Help with Care Plans

This is the correct sequencing by priority for these nursing diagnoses and problems with the related factors:

1. Impaired gas exchange r/t post-anesthesia and immobility
   • Please look at the NANDA taxonomy that contains the definition and related factors for this diagnosis. It tells you that Impaired Gas Exchange is defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (pg. 112, NANDA International Nursing Diagnoses: Definitions and Classifications 2009-2011). If you have a copy of Taber's Cyclopedic Medical Dictionary this information is in the appendix. post-anesthesia and immobility is not the physiologic cause of this patient's excess or deficit in oxygenation and/or carbon dioxide elimination in the alveoli of their lungs. Anesthesia is a medical treatment and you cannot use it as an explanation for one of the body's physiological problems. Ditto with immobility which is a patient problem. There are two main reasons why the alveoli of the lungs fail to do their job in exchanging these two gasses: (1) they are damaged (alveolar-capillary membrane changes) or, (2) they are so gunked up that the gasses have no room to get into the air sacs for air exchange to occur resulting in exchange imbalances (ventilation perfusion imbalance). In a surgical patient without any chronic lung disease, the related factor is ventilation perfusion imbalance.
2. Excess fluid volume r/t infusion of fluids following surgery
   • Somehow I really doubt this is realistic. You are saying that the doctor is making an error. Nurses are monitoring the patient, as is the doctor. Labs are being drawn daily. Overhydration would be seen in the lab data. The sodium levels would be elevated along with other labwork.
3. Self-care deficit r/t decreased mobility
   • You must specify the self-care deficit. There are 4 of them.
   • Decreased Mobility is a entire other nursing problem.
   • If the patient is unable to perform ADLs because of a difficulty to move, the correct way to state that is either weakness, musculoskelatal impairment or neuromuscular impairment
4. Acute confusion r/t dementia
5. Disturbed body image r/t colostomy
   • I would be more specific about what the patient fears about the colostomy doing to disturb her self-picture than the colostomy itself. This is a psychosocial (behavioral) diagnosis, so her thinking should be incorporated in the related factor. Is it something along the line of fear of rejection or is it the thought of disfigurement?
6. Spiritual distress r/t separation from spiritual and cultural ties
   • cultural ties do not make sense for why a person is spiritually distressed.
   • You should include acute illness as a related cause.
7. Risk for infection r/t surgical incision
8. Risk for impaired skin integrity r/t decreased activity, medical restrictions and prolonged bedrest
   • The risk factor is what will result in the skin breaking down. You need to specify the medical restrictions.
   • This diagnosis is redundant because this patient already has Impaired Tissue Integrity as a result of surgery which you failed to diagnose.

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?

You become more proficient at diagnosing as you work with the diagnosing and do more of it. Use the nursing process. Assess. Use a nursing diagnosis reference. Practice. Diagnosing is a mental skill.

Hi everyone I'm at the end of my first yr. of nursing school, I'm doing my clinical right now and I'm trying to do a care plan on Anemia I'm using Activity intolerance but I can't seem to come up with any patient centered goals. She has fatigue, dizziness, weakness. Any help would be greatly appreciated...

Goals are not developed until the nursing diagnoses are determined. The goals are based upon the related factors and the supporting evidence. So, if I am getting your information correct, this patient has the following nursing problem:

• Activity Intolerance R/T ____ secondary to anemia AEB fatigue, dizziness and weakness.

Do you have a pathophysiology for this Activity Intolerance? Were you thinking that it was an imbalance between oxygen supply and demand? Is this blood loss anemia or an iron deficiency anemia? This diagnosis is one that involves symptoms of the respiratory and cardiac systems and when the patient begins to move their heart and respiratory rates elevate causing them to become SOB. That results in the fatigue and weakness so that the patient ends up having to stop the activity. Its unfortunate you don't have some vital signs as well to add to your evidence here.

Post #157 on this sticky thread http://allnurses.com/general-nursing-student/careplans-help-please-121128.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) will give you instructions on how to write a goal statement.

Since I don't know the etiology of the anemia I can only address the energy deficiency. Goals for Activity Intolerance can be things like:

• patient reports taking naps q__h to restore energy
• patient reports recognizing the following signs of energy limitations: []
• patient organizes activities in order to conserve energy
• patient reports adequate endurance for an activity
• taking in adequate nutrition to restore energy (if the anemia is nutrition related)
• Hemoglobin, blood sugar and electrolyte levels are normalized
• patient reports fatigue, lethargy or exhaustion is improved

Hi this is my first time posting! Here is my scenario: My pt is a 58 y/o female with multiple & I mean MULTIPLE diagnosis. I have to do a nursing diagnosis on nutrition. She is obese, approximately 32 lbs above her IBW. She had a gastric bypass surgery in Sept 2008 and since has lost 20 lbs (she is still 30 lbs overweight). All her labs regarding nutrition are WNL, albumin, pre-albumin, etc. So should my diagnosis be related to her obesity or her gastric bypass? Should it be:Imbalanced nutrition, less than body requirements r/t early satiety resulting from small gastric pouch and delayed pouch empyting, or Imbalanced nutrition, more than body requirements r/t poor dietary habits (or inadequate excercise because she said she gained a lot of weight after having complications from her COPD since she couldn't be as active). Which diagnosis is appropriate? I would appreciate any help I can get. I am sure this is very simple & I just can't figure it out due to lack of sleep! Thanks in advance

A diagnosis is based on your assessment information that you have collected. I am pretty sure that Imbalanced nutrition, more than body requirements is an absolutely incorrect diagnosis. No one who has had gastric bypass surgery is physically capable of an intake of nutrients that exceeds metabolic needs, the definition of this diagnosis, unless they devote most of their waking hours to eating something (we call it grazing). The fact that she has been losing weight is evidence that she isn't doing that.

