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| No. 170 | 
Apr 26, 2009, 10:38 PM
 Re: Help with Care Plans Originally Posted by daveintexas8  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.
I think this is how I'll rank them: 1. Impaired Gas Exchange R/T Ventilation Perfusion Imbalance 2. Decreased Cardiac Output 3. Ineffective Tissue Perfusion: Peripheral R/T Interruption of Vascular Flow 4. Excess Fluid Volume 5. Disturbed Sensory Perception: Vision 6. Imbalanced Nutrition: More than Body Requiremtents 7. Pain R/T Surgical Incision 8. Risk of Infection R/T Surgical Incision  | | Advertisement Sponsored Links | | | | No. 171 |
Apr 27, 2009, 09:33 AM
Originally Posted by daveintexas8 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.
This is how I would sequence them and why: - Impaired Gas Exchange R/T Ventilation Perfusion Imbalance (Pneumonia and sputum production) [physiological need for oxygen - lungs]
- Decreased Cardiac Output (Arrhythmia) [physiological need for oxygen - heart]
- Ineffective Tissue Perfusion: Peripheral R/T Interruption of Vascular Flow (PVD) [physiological need for oxygen - other body tissues]
- Excess Fluid Volume (Edema) [physiological need for fluid]
- Imbalanced Nutrition: More than Body Requirements (Diabetes/insulin deficiency) [physiological need for food and nutrients]
- Pain R/T Surgical Incision (Amputation) [physiological need for comfort]
- Disturbed Sensory Perception: Vision [safety need]
- Risk of Infection R/T Surgical Incision [anticipated safety need]
Sputum production is not a symptom of Impaired Gas Exchange; there's another diagnosis you need to use for that. The Decreased Cardiac Output is also responsible for her hypertension. You've got the wrong Imbalanced Nutrition diagnosis to use with diabetes and insulin deficiency. Does your diagnosis list distinguish between Acute and Chronic Pain? She she have pain with her peripheral neuropathy? Any other symptoms of disturbed sensory perception related to her peripheral neuropathy such as numbness in her hands and fingers? No Impaired Physical Mobility having had double below the knee amputations? No self-care deficits are identified; hard to believe that she doesn't need help with some things. | | No. 172 |
Apr 27, 2009, 01:45 PM
Re: Help with Care Plans Originally Posted by Daytonite This is how I would sequence them and why: - Impaired Gas Exchange R/T Ventilation Perfusion Imbalance (Pneumonia and sputum production) [physiological need for oxygen - lungs]
- Decreased Cardiac Output (Arrhythmia) [physiological need for oxygen - heart]
- Ineffective Tissue Perfusion: Peripheral R/T Interruption of Vascular Flow (PVD) [physiological need for oxygen - other body tissues]
- Excess Fluid Volume (Edema) [physiological need for fluid]
- Imbalanced Nutrition: More than Body Requirements (Diabetes/insulin deficiency) [physiological need for food and nutrients]
- Pain R/T Surgical Incision (Amputation) [physiological need for comfort]
- Disturbed Sensory Perception: Vision [safety need]
- Risk of Infection R/T Surgical Incision [anticipated safety need]
Sputum production is not a symptom of Impaired Gas Exchange; there's another diagnosis you need to use for that. The Decreased Cardiac Output is also responsible for her hypertension. You've got the wrong Imbalanced Nutrition diagnosis to use with diabetes and insulin deficiency. Does your diagnosis list distinguish between Acute and Chronic Pain? She she have pain with her peripheral neuropathy? Any other symptoms of disturbed sensory perception related to her peripheral neuropathy such as numbness in her hands and fingers? No Impaired Physical Mobility having had double below the knee amputations? No self-care deficits are identified; hard to believe that she doesn't need help with some things.
I don't really have to do that many plans, so I stopped at 8, but yes, Impaired Physical Mobility, Self-Care Deficit both very much apply. I do need to specify Acute/Chronic Pain. I don't believer she is being bothered by the neuropathy at this point as much as acute pain from the amputation and a sore shoulder.
As far as the Impaired Gas Exchange, my NCP book says "...conditions that cause changes or collapse of the alveoli (e.g. atelectasis, pneumonia, pulmonary edema,...) impair ventilation. I think I see. She will have Impaired Gas Exchange R/T pneumonia and decreased cardiac output. I'm tempted to use the sputum production in an Ineffective Airway Clearance dx, but isn't it correct that if she is coughing up sputum, then it is actually effective clearance?
| | No. 173 |
Apr 27, 2009, 02:19 PM
Re: Help with Care Plans Originally Posted by daveintexas8 I don't really have to do that many plans, so I stopped at 8, but yes, Impaired Physical Mobility, Self-Care Deficit both very much apply. I do need to specify Acute/Chronic Pain. I don't believer she is being bothered by the neuropathy at this point as much as acute pain from the amputation and a sore shoulder.
