Help with Care Plans - page 2

Are you scratching your head or are you maybe even ready to tear your hair out over how to come up with care plans? Here are some words of wisdom from our own beloved Daytonite. Care Plan Basics ... Read More

  1. Visit  Daytonite profile page
    1
    Quote from rwright15
    okay, i don't really know where to post this so i will try here first... i am in l&d rotation right now. i have to do a careplan on a post op cesarean pt. i did one last week on acute pain, and risk for infection... so i would like to do something else for this one. she is a 25yowf, antepartum labs are hgb 4.25, hct 33.3, plts 209... blood loss during surgery was >500ml. i was thinking risk for anemia/iron deficiency something along the lines of this. she has symptoms of pica, requesting large amts of ice, and stating that she "eats it all the time"... there is nothing in her chart substanciating this, just a hunch. so, with the hct being the only abnormal lab, can i do risk for anemia, or risk for hypovolemia? i have the 8th edition nsg dx handbook, but can find nothing along the lines of this in there. what would the correct nanda dx be for this? i will probably do acute pain in addition to this, so which one would be highest priority? any help would be much appreciated.... thanks
    please read post #1 and post #2 of this thread. you need to go through, assemble and analyze this patient's assessment data.

    by pica, i assume you are meaning the eating disorder where a person will ingest anything that is not fit to be classified as human food such as grass, crayons, and i had a patient once who ate plaster. water is a necessary biological need for our bodies. ice is frozen water and eating it does not qualify as a symptom of pica. additionally, being nurses we cannot medically diagnose! pica is a medical diagnosis. all we can do is note the patient's behavior: "consumes large amounts of ice" which, to me, might be consuming large amounts of fluid depending on how much she is actually consuming and is this really a problem? monitoring i&o would tell us right away.

    a post op cesarean patient is basically a surgical patient subject to the complications of a patient who undergoes general or epidural anesthetic. i'm still talking about knowing the signs/symptoms/complications of
    • the surgical procedure that was performed (the c-section)
    • the type of anesthetic used
      • complications of epidural anesthesia are:
        • hypotension
        • rash around the epidural injection site
        • nausea and vomiting from the opiates administered
        • pruritis of the face and neck caused by some epidural narcotics
        • respiratory depression up to 24 hours after the epidural
        • cerebrospinal fluid leakage and spinal headache from accidental
        • dural puncture
        • sensory problems in the lower extremities
      • complications of general anesthesia are:
        • breathing problems (atelectasis, hypoxia, pneumonia,
        • pulmonary embolism)
        • hypotension (shock, hemorrhage)
        • thrombophlebitis in the lower extremity
        • elevated or depressed temperature
        • any number of problems with the incision/wound (dehiscence,
        • evisceration, infection)
        • fluid and electrolyte imbalances
        • urinary retention
        • constipation
        • surgical pain
        • nausea/vomiting (paralytic ileus)
    • how this affected their ability to perform their adls (activities of daily living)
      • movement and walking - yes, they have pain, but how is it affecting their endurance, the amount of time they can be up and moving around at any one time period - this is activity tolerance and there is a nursing diagnosis relating to it
      • is the mother breast feeding? whether she does or doesn't have problems with breastfeeding, there are three nursing diagnoses that address breastfeeding.
    • the patient has an incision. what's being done for it? how will she know what to do in caring for it when she is discharged? who's going to teach her?
    • problems bonding with the infant?
    after considering all these things, then you make a list of the actual symptoms she does have. that list is what you use to look for nursing diagnoses that having matching symptoms (nanda calls them defining characteristics). use a nursing diagnosis reference so you can see all the diagnoses that are available (there are currently 188 of them). there are a number of ways to get this information.
    rwright15 likes this.
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  3. Visit  rwright15 profile page
    0
    Thank you for all of this useful info. I am confused on the pica definition though. Not to argue, by no means can I possibly know more than an actual practicing nurse, but I thought that pica was a craving for anything that was of little nutritional value, food or non-food items. In fact, here is a little snippet from www.americanpregnancy.org
    [What are typical pica cravings during pregnancy?

    The most common substances craved during pregnancy are dirt, clay, and laundry starch. Other pica cravings include: burnt matches, stones, charcoal, mothballs, ice, cornstarch, toothpaste, soap, sand, plaster, coffee grounds, baking soda, and cigarette ashes.]

