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| No. 180 | 
Jun 10, 2009, 06:13 PM
Updated
Jun 11, 2009 at 07:52 AM by Daytonite
Originally Posted by lostinthecountry  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!
I saw your problem already when you posted " but can anyone think of a good medical diagnosis". A nursing care plan consists of nursing diagnoses which are nursing problems based upon the symptoms that the patient will have. Those are determined by making an assessment of the patient. If you read the many replies I have made to this thread you will find what is meant by assessment. Sudden Infant Death Syndrome is a medical diagnosis and it can be broken down into signs and symptoms which you can then use to determine the nursing problems of the patient. Nursing diagnoses are not the same as medical diagnoses.
Since I assume you are writing about the patient, Grieving r/t loss would not be an appropriate nursing diagnosis for the baby. Risk for Impaired Oxygenation r/t SIDS would also be wrong because there is no NANDA diagnosis called Risk for Impaired Oxygenation and you cannot use a medical diagnosis (SIDS) as a related factor in a nursing diagnostic statement.
One potential nursing problem would be Disturbed Sleep Pattern R/T apnea monitoring AEB [symptoms of disturbed sleep in the patient]. Another would be Caregiver Role Strain R/T 24 hour care requirements of patient AEB [symptoms of difficulty in care being given to patient].
You need to look up the pathophysiology and the signs and symptoms of SIDS:  | | Advertisement Sponsored Links | | | | No. 181 |
Jun 10, 2009, 09:37 PM
 Re: Help with Care Plans
Daytonite,
Thanks so much for your incredible insight; the detail and links provided have really helped me. Keep up the great work!
| | No. 182 |
Aug 08, 2009, 08:43 PM
Updated
Aug 08, 2009 at 08:53 PM by MattiesMama
Re: Help with Care Plans
OK so I have a 92 year old patient with a history as follows: Atrial fibrilation, congestive heart failure, chronic diastolic heart failure with ventricular response, HTN, stage III kidney failure, Diabetic, HUGE fall risk (7 times over the past month, he's covered in bruises and skin tears  ) mild dementia, and a colostomy (rectal cancer, in remission)
Obviously there are a lot of ND's I can come up with for him but I'm having trouble narrowing it down to 2...
One I am definately doing is Impaired skin integrity r/t traumatic injury AEB multiple abrasions and skin tears on body and I think I have the care plan for that worked out...but I want to do something regarding his cardiac. I've narrowed it to 2: Activity intolerance r/t inadequate oxygenation secondary to decreased cardiac output AEB generalized weakness, chronic dsypnea and cardiac arrhythmias or Decreased cardiac output r/t diastolic dysfunction and pulmonary congestion AEB cardiac dysrythmias, chronic dyspnea, elevated blood pressure, fluid buildup abdomen and 2+ pitting edema in lower extremities.
To be honest, I want to do the second one, but my issue is what goals could I have for that? Just considering this is a 92 year old who's basically stated that he does not even want to be transferred to the hospital if he starts to go downhill. What kind of nursing measures could I use to improve his cardiac output? This is in a LTC setting, so I kind of have limited resources to work with...
Any ideas? Other suggestions for a NANDA?
ETA: Forgot to put my assessment findings-he had a few episodes of cheyne-stokes respirations, tachypnea, wheezing and apnea. His 02 sat was around 93-95%, responded well to deep-breathing. His BP fluctuated a lot-at one point it was 170/90 and then went down to 140/70 (before he got his BP meds too, which I found odd) His condition fluctuated a lot, in every respect...from A+Ox3 to not even knowing his name, totally calm to very agressive, etc. The first day I had him, I barely had to help him with ADL's and he even did his own colostomy care, but by the third day he was getting a full bed bath and couldn't even wash his own face...thats all I can think of off the top of my head but if more information is helpful I can get it from my notes
| | No. 183 |
Aug 11, 2009, 07:52 AM
Originally Posted by MattiesMama OK so I have a 92 year old patient with a history as follows: Atrial fibrilation, congestive heart failure, chronic diastolic heart failure with ventricular response, HTN, stage III kidney failure, Diabetic, HUGE fall risk (7 times over the past month, he's covered in bruises and skin tears ) mild dementia, and a colostomy (rectal cancer, in remission)
Obviously there are a lot of ND's I can come up with for him but I'm having trouble narrowing it down to 2...
