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| No. 70 | 
Oct 15, 2008, 01:50 AM
Originally Posted by Kacee890 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!!!!
You can get out of jams like this by following the steps of the nursing process. Keep in mind that books are references. A care plan you construct is a customized solution to the patients nursing problems. Patients are unique and not textbooks examples. 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 - from your description of the situation it sounds like the patient is going into organ failure and will die. Still, what you have to work with are these facts. You need to look up information about acute renal failure since some of the patient's symptoms probably match them. Was this patient dysphasic before the fall or has she had a stroke and that is why she fell? Complications of fractured ribs are a pneumothorax and pneumonia.- patient fell
- has a left wrist fracture
- has a right wrist fracture
- fractured left ribs
- dysphasic
- going into renal failure
- Treatments
Step #2 Determination of the patient's problem(s)/Nursing diagnosis Part 1 - make a list of the abnormal assessment data – does looking at the list of abnormal data cause you to reconsider some of your nursing diagnosis choices? You were considering Excess Fluid Volume. Are there symptoms of that here? As this patient was becoming more lethargic and difficult to arouse, was any thought given to how basic needs of bathing, dressing, mobility, eating, toileting, and grooming would be accomplished? One of this patient's problems was dysphasia. How was this manifested?- difficult to arouse (lethargic)
- vital signs decreased throughout the day - by the end of the say BP was extremely low along with pulse, output
- lung sounds were diminished
- little intake and even less output
Step #2 Determination of 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 – focus on the patient at the moment you had her and not what you know is her medical outcome. She has serious fractures that would be causing mobility problems as well as difficulty accomplishing her ADLs. How is she toileting--I assume she has a foley catheter. If she is getting more and more lethargic she in on bedrest which means almost everything needs to be done for her especially since she has two broken wrists. How is she turning? Getting mouth care? Not only that, but with the rib fractures and diminished breath sounds she is a case of pneumonia just waiting to happen.- Deficient Fluid Volume R/T renal organ failure AEB diminishing intake and output and decrease in vital signs, or Imbalanced Nutrition: less than body requirements R/T altered state of consciousness AEB diminished intake
- Impaired Physical Mobility R/T skeletal impairment secondary to bilateral wrist fractures AEB [symptoms of limitations of movement]
- Impaired Verbal Communication R/T compromised circulation to the brain AEB [symptoms of dysphasia]
- Any of the Self-Care Deficits
- Risk for Infection R/T traumatic rib injury [pneumonia]
 | | Advertisement Sponsored Links | | | | No. 71 |
Oct 16, 2008, 11:03 PM
 Re: Help with Care Plans
thanks so much for all the tremendous knowledge i have read here.
ok, so here is my story, i started clinical this week, wed and thu., we were assigned 1 pt each. of course we have to do a careplan but it was not to be graded since my clinical instructor wants us to get the feel for it before she grades us.
my pt had a radical subtotal gastrectomy about 2 weeks ago, from the data that i have gathered he has: stomach cancer (reason for admission)
extensive lysis of adhesion & insertion of Right IJ central Line
hx of diabetes, hypertension and hx of rectal cancer
heart catheterization about 6 mos ago
my ? is, based form that data, i could form my Nursing DX right? pardon me from having NO such knowledge at all. we have discussed nursing process in class but i feel like it was not enough. i dnt even know if the supporting data is the defining characteristics. I am TOTALLY lost! i
i do know that it will take practice to look it up at the NANDA-I but golly-banana-que, i have no idea what to look for.
sorry for having such a long post,any help will be appreciated  | | No. 72 |
Oct 17, 2008, 07:04 AM
Updated
Oct 17, 2008 at 07:05 AM by chevyv
Re: Help with Care Plans
I think its better to do perform your own assessment of the pt if possible. He has stomach ca, but what is his intake? Is he NPO, underweight? Is he ambulating on his own or with assistance? I'm not sure if your instructor wants you to look at labs (this is usually more difficult and time consuming if your not familar with abnormals). What meds is he on and what are they for? How far advanced is the ca? Are they doing a resection? I guess you have the medical dx's, but nursing dx are usually based on our assessment of the whole person. I'll check back to see others response, I'm in my last semester so I may not be accurate in my explanation. Good luck in NS!
If you can't get any more data, you may have to go with more 'at risk for' type dx
| | No. 73 |
Oct 17, 2008, 09:19 AM
Re: Help with Care Plans
thanks for your input when i got there for my clinical he was about 2 weeks in recovery already and he has TPN and he can eat,
he is on a post gastrectomy diet
daily weight watch
the comment i got from his chart is : resection of gastric cancer yesterday when i did his vitals he has a 101.1 temperature,pain level is zero but he has a headache. his pulse is 115 and BP is 112/68.
i know i read from here to check for the "abnormal" i think i have an idea , based from what i have gathered from his data yesterday, but it is overwhelming me because this is my first time writing careplan and i do not know how to get the NANDA equivalent based from my pts datas.
thanks so much
| | No. 75 |
Oct 17, 2008, 10:00 AM
Re: Help with Care Plans Originally Posted by smilesalot  thanks for your input when i got there for my clinical he was about 2 weeks in recovery already and he has TPN and he can eat, he is on a post gastrectomy diet
daily weight watch
the comment i got from his chart is : resection of gastric cancer yesterday when i did his vitals he has a 101.1 temperature,pain level is zero but he has a headache. his pulse is 115 and BP is 112/68. i know i read from here to check for the "abnormal" i think i have an idea , based from what i have gathered from his data yesterday, but it is overwhelming me because this is my first time writing careplan and i do not know how to get the NANDA equivalent based from my pts datas.
