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| No. 60 | 
Sep 21, 2008, 03:29 PM
Originally Posted by nurse_jamie2010  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! 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?? Yes, it is an approved diagnosis. Here are links to webpages about it: We diagnose based on the evidence (symptoms) the patient exhibited. Even if PO2 levels weren't given, there would be other evidence of Impaired Gas Exchange. Read the definition of this diagnosis from a taxonomy reference ( Impaired Gas exchange or http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=23). This diagnosis is very clearly referring to hypoxia although it does not state it since hypoxia would be a medical determination. But look at the defining characteristics that are listed on these pages. Those are symptoms of hypoxia. Is there an Ineffective Airway Clearance or Ineffective Breathing Pattern problem in addition to the gas exchange? They often go hand in hand, especially when there is any kind of pneumonia. Gas exchange only addresses the lack of oxygen, but what is gunking up the airways and blocking the air from getting to the lungs and what is being done for it?
You have other symptoms that need to be addressed: - Unable to eat (Imbalanced Nutrition - need more assessment information)
- fever 101 (Hyperthermia)
- broken skin with drainage (Impaired Skin Integrity or Impaired Tissue Integrity)
- diaphoretic, xerosis (generalized) (the diaphoresis is part of the fevers; the xerosis is an element of the Skin Integrity problem)
 | | Advertisement Sponsored Links | | | | No. 61 |
Sep 21, 2008, 05:25 PM
 Re: Help with Care Plans Originally Posted by Daytonite skin/wound assessment: 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]
I learn so much here. Would you also have risk for infection r/t enterostomal feeding tube and bed sores? I didn't see meds but I also thought there was a temp?
| | No. 62 |
Sep 21, 2008, 06:17 PM
Originally Posted by chevyv I learn so much here. Would you also have risk for infection r/t enterostomal feeding tube and bed sores? I didn't see meds but I also thought there was a temp?
The post with the feeding tube did not involve a fever and only a suspected bedsore that was healed, now the skin intact. But, yes, the presence of any tube is a Risk for Infection because it is invasive.
| | No. 64 |
Sep 26, 2008, 10:37 AM
Originally Posted by groupa2 HELP pls.. im a junior nursing student here in the philippines and need help. as part of our curriculum we need to have a case study, my patient is 73 years old female diagnosed with acute gastroenteritis, her physical assessments were all normal her vital signs were normal.. Im using NANDA but so hard to make one..cause her findings are normal,. can you help me? what would be the possible nursing care could be applied to her.. im new user here.. thanks for helping me..
Answered: See http://allnurses.com/forums/f205/help-336460.html - help | | No. 65 |
Sep 28, 2008, 07:20 PM
Help with Care Plans
hi im a nursing student and am struglling with finding nursing diagnosis for the following senario. i need 5 with rationales and interventions could ne1 please help Mrs Chang is a frail and thin 82 -year-old woman in late stage Parkinson’s disease. Until recently she has been living at home with the support of her 86-year-old husband Mr Chang. Mr and Mrs Chang have been married for 65 years and have one child, who died tragically in a Motor Vehicle Accident (MVA) 12 years ago. Many of their friends have pre - deceased them, and as a consequence they have very little social contact with the outside world. Two weeks ago, whilst mobilising to the bathroom, Mrs Chang tripped and fell becoming trapped between the shower and the bathroom door. In a panicked state, Mr Chang called for an ambulance and Mrs Chang was admitted via the emergency department to the ward you are working in. Diagnostic and radiographic studies confirmed that no bony injuries were sustained as a result of the fall. However, given Mr and Mrs Chang’s social situation and Mrs Chang’s declining cognition and mobility issues the medical staff thought it best to admit Mrs Chang for further assessment and evaluation. | | No. 66 |
Sep 28, 2008, 07:54 PM
Re: Help with Care Plans
I'm having trouble with writing outcomes that are timed. I don't know how long these outcomes should take.