One I am definately doing is Impaired skin integrity r/t traumatic injury AEB multiple abrasions and skin tears on body and I think I have the care plan for that worked out...but I want to do something regarding his cardiac. I've narrowed it to 2: Activity intolerance r/t inadequate oxygenation secondary to decreased cardiac output AEB generalized weakness, chronic dsypnea and cardiac arrhythmias or Decreased cardiac output r/t diastolic dysfunction and pulmonary congestion AEB cardiac dysrythmias, chronic dyspnea, elevated blood pressure, fluid buildup abdomen and 2+ pitting edema in lower extremities.
To be honest, I want to do the second one, but my issue is what goals could I have for that? Just considering this is a 92 year old who's basically stated that he does not even want to be transferred to the hospital if he starts to go downhill. What kind of nursing measures could I use to improve his cardiac output? This is in a LTC setting, so I kind of have limited resources to work with...
Any ideas? Other suggestions for a NANDA?
ETA: Forgot to put my assessment findings-he had a few episodes of cheyne-stokes respirations, tachypnea, wheezing and apnea. His 02 sat was around 93-95%, responded well to deep-breathing. His BP fluctuated a lot-at one point it was 170/90 and then went down to 140/70 (before he got his BP meds too, which I found odd) His condition fluctuated a lot, in every respect...from A+Ox3 to not even knowing his name, totally calm to very agressive, etc. The first day I had him, I barely had to help him with ADL's and he even did his own colostomy care, but by the third day he was getting a full bed bath and couldn't even wash his own face...thats all I can think of off the top of my head but if more information is helpful I can get it from my notes
Before I saw this, I answered your other post on the Nursing Student Assistance Forum about this care plan and spent several hours putting my answer together for you: http://allnurses.com/nursing-student-assistance/help-i-need-414701.html. You are not providing enough assessment data. I think Decreased Cardiac Output is probably the way to go, but in this post you are suggesting Activity Intolerance. Does he have to sit down because he cannot continue walking? Activity Intolerance is when a patient has respiratory and cardiac problems related to activity. They get hypoxia with activity. The evidence of it is elevated heart and respiratory rates with activity, SOB with activity, cyanosis, EKG changes, etc. The patient often has to stop what they are doing and sit down. Part of the problem is you are not constructing your diagnostic statements correctly. The construction of the 3-part diagnostic statement follows this format: P (Problem) - E (Etiology) - S (Symptoms) - Problem- this is the nursing diagnosis. A nursing diagnosis is actually a label. To be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. The appendix of Taber's Cyclopedic Medical Dictionary has this information.
- Etiology- also called the related factor by NANDA, this is what is causing the problem. Pathophysiologies need to be examined to find these etiologies. It is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. You can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
- Symptoms- also called defining characteristics by NANDA, these are the abnormal data items that are discovered during the patient assessment. They can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their ADLs. They are evidence that prove the existence of the nursing problem. If you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. These symptoms will be the focus of your nursing interventions and goals.
| | No. 184 |
Sep 19, 2009, 03:58 PM
Re: Help with Care Plans
Hello. This is my first post.
I would just like to add that Care plans are legal documents. As nurses there is a duty of care to follow the treatment plan advised to the patient through the multidisciplinary team. If anything happens to a patient, the first thing that is asked is usally if there was a careplan and secondly the question that follows is why wasnt it followed?
| | No. 185 |
Sep 24, 2009, 05:47 PM
Re: Help with Care Plans
hi, im a nursing 1 student and im doing my first care plan - i just need your help for some kind of direction. our nursing dx is Self care deficit and we're only doing hygiene and oral care for now.
