 sat was 100% on room air. She was confused at times, but has a hx of dementia. her foley was draining light yellow urine and her priority problem on the day I took care of her was nurtrition - poor appetite and weight loss since admission. As a student are you supposed to do the careplan based on the admitting dx or on the priority for the day? My careplan format specifically asks for the admitting dx.

As a student are you supposed to do the careplan based on the admitting dx or on the priority for the day?

This is a question you need to ask your instructors.

My careplan format specifically asks for the admitting dx.

You stated in your post: Admitting diagnosis is Mental Status Change, Pneumonia, UTI, Early sepsis. That's what I would put on the form.

Whats the priority diagnosis? I think hypoxemia r/t pnuemonia caused the mental status change.

hypoxemia is not an official NANDA nursing diagnosis. pnuemonia is a medical diagnosis and medical diagnoses are not permitted to be used as direct related factors in nursing diagnostic statements. If hypoxemia is the cause of mental status changes, aren't mental status changes the real nursing problem? Is hypoxia their cause, or her underlying dementia? Did you assess her lung sounds to get evidence of hypoxia? Based on the information you supplied, the priority diagnosis I came up with was Imbalanced Nutrition: less than body requirements R/T ??? AEB poor appetite and weight loss since admission and I do not know the etiology because there just wasn't enough information. It could be because of her illness, her medications, or her dementia. I don't know. You worked with this patient and saw the information in her chart. I didn't. If I were your instructor I would question a priority nursing diagnosis of Imbalanced Nutrition: less than body requirements in a patient admitted with mental status changes, pneumonia, UTI, and early sepsis. It sounds like something is missing.

What should my care plan focus on?

A care plan is based on the nursing problems that the patient has. These are determined by applying the nursing process which is the problem solving tool that we use to do this.

Step 1 Assessment - Assessment consists of:

• a health history (review of systems) - we know she is 76 years old, has a history of dementia, was found unresponsive at home
• performing a physical exam - there isn't any physical exam information. For a patient with pneumonia I expected to find information about lung sounds, pulse ox and whether or not there is productive coughing and the color of any sputum. It takes weeks for pneumonia to heal, especially in the elderly. There is also no reference to vital signs. Sepsis is always secondary to a primary infection and she has two of those (a UTI and pneumonia). The symptoms of sepsis are:

• • • Temperature > 38° C or < 36° C
    • Heart rate > 90 beats/min
    • Respiratory rate > 20 breaths/min or Paco2 < 32 mm Hg
    • WBC count > 12,000 cells/μL or < 4000 cells/μL, or > 10% immature form

You mentioned that she was confused, but didn't describe the confusion. Confusion can be disorientation to person, place and time, misperceptions, hallucinations and patients can be agitated. Since weight loss was brought up, during examination the patient should have been weighed and none of those figures are mentioned.

• assessing their ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what can and can't she do? What does she need assistance with?
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to look up and read about each of her medical conditions: pneumonia, UTI, sepsis and dementia. You need to make sure that you didn't miss seeing any of the signs or symptoms of any of these conditions in her. This is how you will improve your assessment skills as well as learn about these diseases. I suspect she still has symptoms of her pneumonia but you missed seeing them. I'll bet she's still being treated medically for it, or am I wrong? Does she need assistance with deep breathing and coughing? Where would you fit that into a care plan?
  • Pneumonia
    • http://www.merck.com/mmpe/sec05/ch052/ch052a.html - Pneumonia. You can link in to several different types of pneumonia
    • http://www.emedicinehealth.com/bacterial_pneumonia/article_em.htm - Bacterial Pneumonia
    • http://www.emedicinehealth.com/viral_pneumonia/article_em.htm - Viral Pneumonia
  • http://www.merck.com/mmpe/sec19/ch280/ch280e.html - Urinary Tract Infection (UTI)
  • http://www.merck.com/mmpe/sec06/ch068/ch068a.html - Sepsis and Septic Shock
  • http://www.merck.com/mmpe/sec16/ch213/ch213c.html - Dementia

• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - no medications were mentioned. Patient does have a foley and there can be complications with a foley catheter.