Did you look up what the gastric bypass surgery is?

• http://www.asbs.org/html/patients/bypass.html - Brief History and Summary of Bariatric Surgery
• http://www.surgeryencyclopedia.com/Fi-La/Gastric-Bypass.html - Gastric Bypass

They deliberately restrict the size of the stomach which results in the restriction of food intake and the inability of the body to absorb nutrients.

Imbalanced nutrition, less than body requirements r/t early satiety resulting from small gastric pouch and delayed pouch empyting

I had a silastic ring bypass several years ago. Early satiety (being satisfied) is a wanted result of this surgery and is part of portion size control. Unless this patient described how much food it took to reach satiety, she may be fooling you. This is why I am wondering what your supporting evidence is. I attend gastric support groups regularly and talk with people who are considering the surgery. They are shocked when they hear us talk about how much (actually, how little) we eat. It is because some people are at 300 and 400 pounds and eating 6000 calories a day. To them, a 1200 calorie diet is a between meal snack.

The reasoning behind the Imbalanced Nutrition: less than body requirements (definition: intake of nutrients insufficient to meet metabolic needs) is restricted size of stomach and inability of the body to absorb nutrients. The symptom of this would be the 20 pound weight loss. Does she have any hair loss? This happens to some bypass patients in the first 6-8 months. Did you ask her about being hungry? One thing that is pretty common with bypass surgery is that many people do not get hungry. We ask that a lot at our support groups and a common answer is, "No, we don't get hungry anymore." We also lose the taste for sweets. In some people this may happen over time. I used to be a big candy eater and now I can walk by candy and cookies and not even crave or want them. There are vitamin deficiencies also. The lab tests are not always done for these because of the expense and the deficiencies don't show symptoms until they are well underway. I take vitamins, minerals and iron replacement daily. What vitamin replacements is this patient taking?

Thanks Daytonite! I really appreciate your help. I thought Imbalanced nutrition more than body requirements, didn't seem right but I just needed to be sure I was on the right track. Could I do a diagnosis for Risk for imbalanced nutrition less than body requirements? Because at the moment she reports: feeling of getting hungry, feeling of being satisfied after eating, no hair loss & her labs are WNL. She is taking Os-Cal as a calcium supplement, but is not taking any vitamins. So it doesn't appear that she has altered nutrition at the moment, but there is a definite risk for it due to gastric bypass & not taking vitamin supplements.
Thanks so much! You are a lifesaver!

I would say no to that. The surgery was done so her anatomy has been altered and the etiology is there. If she is not taking her vitamins then she needs to. Why isn't she taking them? It sounds like she has not been following the recommended medical regime. I'd tag her with Ineffective Health Maintenance and get a lot of teaching in. In a few years she's going to be having malnutrition as a medical diagnosis.

I always have a problem writing appropriate nursing diagnosis. This is sad. What's more, nurses in Malaysia don't really practice this. It's only taught in degree students...

When I was first taught this I didn't understand it either. It is why I work so hard to answer nursing diagnosis questions from students. It is, by far, the most commonly asked type of question with regard to care planning. I try to break the process of diagnosing down. It is very similar to how doctors diagnose medical disease. The difference is that we assess the patients to collect different types of data and then apply this data to a different set of diagnostic problems (nursing diagnoses). Thankfully, our list of nursing diagnoses is much shorter in length than the list of medical diseases and conditions. That, however, doesn't make the process of diagnosing any less mysterious. In all the care planning books I have as references, none of them explains the act of diagnosing very well. I often wonder how medical students are taught this skill.

Hi there. I'm doing a Major Care Plan for this semester. I've got the pathos and care plans down, but was just wanting some guidance on prioritizing my Dx list.

My patient is an elderly female. She presented to the ED with pneumonia. Her past medical dxs include end-stage renal failure, DM, morbid obesity, diabetic nephropathy and neuropathy, a fib, PVD, HTN, etc. She's had double below the knee amputations (one years ago, the other a couple of weeks ago.) You get the idea.....

Anyway, I'm going to go with:

1. Impaired Gas Exchange R/T Ventilation Perfusion Imbalance (Pneumonia and sputum production)
2. Decreased Cardiac Output (Arrythmia)
3. Imbalanced Nutrition: More than Body Requiremtents (Diabetes/insulin deficiency)
4. Excess Fluid Volume (Edema)
5. Ineffective Tissue Perfusion: Peripheral R/T Interruption of Vascular Flow (PVD)
6. Pain R/T Surgical Incision (Amputation)
7. Risk of Infection R/T Surgical Incision

Waddya think? I'm thinking ABCs with my ranking of 1 and 2, but I'm not sure about 3-6. I'm thinking I probably need to bump the tissue perfusion to #3. That's a circulation issue, but then there's the fluid volume! It's all important.

BTW, thanks to all of you that help us students. (esp. Daytonite, of course),

Dave

EDIT: I forgot to add that she is legally blind, so I'll add Disturbed Sensory Perception: Vision, too.