I am having a hard time w/ the nursing intervention - my pt is a 91 y.o. male and was diagnosed w/ dementia. he is extremely weak and sleeps most of the time. he's not able to feed, bath or groom himself any longer. totally dependent. both bladder and bowel incontinence - he's got some missing teeth and discolored. he is wearing diaper pads. his skin is very dry and there's ecchymosis present. he's got dry scalp and some sort of rashes in his scalp/forehead. his eyes - he really couldn't open but presence of crusts throughout the canthus.
I would appreciate if you can help me set my goals, my outcome and nursing interventions. thank you so much!!
| | No. 186 |
Sep 27, 2009, 09:58 AM
Re: Help with Care Plans
Hi, I have a 57 year old patient with no medical history. He has no use of tobacco, alcohol, or drugs. However, he was going to the gym 4-5 x's a week and taking "work-out supplements." His urine was + for benzodiazopines. He went into cardiac arrest at home. CPR was immediately initiated for 10 minutes. At 10 minutes the defibrillator arrived. He was shocked twice. He is now at the hospital sedated on propofol and vented. (Tv 600, Fio2 40, rate 10, peep 8) He does not have any abnormal ABG's. He has a normal temperature, BP's range 110/63-130/75, map 73-89, Resp 12-16, hr 53-57, spo2 95-99. He is on an amidoarone and lidocaine drip. Other medications include Nexium, Aspirin, Zosyn, silvadene, heparin SQ 5000 units, and novolin R. His labs came back with a decreased albumin (2.9), phosphate (2.1), RBC, Hgb, Hct, and platelets. His SGOT/AST was highly elevated (61) and creatinine only slightly elevated (1.4). A HIT panel was sent off yesterday. His CT's show no aneurysms or dissections, or incranial bleed. There is a suspicion of mild right lower lobe infiltrate. Upon assessment he only opened his eyes to physical stimulation (he was sedated). He generalized edema 1+. His lung sounds were diminshed at the right base and he had a scant amout of thick, tan/bloody sputum. He also had a productive cough. His abdomen was soft but slightly distended with hyperactive bowel sounds. He was on TF at 50 cc/hr. However, we turned the sedation off later in the day and he opened his eyes to verbal stumuli, had strong hand grasps bilaterally and followed command. He became to aggitated and we had to increase sedation. Anything not mentioned was normal. My nursing diagnoses for him are:
1. Impaired gas exchange r/t ventialtion perfusion imbalance
2. Decreased cardiac output r/t altered rhythm and stroke volume
3. Decreased tissue perfusion: Cerebral?? (I need something to do with neuro... He was on sedation since he arrested. They tried to take him off once and he was not tolerant, on the day that i took care of him he followed verbal command and opened his eyes but he was very aggitated...)
4. Risk for infection (He is on prophylactic Zosyn, vented, and has burns on chest from shock)
5. Moderate anxiety (He was very aggitated when sedation was taken off... He grimaced, tried to yank at vent, started choking, he cried, and he couldn't sit still)
Any input would be greatly appreciated. Thanks!
| | No. 187 |
Oct 04, 2009, 09:03 AM
Originally Posted by nursewannabe1926 hi, im a nursing 1 student and im doing my first care plan - i just need your help for some kind of direction. our nursing dx is Self care deficit and we're only doing hygiene and oral care for now.
I am having a hard time w/ the nursing intervention - my pt is a 91 y.o. male and was diagnosed w/ dementia. he is extremely weak and sleeps most of the time. he's not able to feed, bath or groom himself any longer. totally dependent. both bladder and bowel incontinence - he's got some missing teeth and discolored. he is wearing diaper pads. his skin is very dry and there's ecchymosis present. he's got dry scalp and some sort of rashes in his scalp/forehead. his eyes - he really couldn't open but presence of crusts throughout the canthus.
I would appreciate if you can help me set my goals, my outcome and nursing interventions. thank you so much!!
A care plan is the identification of patient problems and developing strategies to do something about them. In this particular instance, you are identifying a hygiene and oral care self-care deficit as the nursing problem. Now, in order for all problems to exist there must be evidence of them. This evidence is found when you assess the patient. This evidence is important because it is what you will base your nursing treatment upon. You are asking for help in setting up goals, outcomes and nursing interventions for this person and this is done by focusing on what these hygiene and oral care self-care deficits are.
