Help with Care Plans

tullosrn2010 · Oct 18, 2008, 07:58 PM

Re: Help with Care Plans

im working on my first care plan.....im having trouble coming up with goals/outcomes for the nsg dx: risk for aspiration r/t difficulty swallowing...any takers??

RiversideCA-LVN · Oct 18, 2008, 10:05 PM

Re: Help with Care Plans

I need help writing a care plan for a 43yr old caucasian, male complete C3 SCI patient with autonomic dysreflexia. He is ventilator dependent with trach, total assist of ADLs, total care, GT, irequires intermittent catheter every 4 hrs, other diagnoses are depression, hypothyroidism, and BPH
Subjective data: severe throbbing headache "10/10",nausea, feels anxious, and c/o blurred vision
Objective data: 99.6, respirations 20, BP 186/102, HR 45, diaphoresis on head and neck, skin flushed on face, goosebumps
I tried care plan constructor but couldn't find autonomic dysreflexia but it is on the NANDA nursing diagnosis list. Any help would really be appreciated. This is my first care plan in my BSN program and I am kind of freaking out!!

*Daytonite* · Oct 19, 2008, 05:11 AM

Originally Posted by sexxy3lady

I'm doing a careplan on MRSA. My diagnosis is "Potential for Systemic infection R/T septic Right knee" is that ok?

The wording "Potential for" is no longer used by NANDA and has been changed to "Risk for". What is the risk factor? What has happened in the right knee that is making it possible that sepsis might occur? Sepsis is a systemic infection so "septic right knee" cannot be used. Is this an arthritic knee? Or a knee injured from trauma? What will set off the infection?

*Daytonite* · Oct 19, 2008, 05:17 AM

Originally Posted by tullosrn2010

im working on my first care plan.....im having trouble coming up with goals/outcomes for the nsg dx: risk for aspiration r/t difficulty swallowing...any takers??

Goals/outcomes are the predicted results you expect to see when your nursing interventions are performed as you have prescribed them on the care plan. Your interventions are based upon the data you collected about the patient. Since you have provided none of that information, there is nothing to specifically tell you. See this post for specific information on how to construct a goal statement: http://allnurses.com/forums/2509305-post158.html

*Daytonite* · Oct 19, 2008, 06:03 AM

Originally Posted by RiversideCA-LVN

I need help writing a care plan for a 43yr old caucasian, male complete C3 SCI patient with autonomic dysreflexia. He is ventilator dependent with trach, total assist of ADLs, total care, GT, irequires intermittent catheter every 4 hrs, other diagnoses are depression, hypothyroidism, and BPH
Subjective data: severe throbbing headache "10/10",nausea, feels anxious, and c/o blurred vision
Objective data: 99.6, respirations 20, BP 186/102, HR 45, diaphoresis on head and neck, skin flushed on face, goosebumps
I tried care plan constructor but couldn't find autonomic dysreflexia but it is on the NANDA nursing diagnosis list. Any help would really be appreciated. This is my first care plan in my BSN program and I am kind of freaking out!!

First of all, care plan books are only giving you suggestions for diagnoses, goals and interventions. It is still up to the nurse to use critical thinking skills and the nursing process to determine the patient's problems (diagnose) and come up with strategies to do something about them (nursing interventions). There are 5 steps to the nursing process but the first 3 are pretty intensive and most important to the development of a care plan. Keep in mind that a care plan is a work of problem solving and the nursing process is a tool for problem solving.

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

complete C3 SCI (spinal cord injury)
autonomic dysreflexia
depression
hypothyroidism
BPH
- Medical Treatments:
  - ventilator
  - trach
  - GT (gastric tube)
  - intermittent catheter every 4 hrs

Step #2 Determination of the patient's problem(s)/Nursing diagnosis Part 1 - make a list of the abnormal assessment data – can't help but notice that there is no respiratory data here and patients with trachs on ventilators have problems with secretions at the least and usually perfusion if this is a new trach. If it is an old trach then infection is sometimes a chronic issue. What is going on with the patient's skin? These patient's are at a great risk for decubitus.

HR 45
BP 186/102
severe throbbing headache "10/10"
c/o blurred vision
skin flushed on face
goose bumps
diaphoresis on head and neck
nausea
feels anxious
total assist of ADLs
total care

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

Autonomic Dysreflexia R/T ??? AEB HR 45, BP 186/102, severe throbbing headache "10/10", c/o blurred vision, skin flushed on face and goose bumps
- What set off the patient's reactions? Was it time for him to be catheterized? Did he need to have a BM? Is it something that was done by the caregivers that stimulated this response? One of those reasons will be the related factor.
Feeding Self-Care Deficit R/T neuromuscular impairment
Toileting Self-Care Deficit R/T neuromuscular impairment
Anxiety R/T situational stress AEB statements of feeling anxious and complaints of nausea
Risk for Impaired Skin Integrity R/T impaired sensation and immobility
Risk for Infection R/T invasive procedures (trach, GT, intermittent catheterizations)

lawyerronald · Oct 20, 2008, 09:13 AM

Re: Help with Care Plans

Thanks so much for been part of allnurses. I never regreted doing so and the first and formost benefit been my ability to know the inner core and perspectives of nursing diagnoses which I found difficult to understand when my tutor was doing all possible to bring to me the understanding.

cicilia123 · Oct 21, 2008, 04:45 PM

Re: Help with Care Plans

Thank you so much.

jmarz · Oct 22, 2008, 07:08 PM

Re: Help with Care Plans

hey, anyone here could help me to Formulate ncp for leptospirpsis..
tnx a lot

jmarz · Oct 22, 2008, 07:09 PM

Re: Help with Care Plans

hey, anyone here could help me to Formulate ncp for leptospirosis..
tnx a lot

*Daytonite* · Oct 22, 2008, 07:35 PM

Originally Posted by jmarz

hey, anyone here could help me to Formulate ncp for leptospirosis..
tnx a lot

There are plenty of previous posts on this thread for you to look at to help you formulate how to work out a care plan. What you need to do is look up information about leptospirosis which is an infection spread by rats which, I believe, is also called Weil's disease.

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Help with Care Plans

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