thanks so much
Did you invest in any nusing care plan books yet? They are a life saver. The temp and pulse are definately abnormal. Is he up and about yet? I would think he is.... Did you write down the meds he's on? That part will tell you alot once you can look them up. How is his weight since admission to now? If you can, check out his lab work to see if the white blood cells are elevated (sometimes the increase in temp is a sign of infection). The increase in pulse has me wondering if his body is compensating for something- but I've never had a ca of the stomach before. Keep us posted on your progress.  | | No. 76 |
Oct 17, 2008, 10:41 AM
Re: Help with Care Plans
thanks for input.
i have nursing diagnosis book but as fas as careplan books, i have none yet. they are all expensive and i can only buy books every husbands payday, one at a time 
as far as the pts is concern, he is very much ambulatory, he actually walks the hallway once in the am and once in the pm. Wednesday, he was looking good as far as eating and talking but Thursday he was a little tired he said because he did not get a good night sleep and so had a headache when i got there, he walked the hallway once though.
for his labs his wbc is 7.3 k/cmm. im actually still working on calculating lab values because it's kind of different from what i was taught from school
will keep you posted, thanks so much
| | No. 77 |
Oct 17, 2008, 12:57 PM
Re: Help with Care Plans
Some of the major book stores, such as Barnes and Noble, have care plan books (yes, they can be pricey), but they have chairs where you can sit and look over books........at least to help you decide which one you would like to buy while helping you get this care plan done. Just a thought.....
Hope that doesn't ruffle feathers, when your on a strict budget, you sometimes have to do what you have to do. I'm certainly not advocating using without buying or the try before you buy mantra, I'm just trying to suggest the poster see which book works for her.
| | No. 78 |
Oct 17, 2008, 10:49 PM
Originally Posted by smilesalot thanks so much for all the tremendous knowledge i have read here.
ok, so here is my story, i started clinical this week, wed and thu., we were assigned 1 pt each. of course we have to do a careplan but it was not to be graded since my clinical instructor wants us to get the feel for it before she grades us.
my pt had a radical subtotal gastrectomy about 2 weeks ago, from the data that i have gathered he has: stomach cancer (reason for admission)
extensive lysis of adhesion & insertion of Right IJ central Line
hx of diabetes, hypertension and hx of rectal cancer
heart catheterization about 6 mos ago my ? is, based form that data, i could form my Nursing DX right? pardon me from having NO such knowledge at all. we have discussed nursing process in class but i feel like it was not enough. i dnt even know if the supporting data is the defining characteristics. I am TOTALLY lost! i i do know that it will take practice to look it up at the NANDA-I but golly-banana-que, i have no idea what to look for. sorry for having such a long post,any help will be appreciated
This is the nursing process applied to 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.
- 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)
I went through your 3 posts and pulled out the data that pertained to care planning. You seem to be unsure as to what "abnormal" data is. You need to be able to recognize what is normal about a physical assessment in order to recognize what is abnormal. For example, this patient has a headache and a fever. Is that normal? In a normal assessment people do not have headache or fevers.
Your information indicates that this patient had abdominal surgery and has an IJ line with TPN infusing. Is this how he is getting his nutrition and feeding? Is that normal? Why isn't he eating orally? Is TPN how you and I eat? What is his incision looking like 2 weeks post-op? Is anything being done for it. What is thought to be the reason for this temperature elevation? Is it related to the surgery or the IJ line? What, if anything, is being done for it? What are the complications of these treatments the patient is getting (the IJ, TPN, surgery)? These are questions I had as I read through your posts and that is all part of gathering data (assessment) which is the first step of the nursing process. 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 - you need to look up stomach cancer and subtotal gastrectomy. Is the gastrectomy a treatment for the stomach cancer? What complications can occur? Are other treatments anticipated such as chemotherapy or radiation therapy? Does the patient require teaching regarding further treatments? Was TPN an expected treatment or did something occur that required the patient to go on TPN?Step #2 Determination of the patient's problem(s)/Nursing diagnosis Part 1 - make a list of the abnormal assessment data – this is the only actual abnormal data you posted. Everything else was history, assessment data or medical treatments currently being performed.Step #2 Determination of 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 – you asked if based from that data you could form nursing diagnoses. Yes, However, there is probably more data that you have overlooked or missed. I say this because this patient would not be in the hospital unless he needed to be. Think back to what the nurses were doing for him. Those were interventions. What nursing problems do they match up to? (In other words, kind of back into the nursing problems when you get stuck.) Defining characteristics are the NANDA language for the signs and symptoms, or evidence, that supports the existence of a nursing problem (the nursing diagnosis).
From your data, I can diagnose the following: - Hyperthermia R/T ??? AEB temperature of 101.1 and pulse is 115.
- Fatigue R/T sleep deprivation AEB patient's statement of complaint of headache due to not getting enough sleep
| | No. 79 |
Oct 18, 2008, 06:57 PM
Re: Help with Care Plans
I'm doing a careplan on MRSA. My diagnosis is "Potential for Systemic infection R/T septic Right knee" is that ok?
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