I went through the information that you posted and what you provided with relation to his hygiene and oral care was not very specific: - not able to bath or groom himself any longer - not able or just does not even attempt to bath or groom himself. You must list these out. . .EX: will not hold washcloth when handed to him and wash self; EX: will only wash face and hands when taken to sink and prompted by given a washcoth and running water provided; EX: Screams and refuses shower on shower days
- he's got some missing teeth and discolored - this is not telling us anything about how he cares for his teeth. Does he do any brushing, rinsing, etc? EX: Never asks to brush teeth. Never observed performing any self oral care and teeth always noted to have food particles clinging to them.
- his eyes - he really couldn't open but presence of crusts throughout the canthus
- Deficit in ADL must be described - A deficit is what the patient lacks in doing for himself and you need to list those as the evidence proving the existence of this problem. The dementia is the underlying cause.
Your goals, outcomes and nursing interventions will then focus on reversing or assisting the patient in doing something about those specific hygiene and oral care deficits that you have identified. Goals and outcomes quite simply are what you predict will happen as a result of your nursing interventions for these apecific things being followed. | | No. 188 |
Oct 04, 2009, 09:20 AM
Originally Posted by apromm Hi, I have a 57 year old patient with no medical history. He has no use of tobacco, alcohol, or drugs. However, he was going to the gym 4-5 x's a week and taking "work-out supplements." His urine was + for benzodiazopines. He went into cardiac arrest at home. CPR was immediately initiated for 10 minutes. At 10 minutes the defibrillator arrived. He was shocked twice. He is now at the hospital sedated on propofol and vented. (Tv 600, Fio2 40, rate 10, peep 8) He does not have any abnormal ABG's. He has a normal temperature, BP's range 110/63-130/75, map 73-89, Resp 12-16, hr 53-57, spo2 95-99. He is on an amidoarone and lidocaine drip. Other medications include Nexium, Aspirin, Zosyn, silvadene, heparin SQ 5000 units, and novolin R. His labs came back with a decreased albumin (2.9), phosphate (2.1), RBC, Hgb, Hct, and platelets. His SGOT/AST was highly elevated (61) and creatinine only slightly elevated (1.4). A HIT panel was sent off yesterday. His CT's show no aneurysms or dissections, or incranial bleed. There is a suspicion of mild right lower lobe infiltrate. Upon assessment he only opened his eyes to physical stimulation (he was sedated). He generalized edema 1+. His lung sounds were diminshed at the right base and he had a scant amout of thick, tan/bloody sputum. He also had a productive cough. His abdomen was soft but slightly distended with hyperactive bowel sounds. He was on TF at 50 cc/hr. However, we turned the sedation off later in the day and he opened his eyes to verbal stumuli, had strong hand grasps bilaterally and followed command. He became to aggitated and we had to increase sedation. Anything not mentioned was normal. My nursing diagnoses for him are:
1. Impaired gas exchange r/t ventialtion perfusion imbalance
2. Decreased cardiac output r/t altered rhythm and stroke volume
3. Decreased tissue perfusion: Cerebral?? (I need something to do with neuro... He was on sedation since he arrested. They tried to take him off once and he was not tolerant, on the day that i took care of him he followed verbal command and opened his eyes but he was very aggitated...)
4. Risk for infection (He is on prophylactic Zosyn, vented, and has burns on chest from shock)
5. Moderate anxiety (He was very aggitated when sedation was taken off... He grimaced, tried to yank at vent, started choking, he cried, and he couldn't sit still)
Any input would be greatly appreciated. Thanks! Ineffective Airway Clearance (because of the diminished lung sounds, productive cough and thick, tan/bloody sputum he is producing)
How are you accounting for his generalized edema? Impaired Verbal Communication
Is his agitation due to Acute Confusion R/T brain damage? Risk for Infection (because of the presence of the ET tube, IV and GT)
| | No. 189 |
Oct 26, 2009, 12:15 AM
Updated
Oct 26, 2009 at 12:17 AM by mstacyi
Re: Help with Care Plans
ok so I need help! I did a search on here and didn't find anything that I my patient could relate to. 63 y/o African American female who was last seen with increased dyspnea and weight loss. At some point, her medical records become blurry when she was readmitted to to ICU 09/13/09. She was readmitted based on exacerbation chronic obstructive pulmonary disease and respiratory distress requiring intubation. On admittance, there was no hemoptysis, no abdominal pain, no palpation or chest pain.