As far as the Impaired Gas Exchange, my NCP book says "...conditions that cause changes or collapse of the alveoli (e.g. atelectasis, pneumonia, pulmonary edema,...) impair ventilation. I think I see. She will have Impaired Gas Exchange R/T pneumonia and decreased cardiac output. I'm tempted to use the sputum production in an Ineffective Airway Clearance dx, but isn't it correct that if she is coughing up sputum, then it is actually effective clearance?
You can't say Impaired Gas Exchange R/T pneumonia and decreased cardiac output. You cannot use a medical diagnoses (pneumonia) or another nursing diagnoses (decreased cardiac output) as the related factor on a physiologic nursing diagnosis. If you need to relate a nursing diagnosis (decreased cardiac output) to the nursing problem then just diagnose that as a nursing problem which you have already done. The cause of Impaired Gas Exchange is that the oxygen and carbon dioxide are unable to move across the membrane separating the alveoli and the capillaries which is where these two gasses are swapped in our bodies. Decreased cardiac output has nothing to do with that process. The part pneumonia plays in it is that the pus (an end product of the inflammation) that collects in the alveoli interferes (gets in the way) with the gas exchange process. That's why the taxonomy calls it "ventilation perfusion imbalance". Oxygen and carbon dioxide are getting to the lungs (oxygen via inspiration; carbon dioxide via the capillaries of the pulmonary circulation), but because of all the congestion as a result of the pneumonia the exchange can't be made.
Coughing up sputum is Ineffective Airway Clearance R/T exudate in bronchi secondary to pneumonia AEB productive cough (it would be nice if you describe the sputum and the amount the patient is producing). Does she have clear breath sounds? Adventitious breath sounds are evidence of this as well and would be expected with pneumonia and a productive cough.
| | No. 174 |
May 13, 2009, 09:25 AM
Re: Help with Care Plans
Help! I can't come up with a 3rd nursing diagnosis for my patient. She is a 57 yr. old pt with a hx of stage 3 renal failure, IDDM, HTN, hyperlipidemia, and neuropathy. She was admitted for observation due to hyperglycemia and elevated BUN and creatinine. She was discharged home the day I had her. She was placed on a 1800 cc fluid restriction. She's not on dialysis, she has a AV fistula, and an insulin pump. She's active, no breathing complications, no pain, voiding fine, and seems to be very educated and compliant with her health care management. So, far I have Risk for fluid volume excess and risk for injury. Please help.
| | No. 175 |
May 13, 2009, 10:05 AM
Originally Posted by Jenni-sue Help! I can't come up with a 3rd nursing diagnosis for my patient. She is a 57 yr. old pt with a hx of stage 3 renal failure, IDDM, HTN, hyperlipidemia, and neuropathy. She was admitted for observation due to hyperglycemia and elevated BUN and creatinine. She was discharged home the day I had her. She was placed on a 1800 cc fluid restriction. She's not on dialysis, she has a AV fistula, and an insulin pump. She's active, no breathing complications, no pain, voiding fine, and seems to be very educated and compliant with her health care management. So, far I have Risk for fluid volume excess and risk for injury. Please help.
Since she was admitted for observation because of the elevated BUN and creatinine why not do Deficient Knowledge, renal failure? Or, Deficient Knowledge, complications of renal disease?
| | No. 176 |
May 15, 2009, 05:04 AM
Re: Help with Care Plans
Thank u so much for helping me to clear my head....I'm still in school and doing pretty ok except this area. thanks again
| | No. 177 |
Jun 08, 2009, 03:52 PM
 Re: Help with Care Plans can some one help with care plan i seem to never satisfy my instructor. my pt is 89 she is diagnosed with orthostatic dizziness, hypotension, her past medical hx consists of iddm, peripheral neuropathy, dementia, mi, chf, ashd, gerd, cad, cardiomyopathy,syncope, bladder suspension,urinary retention, urinary incontinence, uti, hysterectomy,sinus surgeryu,left lumpectomy, chronic atrial fib, anemia, meds she is on is alomide, coumadin, prilosec, tyelenol tab, vit b12 miralax coreg, novolog, lantus chest xray showed enlarged heart without congestion,gluc.143,bun 21, creat 0.8,gfr >60, na 143, k 4.3,cl 111,co2 26,hco3 25 agap 16, sed rate 46, troponin <0.03, ckmb 3.7, vit b12 926,folate >20tsh 4.070, rbc 3.87, pt had decreased breath sounds, dizzy, nauseated, headache , pedal pulses were a +2, confused
can some one help me with this?
thanks Mary
| | No. 178 |
Jun 08, 2009, 09:00 PM
Originally Posted by weesie1244 can some one help with care plan i seem to never satisfy my instructor. my pt is 89 she is diagnosed with orthostatic dizziness, hypotension, her past medical hx consists of iddm, peripheral neuropathy, dementia, mi, chf, ashd, gerd, cad, cardiomyopathy,syncope, bladder suspension,urinary retention, urinary incontinence, uti, hysterectomy,sinus surgeryu,left lumpectomy, chronic atrial fib, anemia, meds she is on is alomide, coumadin, prilosec, tyelenol tab, vit b12 miralax coreg, novolog, lantus chest xray showed enlarged heart without congestion,gluc.143,bun 21, creat 0.8,gfr >60, na 143, k 4.3,cl 111,co2 26,hco3 25 agap 16, sed rate 46, troponin <0.03, ckmb 3.7, vit b12 926,folate >20tsh 4.070, rbc 3.87, pt had decreased breath sounds, dizzy, nauseated, headache , pedal pulses were a +2, confused
can some one help me with this?
thanks Mary
Hi, Mary!