    They state that a craving for items such as this might indicate an iron deficiency. So, what I am wondering, would it be a medical diagnosis still if we said risk for low blood volume r/t pregnancy ?? The only post surgical problem this pt had was pain. I may use self care deficit, but my instructor is always asking "what will kill your patient first".... In this case, all I can think of is the blood loss, and infection..... Thanks
  4. Visit  Daytonite profile page
    2
    Quote from rwright15
    I am wondering, would it be a medical diagnosis still if we said risk for low blood volume r/t pregnancy ?? The only post surgical problem this pt had was pain. I may use self care deficit, but my instructor is always asking "what will kill your patient first".... In this case, all I can think of is the blood loss, and infection..... Thanks
    My advice is not to address pica. The actual problems this patient are going to have for sure are related to her incision and mobility. Then, she has potential problems related to possible complications (fluid loss due to blood loss, infection due to incision infection, thrombophlebitis if she is spending more time in bed than she should, UTI)
    ren246 and rwright15 like this.
  5. Visit  rwright15 profile page
    0
    Thank you so much, that sounds great!! I think I will go with mobility.... Thank you again for the wisdom. You are truly an asset to this website...
  6. Visit  chevyv profile page
    0
    Thank you all for helping me sort out the Potential Complication part of my last 2 care plans. My instructor wrote that I had really good data and did a good overall job. I will continue to work on wording..... Others had to redo theirs, so I'm grateful that I found this site or I'd be burning the midnight oil so to speak instead of relaxing and spending time cruising this site .
    Thanks again!
  7. Visit  Multicollinearity profile page
    0
    My clinical instructor requires us to list 'as manifested by' for risk diagnoses. She said to ignore our textbooks that say 'risk for' is a two-part.

    In fact, we had a major paper due recently (not part of weekly clinical care-plans) and she booted my paper right back to me to fix and make 'risk for' a three part diagnosis. I thought she was just doing this in our weekly carepans for clincal, but no. It's for major papers as well. Is this unusual?
  8. Visit  Daytonite profile page
    1
    Quote from multicollinearity
    my clinical instructor requires us to list 'as manifested by' for risk diagnoses. she said to ignore our textbooks that say 'risk for' is a two-part.

    in fact, we had a major paper due recently (not part of weekly clinical care-plans) and she booted my paper right back to me to fix and make 'risk for' a three part diagnosis. i thought she was just doing this in our weekly careplans for clinical, but no. it's for major papers as well. is this unusual?
    it doesn't follow nanda guidelines. however, this is a school and grading situation and you are obliged to follow the rules you are given. this is really not a problem as long as the instructor applies the rules consistently in grading. i would make sure that your manifested evidence for these diagnoses clearly relates to a specific problem that you're addressing.

    in my bsn program we were not allowed to use nanda wording (language) for our nursing diagnoses. we had to construct nursing diagnoses using language that conveyed the nursing problem but did not duplicate what nanda said. it was possible to do that using a copy of roget's thesaurus for reference.
    Multicollinearity likes this.
  9. Visit  imac profile page
    0
    2nd semester student here...I need some help...My patient last night was a 98 yr old female w/admitting diagnoses of Jaundice. She also had a small stage 2 pressure ulcer-sacral. Her past history included multiple falls, Hypertension, CHF, Renal Failure, Osteoporosis. Currently suffering from severe diarrhea, and also had an ERCP done on 4/17--"multiple stones, stent placed" The only medications listed was Flagyl, 250 mg at 16:00 and 22:00, Darvocet bid and ASA 81 mg / day
    she was currently on 3 liters of O2 nasal cannula.
    When I initially went to her room, I was told that she had been moved to a room closer to the nurses station as she was failing quickly. She was not responding other than opening her eyes once in awhile, when I spoke to her and was restless, but earlier in the day she I was told by the nurse that she was having pretty normal conversations with her.
    Pulse was 93, respirations: 36 BP 102/82 pulse ox 73.
    She was put on 15 liters O2 non rebreather mask.
    she went further downhill... Resp. 42 & shallow, BP 60/36 pulse 90,and within 2 hours her care was changed to "comfort measures" --(had a DNR)--all meds d/c'd, morphine 1-2 mg q 2 hours, IV. They didn't think she would make It through the night.
    I'm attempting to start a careplan to turn in to my instructor. (boy, its tough to not get emotional!) I admit to having problems prioritizing (as indicated by my last request for help!) but where do I start? Do I begin with the information I was given, and then progress to "Death anxiety?" I need 4 Nursing Diagnoses... I have several in mind, but this patient was dying. I think her pain and making her as comfortable as possible is most important, yet working up 3 assessments, 3 interventions and 3 teachings on FOUR diagnoses has me in a quandry.
    I'm starting to work on this now, and will check back for some advice if someone can help. I really appreciate it!
  10. Visit  Daytonite profile page
    1
    imac. . .how to go about starting a care plan was detailed in the first few posts of this thread.
    1. make a list of your patient's symptoms
      • jaundice
      • stage 2 pressure ulcer on the sacrum (what were the measurements, any drainage, appearance?)
      • history of multiple falls
      • severe diarrhea (how many a day?)
      • multiple stones and stent placed per ercp on 4/17 (where were these stones and were they the cause of the jaundice?)
      • flagyl, 250 mg (why was she getting flagyl? what kind of infection was being treated?)
      • darvocet bid (where was the pain that this was addressing?)
      • asa 81 mg / day
      • 15 liters o2 non rebreather mask (did you get any lung sounds or blood gas results?)
      • pulse was 93, respirations: 36, then went to resp. 42 & shallow, bp 60/36 pulse 90
      • pulse ox 73
      • not responding other than opening her eyes once in awhile
      • restless
      • her care was changed to "comfort measures" - dnr
      • all meds d/c'd, morphine 1-2 mg q 2 hours, iv
    2. using that list you will
      • determine your patient's 4 nursing problems (nursing diagnoses)
        • if you had more lung assessment information other diagnoses could be used - these are prioritized by maslow
          • impaired gas exchange (supporting evidence: pulse ox of 73, restlessness, pulse of 93)
          • ineffective breathing pattern (supporting evidence: respiratory rate of 42 and pulse of 93)
          • diarrhea (supporting evidence: severe diarrhea - needs more description)
          • impaired physical mobility (supporting evidence: not responding other than opening her eyes once in awhile, placed on morphine - you also need more description that she is not moving or turning on her own)
          • impaired skin integrity (supporting evidence: description of the stage ii sacral ulcer)
          • chronic pain (supporting evidence: ?, getting an analgesic)
          • risk for falls (supporting evidence: history of multiple falls)
      • determine goals - based upon the results you expect from the nursing interventions you will be ordering (writing goal statements: http://allnurses.com/forums/2509305-post157.html)
      • determine nursing interventions - ordered for the supporting evidence (symptoms) associated with each nursing diagnosis
    to use death anxiety the patient has to be making statements to you or the others on staff about concerns about her death, yet you have listed nothing about that.

