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

Are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? Here are some words of wisdom from our own beloved Daytonite.


Care Plan Basics:
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. They are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. There are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. What you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

How does a doctor diagnose? He/she does (hopefully) a thorough medical history and physical examination first. Surprise! We do that too! It's part of Step #1 of the nursing process. Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case. Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Another surprise! We do that too! We call it "critical thinking and it's part of Step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis.


Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

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)
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)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

Now, listen up, because what I am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself IS a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems. Why? Because as a working RN you will be using that method many times a day at work to resolve all kinds of issues and minor riddles that will present themselves. That is what you are going to be paid to do. Most of the time you will do this critical thinking process in your head. For a care plan you have to commit your thinking process to paper. And in case you and any others reading this are wondering why in the blazes you are being forced to learn how to do these care plans, here's one very good and real world reason: because there is a federal law that mandates that every hospital that accepts Medicare and MedicAid payments for patients MUST include a written nursing care plan in every inpatient's chart whether the patient is a Medicare/MedicAid patient or not. If they don't, huge fines are assessed against the facility.

You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids. Let me give you a simple example:

You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" you're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. What you have just done is STEP #1 of the nursing process--performed an assessment. You determine that you have a flat tire. You have just done STEP #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do I do?" you are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! You have just done STEP #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done STEP #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be OK and off you go and on your way. You have just done STEP #5 of the nursing process--evaluation (determined if your goal was met).

Can you relate to that? That's about as simple as I can reduce the nursing process to. But, you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.

CARE PLAN REALITY: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be a medical disease, a physical condition, a failure to be able to perform ADLs (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of Step #1 of this whole nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers. Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. In order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from Step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLs (because that's what we nurses shine at). The ADLs are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. And, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. Did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list. This is all part of preparing to move onto Step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. But, you have to have those signs, symptoms and patient responses to back it all up.

CARE PLAN REALITY: What you are calling a nursing diagnosis (Ex: Activity Intolerance) is actually a shorthand label for the Patient Problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition).

Activity Intolerance (page 3, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008)

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities
(does this sound like your patient's problem?)

Defining characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

Related Factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

I've just listed above all the NANDA information on the diagnosis of Activity Intolerance from the taxonomy. Only you know this patient and can assess whether this diagnosis fits with your patient's problem since you posted no other information.

In order to choose nursing diagnoses, you also need to have some sort of nursing diagnosis reference. There is some free information on the Internet but it is limited to about 75 of the most commonly used nursing diagnoses. There is a post that has the weblinks to them (see post #109 on the thread:

http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html

One more thing . . . CARE PLAN REALITY: Nursing Diagnoses, nursing interventions and goals are ALL based upon the patient's symptoms, or defining characteristics. They are all linked together with each other to form a nice related circle of cause and effect.

You really shouldn't focus too much time on the nursing diagnoses. Most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. The nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.