Help with my first Caremap/care plan

Nursing Students General Students

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Specializes in CVICU, CPCU, Cath Lab/IR.

this is my first care plan and i need a little guidance. i have to have two nursing diagnosis, with 3 interventions for each short term goals for each diagnosis with 1 long term goal.

i have a 68 year old female who has been diagnosed with stage iv lung cancer that has gone to the spine, atril fib, anemia, neutropenia, hypokalemia, abdominal aortic aneurism, copd, pud.

she is 5'2'' 102 pounds. vitals are 99.3, apical pulse 70, radial 20, bp 108/54

she does not walk around because she fears that she will fall, but she can move from her wheel chair to the bed. she is incontinent and uses briefs and has skin break as well as a hemorrhoid.

abnormal lab values

sodium 130 (low)

chloride 93 (low)

creatine .44 (low)

magnesium 1.6 (low)

rbc 3.57 (low)

hemoglobin 10.2 (low)

hemacrit 33.1 (low)

mchc 30.7 (low)

rdw 15.6 (high)

monocyte 12.0 ( high)

current medications

phenergan 25 mg tab po prn

morphine sul table 30mg po every 8 hours

demeclocycline 150mg tab bid

sod chloride tab 1 gm po bid

furosemide tab 20mg po once daily

protonix tab 40mg po once daily

mag64 tab 64mg sr po once daily

the nursing diagnosis i am thinking about using is impaired skin integrity r/t physical immobilization and humidity caused by excretions as evidence by disruption of the epidermis in perianal area and buttocks.

1st short term goal: keep change brief every two hours or as need and skin will be clean and dry by 2:00 pm on 11/1/2008.

2nd short term goal: keep impaired skin covered with barrier cream to protect wound and surrounding area by 2:00 pm on 11/1/2008

long term goal: have area free of skin breakdown by 12/1/2008

for the second diagnosis i was thinking bowel incontinence r/t toileting self care deficit as evidence by red perianal skin and constant dribbling of soft stool.

1st short term goal: provide patient with a high fiber diet and adequate fluids by 2:00 pm on 11/1/2008.

2nd short term goal: provide exercise’s to increase perineal muscles by 2:00pm on 11/1/08.

long term goal: establish a bowel program so the patient knows when to defecate by 12/1/2008.

i am not sure if i am on the right track, but i would appreciate any input!

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Specializes in Peds Hem, Onc, Med/Surg.

i think that you are headed the right way. i don't know how your program does it but for the goals for us had to have an outcome that could be measured. for example your first one

keep change brief every two hours or as need and skin will be clean and dry by 2:00 pm on 11/1/2008.

the skin will be free of pain, redness, swelling, infection.

but our instructor was really anal about that type of thing.

i think you have good ones. i would have gone with risk for falls, impaired gas exchange, ineffective airway clearance and the first one you used because i feel that these would be a higher priority.

good job!

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Specializes in CVICU, CPCU, Cath Lab/IR.

So far they have not told us about prioritizing diagnosis yet, but I am sure once we get the concept down they will.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

impaired skin integrity r/t physical immobilization and humidity caused by excretions as evidence by disruption of the epidermis in perianal area and buttocks.

1st short term goal: keep change brief every two hours or as need and skin will be clean and dry by 2:00 pm on 11/1/2008.

2nd short term goal: keep impaired skin covered with barrier cream to protect wound and surrounding area by 2:00 pm on 11/1/2008