ABGs: Ph 7.3, pCO2 66, pO2 82, hCO3 32.5, sat 97.2, CARB hbg 3.0.
Xrays: 1.Left pleural effusion 2.Cardiomegaly Vital signs on admittance were: Temp: 98.4 °F; HR: 77 bpm; RR: 28 br/min; BP:125/99; O2 Sats: 94% on 2L NC Working Diagnosis: COPD, Respiratory failure, Tracheostomy
Relevant Medical History: COPD Smoker Chronic back pain MRSA sputum History of right leg wound ETOH abuse Extubated and reintubated after almost 6 hours Kyphosis Habits: Smokes about 2 packs per day. She stated that she had cut back during the last 2 week before her admittance. Assessment On examination Mrs. M is alert and oriented X 3 to place, name, and specification. She has dysphagic and impaired Speech d/t tracheostomy in placed 9/24/09, but was able to communicate with pen and writing pad. She has generalize weakness and appeared to be unsteady when ambulating to the BSC and chair. She has limited ROM d/t chairfast; can ambulate to chair TID with 1 person assistance. Kyphosis is noted. No circulatory problems were noted. Unstable vital sign; BP: 90/50. Apical pulse regular rate and rhythm; S1, S2 noted. Upon auscultation, fine crackles were heard bilaterally in the upper and middle lobes during exhalation. A non-productive cough also noted. She breathes thought the trach with O2 at 10L through T-trach; she does self suction as needed. Her eyes, ears, nose, and throat is WNL. She is NPO. She has a PEG tube in placed with regular Jevity at 60ml/hr, residual check Q4H (if >50 hold feeding). LBM 10/21/09. Bowel sound present in all four quadrants and abdomen is soft and non-distended. Her skin is moist and she also has poor turgor. Feet warm, dry, intact, capillary refill toes < 2sec. She is at risk for skin brake down d/t current Braden scale score at 16. IV is CDI, located on right wrist, HL. PEG tube incision site on left lower abdomen is free from redness or drainage with gauzes intact. Uses BSC and bedpan. Urine is clear yellow. C/O acute cramping and throbbing pain in fingers, toes, coccyx rated at 10/10 based on (0-10) pain scale. Appeared to be anxious, had anxiety for the MD to visit in the AM. Currently at risk for fall, scared 7 on the Hendrich II Fall Risk Scale, flower pitcher picture on door. Underweight BMI – 16.9. Call bell within reach on right hand. Instructed to call for assistance as needed. Demonstrated understanding by writing “yes” on writing pad. Vital signs assessed Q4H. Nursing assessment Q4H. NKA.
This is for a long care plan so I dont even know if I should include the highlighted red in my long care plan?
I am working two nursing diagnoses: 1.Acute Pain R/T musculoskeletal pain AMB: when patient writes her fingers cramps and she will drop the pen, patient wrote “my fingers and toes hurt” and also patient points at her coccyx to indicate where the pain is located rated at 10/10 on (0-10) pain scale. HX: Kyphosis, Chronic back pain. 2.Impair gas exchange R/T destruction of alveolar walls AMB: Severe SOB, no relief of SOB with Albuterol nebulizer and Combivent, hypercapnea (pCO2-66), confusion.
I think that I got the impair gas exchange rite, but I am not sure about teh acute pain. I know that she she had cramps in her fingers and toes, but there is no truma or injury to the fingers or toes ( i am guessing it is referr pain) but from where. There is nogthing in the chart to indicate why she would be having pain in her fingers and toes.
Please help! thanks
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