Help with Care Plans

Daytonite, you're awesome! Thanks for the ideas!!!!!!!!!!!!!

hi , i need to know if i am on the right path. I have a pt who has hematuria and urinary retention. his H7H a nd rbc are low and he had a blood transfusion yesterday. he has a history of hypertension, diabetes and neuropathy. he has a continous bladder irrigation foley with normal saline for the bloody urine. I came up with risk for injury and altered tissue perfusion renal, because of his low blood labs. is this right? he alo complains of fatigue nad he is out of bed with assistance. thanks

Utilize the nursing process to help you. It is our tool to help us problem solve.
Step #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)

1. • a physical assessment of the patient
   • assessment of the patient's ability and any assistance they need to accomplish their ADLs (activities of daily living) with the disease
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. This includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. If this information is not known, then you need to research and find it.
   • http://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - Medical Disease Information/Treatment/Procedures/Test Reference Websites

You have a patient who has:

• urinary retention
• a history of hypertension
• diabetes
• neuropathy

You need to determine if any of these conditions are contributing to his current problems by following the above assessing guidelines to find out if you missed anything. Then, you can move on to the next step.

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

• low H&H/low RBCs that has already required a transfusion
• bloody urine (hematuria)
• complains of fatigue
• needs assistance to get out of bed

Step #2 - Determine the patient's problem(s)/Nursing diagnosis/Part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
It helps to have a book with nursing diagnosis reference information in it. There are a number of ways to acquire this information.

• Your instructors might have given it to you.
• You can purchase it directly from NANDA. NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International. Cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
• Many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. This information will usually be found immediately below the title of a nursing diagnosis.
• The NANDA taxonomy and a medical disease cross reference is in the appendix of both Taber's Cyclopedic Medical Dictionary and Mosby's Medical, Nursing, & Allied Health Dictionary
• There are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/
  • http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm

You have suggested:

• Altered Tissue Perfusion: renal
  • to use this you need evidence to support that there is hypoxia (low oxygenation) of the renal tissues. The evidence of that is usually the signs and symptoms of renal failure. Hematuria is not enough. Does this patient have renal failure? I don't see this as being a good diagnosis to use unless there is more evidence that you just haven't presented.
• Risk for Injury (an anticipated problem)
  • what is the anticipated problem? What is the risk you are identifying?

I still see the low H&H/low RBCs and fatigue unaccounted for. Since the patient has already been transfused we know he has an anemia problem. Transfusions are given to "plug the dike" so to speak and never to fix the problem completely. So, even though hemorrhage or anemia wasn't stated by the doctor, the evidence is certainly there. In nursing language, this is a fluid deficit because it involves the blood, a body fluid. So, you have another problem

• Deficient Fluid Volume R/T blood loss through the urinary system AEB bloody urine, low H&H, low RBCs and complaints of fatigue
  • I would also go back and look at other evidence of dehydration you have that you might have overlooked, such as elevated pulse rates, respiratory rates, dry skin and mucous membranes
• You can also separate out fatigue and give it it's own diagnosis but it needs specific symptoms to support it. A nursing diagnosis reference will list the symptoms (defining characteristics) in case you did see them in the patient, but overlooked them: Fatigue R/T anemia AEB [need more specific symptoms] Fatigue

I want to address the data that the patient needs assistance getting out of bed. This is a mobility issue and goes to the heart of nursing and ADLs. This is what we nurses do--assist patients. Nobody else is going to do it. Go back to Step #1 of the nursing process and look at what it directs you to assess:

assessment of the patient's ability and any assistance they need to accomplish their ADLs (activities of daily living) with the disease

The reason is because within the nursing diagnoses are a whole bunch of them that address accomplishing ADLs (bathing, dressing, mobility, eating, toileting, and grooming). Anything that a patient needs assistance with or can't perform by themselves to help them get through their day is a patient problem that needs to become part of the care plan. So, you know this person better than I do. What is the likely reason for his limited movement? Did anything in his chart provide clues? The neuropathy maybe?

• Impaired Physical Mobility R/T ??? AEB needing assistance to get out of bed

The last thing I would ask is does this patient have any tests or procedures scheduled or likely to be performed? If so, teaching would be appropriate.

One last thing. . .with a foley catheter in place and a history of diabetes, this patient is at a Risk for Infection R/T presence of indwelling urinary catheter and hyperglycemia.

thank you daytonite, looking at my data from my assessment i can see the fluid volume problem

Daytonite - I wanted to let you know I received full points for my care plan that you helped me with (I needed a nursing dx for a healthy newborn). Thank you again for all of your help!