Did you read some of the other posts on this thread? The first thing you need to do is break your data down and classify it. . . Step 1 Assessment - Assessment consists of:- a health history (review of systems) - This is an 89 year old female who was diagnosed with orthostatic dizziness and hypotension. Past medical history of IDDM, peripheral neuropathy, dementia, MI, CHF, ASHD, GERD, CAD, cardiomyopathy, syncope, urinary retention, urinary incontinence, a UTI, chronic atrial fibrillation, and anemia. Surgeries done consist of a bladder suspension, hysterectomy, sinus surgery, and a left lumpectomy.
- performing a physical exam - Assessment included decreased breath sounds, dizziness, nausea, headache, pedal pulses of +2, and confusion. Abnormal labwork showed a glucose of 143 (unknown if this is fasting or postprandial), BUN 21 (normal is 10 to 20), serum chloride 111 (normal is 90-110 mEq in elderly adults), sedimentation rate 46 (normal is 20 or less/hour for a female), Vitamin B-12 926 (normal adult 200-900), and RBCs 3.87 (normal elderly female 4.2-5.4). Where is her PT level since she is on Coumadin?
- assessing their ADLs (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - No assessment of this patient's ADLs was included in the information you provided.
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - Since I am assuming that this patient was probably admitted with the orthostatic dizziness and hypotension (did she fall, by the way? And, what was, and is, her current blood pressure?) then these conditions need to be assessed for and looked up:
Some of her other medical conditions need to be examined and learned about as well:Now, the reason I posted these websites is because you are missing a lot of information (signs and symptoms) that you need for this care plan. From the labwork, the medications and the long list of medical history that was posted I expected to see this patient having a lot of abnormal assessment items, particularly Self-Care Deficits. There was nothing. By reading about these different conditions, look at the signs and symptoms and see if you missed seeing any of them in this patient and add them to a list now. You need that information in order to come up with this patient's diagnoses. All nursing diagnoses must have evidence (signs and symptoms to support them.
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - Medications she is on are alomide (this is given for ocular hypertension--does she have glaucoma or are they trying to prevent it? Does she have vision problems?), coumadin (anticoagulant), prilosec (for the GERD), tylenol tab (for pain--is this for her headache?), vit B12 (for her B-12 deficiency), miralax (laxative--does she have a constipation problem?), coreg (antihypertensive--does she have high blood pressure--no vital signs were posted), novolog (for diabetes), and lantus (for diabetes). A chest xray showed an enlarged heart without congestion (Is this patient obese?).
Step #2 Determination of the patient's problem(s)/Nursing diagnosis - Make a list of the patients abnormal assessment data. This data becomes the evidence that will support the nursing diagnoses you will choose. Every nursing diagnosis has a list of defining characteristics (signs and symptoms). The only information you listed (and I am sure there is more you just haven't thought to include) is- decreased breath sounds
- dizziness
- nausea
- headache
- pedal pulses of +2
- confusion - this really needs to be more specific
- glucose of 143 (unknown if this is fasting or postprandial)
- BUN 21 (normal is 10 to 20)
- serum chloride 111 (normal is 90-110 mEq in elderly adults)
- sedimentation rate 46 (normal is 20 or less/hour for a female) - this is a general indication of an infection somewhere in her body, best guess is that it is the respiratory or urinary track in the elderly
- Vitamin B-12 926 (normal adult 200-900)
- RBCs 3.87 (normal elderly female 4.2-5.4)
From these, possible nursing diagnoses are. . .- Decreased Cardiac Output
- Ineffective Tissue Perfusion, peripheral
- Imbalanced Nutrition: less than body requirements
- Nausea
- Total Urinary Incontinence
- Acute Pain
- Chronic Confusion
- Ineffective Protection
- Risk for Infection
- Risk for Impaired Skin Breakdown
- ???? mobility, visual problems, self-care deficits, constipation (is she incontinent of bowel?)
| | No. 179 |
Jun 10, 2009, 01:16 PM
Nursing Diagnosis for SIDS
Hi All,
I chose the topic of Sudden Infant Death Syndrome for a term paper for school and have found lots of journal articles, but have to submit 2 complete nursing diagnosis and could not think of 2 medical dx. Grieving r/t loss could be one, but can anyone think of a good medical diagnosis.
Risk for Impaired Oxygenation r/t SIDS doesn't sound right. SIDS is such a horrible disease and truly so sudden and permanent, it doesn't seem like there are any good choices for diagnosis.
Thanks so much for all of your help!
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