| | No. 67 |
Sep 28, 2008, 10:26 PM
Updated
Sep 28, 2008 at 10:32 PM by Daytonite
Originally Posted by purple882 hi im a nursing student and am struglling with finding nursing diagnosis for the following senario. i need 5 with rationales and interventions could ne1 please help
Mrs Chang is a frail and thin 82 -year-old woman in late stage Parkinson’s disease. Until recently she has been living at home with the support of her 86-year-old husband Mr Chang. Mr and Mrs Chang have been married for 65 years and have one child, who died tragically in a Motor Vehicle Accident (MVA) 12 years ago. Many of their friends have pre - deceased them, and as a consequence they have very little social contact with the outside world.
Two weeks ago, whilst mobilising to the bathroom, Mrs Chang tripped and fell becoming trapped between the shower and the bathroom door. In a panicked state, Mr Chang called for an ambulance and Mrs Chang was admitted via the emergency department to the ward you are working in. Diagnostic and radiographic studies confirmed that no bony injuries were sustained as a result of the fall. However, given Mr and Mrs Chang’s social situation and Mrs Chang’s declining cognition and mobility issues the medical staff thought it best to admit Mrs Chang for further assessment and evaluation. Diagnosing follows a systematic routine of first assessing the patient and pulling out all the abnormal data. That abnormal data becomes your signs and symptoms that become the foundation (evidence) of any nursing diagnoses you end up using. You need nursing diagnosis references to help you. Doctors do exactly the same thing when diagnosing. The difference is that we diagnose nursing problems. You really haven't listed any of the patient's symptoms except that they have very little contact with others, the patient fell and that she has some declining cognition. There is no further description of her mobility issues, whatever they are. There is not enough information there for 5 nursing diagnoses. Follow this process when care planning. . .- 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)
- 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
- 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)
- 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:
- Planning (write measurable goals/outcomes and nursing interventions)
- goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. They have the following overall effect on the problem:
- improve the problem or remedy/cure it
- stabilize it
- support its deterioration
- interventions are of four types
- Assess/monitor/evaluate/observe (to evaluate the patient's condition)
- NOTE: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during Step 1.
- Care/perform/provide/assist (performing actual patient care)
- Teach/educate/instruct/supervise (educating patient or caregiver)
- Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
| | No. 68 |
Sep 29, 2008, 11:54 AM
Originally Posted by Sunset87 I'm having trouble with writing outcomes that are timed. I don't know how long these outcomes should take.
It depends upon what your interventions were that contribute to the outcome. You need to research the subject of the outcome to find out what the expected time would be. That is part of the learning involved with these care plans.
| | No. 69 |
Oct 14, 2008, 02:56 PM
Re: Help with Care Plans
I am a second year nursing student trying to write a careplan. I am really struggling with this one and any insight would be awesome! I had a client for clinicals last weekend that I need to do a careplan on. This was an elderly woman who got admitted to the med surg floor after a fall. She had a L wrist fx and a R wrist fx and also fractured left ribs. She was in bad shape. This client was dysphasic and very difficult to arrouse (lethargic). Vital Signs were stable upon arrival and decreased throughout the day. By the end of the say BP was extremely low along with pulse, output, ect. When I came onto the floor on Sunday the physician said the client would most likely not make it through the day. Renal Failure was occuring and vitals were rapidly decreasing. She was on 5L of 02 and stats were 94%. Lung sounds were diminished. There was little intake and even less output. Family was there at the bedside. I am supposed to write a care plan and I am having huge problems with diagnoses to fit this client. My first thought was Risk for Infection, however, this cannot be a priority diagnosis because it is a risk. Then I wanted to do Excess Fluid Volume however our NANDA books do not reccommend this diagnosis because it is more of a collaborative diagnosis. Impaired Comfort is not recognized by NANDA and cannot be used. IM STUCK!! I need a total of 3 diagnoses and 10 interventions with rationales for each and I do not even know where to begin. ANY input would be much appreciated...Thanks!!!!
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