long term goal: have area free of skin breakdown by 12/1/2008

  • because you didn't provide any description of this skin breakdown i have no way of knowing if this diagnosis is appropriate. this diagnosis is for stage i and stage ii decubitus ulcers. stage ii decubitus is when the top layer of skin has been sheered off.
  • related factor: include "moisture". the skin macerates and softens because of sitting in wet urine so that a sheering force easily causes the skin to come off. this patient is also neutropenic which is going to compromise her healing. that should be included as a related factor.
  • rather than "disruption of the epidermis in perianal area and buttocks" which sounds like it came from the taxonomy, describe the wounds. the perianal area belongs as evidence and treatment with your second diagnosis.
  • it is difficult for me to really assess these goals without seeing your interventions.
    • "keep change brief every two hours or as need" is a nursing intervention, not a goal. a goal is what you predict is going to happen as a result of the nursing interventions you order. finish this sentence: "as a result of her briefs being changed every two hours i expect ____ to happen." that is your goal.
    • "skin will be clean and dry by 2:00 pm on 11/1/2008". any time rounds are made and her diaper is checked it will be a 50/50 chance it is going to be wet or dry. i don't think this is a realistic goal.
    • "keep impaired skin covered with barrier cream to protect wound and surrounding area by 2:00 pm on 11/1/2008" this is another nursing intervention and tacking on a date and time makes it sound like following up on a delegated task.
    • "have area free of skin breakdown by 12/1/2008" goals are results you expect to happen. i would just say, "open skin areas on perianal area and buttocks will be covered with new granulation tissue by 12/15/08." i don't think it will take a month. a scratch on the skin takes 7 days to heal. a stage 2 decube should have complete granulation in 2-3 weeks depending on how large and how cooperative the patient is with treatment.

bowel incontinence r/t toileting self care deficit as evidence by red perianal skin and constant dribbling of soft stool.

1st short term goal: provide patient with a high fiber diet and adequate fluids by 2:00 pm on 11/1/2008.

2nd short term goal: provide exercise’s to increase perineal muscles by 2:00pm on 11/1/08.

long term goal: establish a bowel program so the patient knows when to defecate by 12/1/2008.

  • you already addressed "red perianal skin" in impaired skin integrity. you need to address it here or in the other diagnosis, but not both. it belongs here.
  • give some attention to this hemorrhoid with the perineal care to her excoriated anal area.
  • i see the same problems with your goals. the short term goals are nursing interventions.
  • if the patient doesn't know when she has to defecate now, what are you going to be doing that is going to change her ability to know when she has to defecate? your related factor states that the reason she is incontinent is because of a "toileting self care deficit". what is that deficit? not knowing when she has to defecate isn't a self-care deficit--it's a neurosensory problem--and i don't think there is anything you can do to change that.

i'm not trying to be mean, but i am pointing out how there must be flow and logic to the problem identification, the evidence (signs and symptoms) that support it, the nursing interventions that act on the evidence or the cause of the problem to attempt to change it, the goals which are the predicted outcomes of the interventions and the evaluation which tells you if the evidence has changed or not. your care map will show those relationships. a great deal of written care plans has to do with how you construct the wording.

this lady has mets to the bone and spine. i see she is on calcium replacement, her magnesium is low, she's on morphine for pain and she is afraid of falling. i agree. she's going downhill and nothing is going to change that, but we can support it. she's at risk for falls and for pathologic fractures of the spine just being on bed rest. how about using impaired physical mobility r/t loss of bone integrity?

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Specializes in CVICU, CPCU, Cath Lab/IR.

daytonite thank you so much for your response.

i didn't think that you were being mean at anytime infact that is why i posted my careplan on here. this is my first care plan!

the reason we put the time and date on each goal is because our instructor told us that since this is the time we leave we must put it on there even if it is unrealistic.

the break down on her bottom is from feces and it looks more like a diaper rash than an ulcer. i think a major problem is that she had problems with her rectal sphincter because when she coughs stool comes out. i do not believe the facility has been changing her often enough because the rash.

her chart states that she will use the toilet if prompted but with my experience she will not, because she fears falling. i was thinking that this is her toilet care deficit.

i do like your diagnosis better and i will work on that as well as my other diagnosis.

thanks for your time:bow:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Her anal excoriation is because of the acidity of the fecal contents. A protective barrier cream like Desitin (zinc oxide) should take care of that. I'd go with the Impaired Physical Mobility and Impaired Skin Integrity (in that order) as her two major problems.

Goals can:

  • improve the problem or remedy/cure it
  • stabilize it
  • support its deterioration

We would love for everyone to be cured, but in some cases it won't happen. This lady's skin problems can be improved. You can be hopeful for improvement of her physical mobility, but stabilization and her safety might be the realistic choice.

Good work for a first effort!

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