Step #2 Determination of the patient's problem(s)/Nursing diagnosis Part 1 - make a list of the abnormal assessment data

• poor appetite and weight loss since admission
• confused at times

Step #2 Determination of the patient's problem(s)/Nursing diagnosis Part 2 - match your abnormal assessment data to likely nursing diagnoses - based on the information you posted and sequenced by Maslow's Hierarchy of Needs. . .

• Imbalanced Nutrition: less than body requirements R/T ??? AEB poor appetite and weight loss since admission [needs better description]
• (Acute or Chronic) Confusion R/T dementia AEB confused at times [needs better description]

"You need to make sure that you didn't miss seeing any of the signs or symptoms of any of these conditions in her. This is how you will improve your assessment skills as well as learn about these diseases. I suspect she still has symptoms of her pneumonia but you missed seeing them. "


I think this is the key. I have more detailed info on this pt. I was just looking for guidance on where to begin. i think I really wanted to focus on nutrition and was trying to justify it. You've set me on the right track, so thank you.

1ldowife. . .as I said, if I were your instructor I would question a priority nursing diagnosis of Imbalanced Nutrition: less than body requirements in a patient admitted with mental status changes, pneumonia, UTI, and early sepsis. It sounds like something is has been overlooked.

Desperately needing help...pt with +1 pitting edema, post-surg from an abdominal mass, 84yo, A&O x2, hadn't missed church in 37 years, NPO, on D1/2W NS with K, lives alone.... any help, would be appreciated...I have excess fluid volume (but really don't know what the related to would be)...also have spiritual distress,

my problem is my instructor thinks Im using ND's that are "a given" (ie-risk for infection, risk for falls, impaired mobility)

Thanks in advance for any help!

Certain ND's are "a given" for postoperative patients that have undergone general anesthesia. However, diagnosing follows a consistent process of first assessing the patient and then assembling the abnormal data you find from your assessment activity and using it to determine what the nursing problems are and establishing what labels go with them (nursing diagnoses). I will include these "given" nursing problems while going through how you should be incorporating looking for them in your assessment of this patient.

Assessment is quite involved and consists of:

• a health history (review of systems) - this you would have done by asking questions of the patient and reviewing information in the chart. Historical information that you have posted about the patient here are that they are 84 years old, is post-surgical from an abdominal mass, lives alone, and hasn't missed church in 37 years. My first question when I read this information was if the mass was cancerous? Second was what was the significance of mentioning that the patient had not missed church in 37 years? Is that important to healing from an incision in the abdomen?
• performing a physical exam - a big part of the reason we perform physical examinations is to check for abnormalities. The only physical exam data that was posted was that the patient had +1 pitting edema and was A&O x2. Where was this pitting edema? Which element was the patient not oriented to: person, place or time? Since the patient had major surgery (removal of an abdominal mass) what does the incision look like? Where is your abdominal assessment? Patients get paralytic ileus following major abdominal surgery (this is an expected complication) so they must be constantly assessed for the return of intestinal activity--where is your assessment of that? NPO is not an assessment, but a medical treatment. Anyone undergoing general anesthesia must be monitored for the signs and symptoms of these potential complications:
  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus

None of those assessments have been included in your post. Post op patients at the least should be doing deep breathing exercises every couple of hours as well as being repositioned to keep circulation stimulated. When the patient goes into surgery, they have already been at least 8 hours without fluid. With their abdominal tissues open to the atmosphere more fluids are lost through invisible means. This creates a situation of electrolyte imbalance because electrolytes do not evaporate into the air along with water that is lost.

• http://www.surgeryencyclopedia.com/La-Pa/Laparotomy-Exploratory.html - Exploratory Laparotomy
• http://www.surgeryencyclopedia.com/Pa-St/Postoperative-Care.html - Postoperative Care