I'm writing my first care plan. I really don't know where to start. I'm supposed to be focusing on skin, so I'm trying to pick diagnoses and the priority diagnosis. Would having an enterostomal feeding tube be Actual or Risk for Impaired Skin Integrity?
Is Ineffective tissue perfusion higher priority than impaired skin integrity?
I don't think I did my assessment correctly, so I don't have enough information to write a care plan.

Care plans are the identification of a patient's nursing problems and your strategies to solve them. We use the nursing process as a tool in helping us in that identification. You start by following the steps of the nursing process in the sequence that they occur.


Step #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

All I know about this patient is that they have an enterostomal feeding tube and nothing more. Assess the patient. Look at the site where this tube exits their body. What does it look like? Describe it? Is the patient able to take any oral food or fluids at all? Is their ability to swallow been impaired? Why was this tube put into this patient? Did this patient have a stroke? Alzheimer's? Has the patient been weighed recently? What was their weight? Have they gained or lost weight over the last few months? What do their mouth and teeth look like? Can the patient talk? Now, look up information about these tubes, why they are used and what the care for them is.

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

There is no crime without evidence. To have an actual skin problem, there must be evidence of it. If there is no evidence of a problem, then there will have to be an anticipated or Risk for problem.

Get evidence first. No evidence--no diagnosis or a Risk for diagnosis must be used.

Priorities can be based on Maslow's Hierarchy of Needs unless your instructors have told you to use some other system. Here is a link to information on Maslow: http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs

Is Ineffective tissue perfusion higher priority than impaired skin integrity? Yes. Impaired Skin Integrity is more of a nourishment and safety issue.
I don't think I did my assessment correctly, so I don't have enough information to write a care plan. You may have figured out your problem. You didn't post any of your assessment, so I have no opinion, nor can I provide much more help. Becoming proficient in assessing takes time and experience. By looking at reference material now you will jog your memory of things you might have overlooked seeing in this patient and just didn't realize they were important symptoms to pick up on at the time.

Just a few quick questions.... This is my 2nd care plan so I'm still learning, here are my questions...

I have an HIV+ pt and here is a few subj and obj info

Unable to eat
broken skin with drainage
incont. of diarrhea 3-4 times per day
fever 101
diaphoretic, xerosis (generalized)

I am thinking that I would use either fluid vol deficit or diarrhea as my Nursing dx but I'm unsure if diarrhea is a NANDA approved dx??

Another question, This sample case study also mentions recent post hospitalization with Pneumocystitis (PCP) and this case study has a setting of you visiting the pt at home, He still exhibits signs of still having this Pneum and disorientation, but doesn't list PO2 levels or any blood gas info to base Impaired gas exchange plus the resp rate is said to be 20?? I just dunno which would be the one to use as Priority???

any input would be helpful!

THANKS!

Thanks so much Daytonite for responding so quickly. I know that my problem was in the assessment. It was my first day in clinicals on Thursday and I had no idea what I was doing. I was told to do a skin assessment and that was it. I wasn't really sure how to do a skin assessment. We learned on Wednesday about skin assessments (basically recognizing abnormalities). It was my first time interacting with a real patient and I'm sure I did the whole assessment wrong. I didn't know what I was looking for or anything. I didn't know what information I needed from the patient's chart. I got the admission date and admitting medical diagnosis. My patient was a 77 year old woman post CVA, hypertension, and diabetes. She is immobile and nonverbal. The one thing that stood out to me during the skin assessment was a pink area over the bony prominence of her thigh bone. I think it was a healed pressure ulcer?
Thanks for trying to help me. Next time I will try to assess as much as I can and read the chart to get information. It's too late now for me to get more information, but I need to write a care plan.

skin/wound assessment:

• http://www.meddean.luc.edu/lumen/med...pd/pstep76.htm
• http://www.nursing.uiowa.edu/sites/chronicwound/
  • http://www.nursing.uiowa.edu/sites/c...efinitions.htm

Step #1 - Assessment - look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• post CVA
• hypertension
• diabetes

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

• immobile
• nonverbal
• pink area over the bony prominence of her thigh bone

Step #2 - Determine the patient's problem(s)/Nursing diagnosis/Part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• Impaired Physical Mobility R/T neuromuscular impairment secondary to CVA AEB immobility [you should be able to be more specific with the patient's limits in movement]
• Impaired Verbal Communication R/T damage to central nervous system secondary to CVA AEB absence of speech [did the patient respond to commands at all?]
• Risk for Impaired Skin Integrity R/T immobility and chemical irritants [bed sores; drainage around enterostomal feeding tube exit site causing potential skin breakdown]