• assessing their ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - with an abdominal incision that probably hurts, is this patient jumping in and out of bed by themself to go to the bathroom? Are they even getting out of bed? If this person were at their home right this moment, could they do what needed to be done for themself, or do they need the help of another person?
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this is important to the development of the "related to" parts of your nursing diagnostic statements because by knowing what the pathophysiology of the patient's medical condition is will lead to the cause of many of the problems. I must go back to one of my first questions. . .was this abdominal mass cancerous? Why was this surgery done in the first place? What does the doctor say is going on in this patient's abdomen that warranted taking this person to the OR and opening them up? That is extremely important information to know. We need to know what the doctor is thinking and what his medical plan of care is as well. What other medical problems does this patient have? At 84 years old I can't believe that there isn't some other medical disease or condition going on. They all need to be considered. And, you need to look each one of them up, read about its pathophysiology, its signs and symptoms and any complications they may pose to a person. Why? Because you may have missed seeing these signs and symptoms in the patient. This is how you will learn to improve your assessment skill as well as learn about these specific diseases and conditions. Edema occurs for many different reasons, not just because of excess fluid in the system. Why is it happening to this patient? See http://www.medicinenet.com/edema/article.htm to learn about edema. After considering all the patient's known medical conditions and medications the explanation for the edema should be clearer.
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - I know this patient is probably on something for pain. ??? What other medications is the patient getting and why? What are their side effects? Being NPO is a treatment that has been ordered by the doctor. Why? See http://www.merck.com/mmpe/sec02/ch011/ch011g.html (Paralytic Ileus; Adynamic Ileus; Paresis). D1/2W NS with K is another treatment ordered by the doctor. Why? Can we survive without fluid? What electrolytes need to be continuously replaced in our bodies? See Table of Commonly Used IV Solutions.doc. Are any dressing changes being done?

Assemble abnormal data: all you provided is. . .

• +1 pitting edema - not enough information to determine why the edema is present
• A&O x2

Determine nursing problems from the assessment and abnormal data:

• Acute Confusion R/T effects of anesthesia and age AEB disorientation to (person, place or time).

The nursing diagnoses you propose. . .

excess fluid volume

Not likely since this is a postop situation. At 84 years old I was looking for possible heart failure to explain the patient's edema, which I assumed was in the lower extremities, or immobility. Edema in the lower extremities is often the result of a circulation problem.

spiritual distress

This may be, but this is a postop patient that just had their abdomen cut open. I don't think your instructor is going to be impressed that this is one of the only problems that you found. What about keeping the lungs clear, getting this person mobile again, incisional pain, keeping the abdominal wound clean and assisting it to heal? After all, that is why the patient is there for our nursing help.

Now, this thread from 2 years ago is also about a postoperative patient's care plan although it is a different type of surgery. However, the givens are pretty much the same. I did give 3 diagnoses from the information the OP presented. Have a look at these given nursing problems.

• http://allnurses.com/nursing-student-assistance/need-help-my-210790.html - Need help with my very first careplan

I know what you mean about they shouldn't be overjoyed about the spiritual thing, but for some reason our instructors want their 'happiness' to be up there on the list of priorities because if they are stressed or unhappy then the body may 'resist' healing or something to that effect. I, personally think acute pain trumps all else, but they are "tired" of seeing that as a ND. I guess more than anything, I'm having trouble reading minds

I will put your list and advise to good use though, thank you so much.


Side note- I don't know if you get paid to do what you do, but I think allnurses.com should hold a bake sale or something to raise money to give to you as a thank you for how much you do on this site and how many people you help....until then, my gratitude is what I can offer!...so THANK YOU!

If you are required to include psychosocial diagnoses then sequence them appropriately. Physiological needs come first and psychosocial needs last. People die of lack or air and food first before missing church services. so sequence respiratory and nutrition diagnoses before spiritual ones. See Maslow: http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs. Pain is a comfort issue. I don't think it is a priority either although some instructors do. With Maslow, it is a physiological need, but at the low end of the physiological needs. Impaired Skin with surgical patients is another controversial one. Some see it as a safety need for protection and others see a break in the skin as a physiological need. The cause (etiology) of the problem may also determine where the diagnose lands in the list of the sequencing.

Here are my 8 ND's that I came up with
1
Impaired gas exchange r/t post-anesthesia and immobility
2
Disturbed body image r/t colostomy
3
Excess fluid volume r/t infusion of fluids following surgery
4
Acute confusion r/t dementia
5
Self-care deficit r/t decreased mobility
6
Spiritual distress r/t separation from spiritual and cultural ties.
7
Risk for infection r/t surgical incision
8
Risk for impaired skin integrity r/t decreased activity, medical restrictions and prolonged bedrest


I don't know if this is enough to go on, but is this more on the right track? I put the "risk for" last since it is not an actual dx

I am truly at a loss and I feel like sometimes I have to reallly stretch to come up with some of these. Is that common with nursing students? or am I just not seeing what I need to see?