    to diagnose, you really need to use a nursing diagnosis reference since every nursing diagnosis has a set of defining characteristics (symptoms) and your patient must match with at least one of them. i used nanda-i nursing diagnoses: definitions & classification 2007-2008 to double-check the supporting evidence (defining characteristics) for the diagnoses i chose above.

    in my opinion, the two top priority diagnoses that i would treat are where most of the nursing care would be focused: keeping the airway open and keeping the patient turned
    1. ineffective breathing pattern
    2. impaired physical mobility
    the choice of what to use for priority diagnosis depends on the behavior the patient is exhibiting. you seem to indicate that she has pain, but my thinking is that her breathing is probably more of a problem which the morphine will help. here are links to information about end of life care, but they are not nursing sites. they will give you an idea of what "comfort care" involves.
    Last edit by Daytonite on Apr 27, '08
    LindseyAF likes this.
  11. Visit  imac profile page
    0
    I really appreciate the time you've taken to reply to my request. I wish I could send you a box of chocolate!
    I have a bit more information...Some of the information is missing, and even my instructor could not find it in the chart.
    The pressure ulcer was about 3 cm in diameter, slight drainage...serosanguaneous Although the patient wasn't talking by the time I got there, she would grimace and moan slightly when positioned on her back, so we opted to move her from side to side..however, the nurse said she had alot of pain in her left hip, verbalized by the patient earlier in the day. Xray did not show any fracture. The darvocet was prescribed for the complaints of pain from lying on her back (?pressure ulcer?) and her
    hip.
    The only entry in the chart regarding he ERCP was that she had Obstructive Jaundice.
    The "severe diarrhea"--that was my description. In thinking about it, it was watery stools, but 4 to 5 per day. We could not find an indication for the Flagyl.
    her lung sounds were clear, but her very shallow breathing made it difficult to evaluate completely as she couldn't respond with deep breathing. Did I miss something here?
    No ABG's were drawn - her respirations went down quickly, and the nurse got an order for the rebreather mask asap---before that she was on 3 liters / nasal cannula (Not sure if I mentioned that)
    Her labs were: WBC 8.9 RBC 3.93 (L) Hgb 13.4, Hct 39.5, Platelet count 127 (L) Na 141, K 3.7 BUN 66 (H) CREATNINE 3.1 (H) GFR i 15 (less than 15 is kidney failure, right?) These were drawn that morning.
    The staff nurse told me that when she was talking earlier in the day, she told her "I think I'm dying-I hope my family understands-I'm tired"
    I have worked up impaired gas exchange and ineffective breathing pattern so far, and started on pain. I just don't know if I have enough based on her statement of death to consider it death anxiety--she was definitely anxious/restless, but I would be too if I couldn't get enough O2!
    Just want to say that I think you are a saint. I've printed and spent some more time on this site, including the links you suggested. They too were helpful. Thanks again for your time.
  12. Visit  frstlady profile page
    0
    Thank you so much for that very detailed description. I am going into my second year at a Community College and I am hoping with your help that I will be able to write authentic care plans using my own assessment findingsand not some book that a seasoned professional has written. We as students sometimes take the short cut if only we would take our time and actually get the understanding. We are so overwhelmed with work and listening to other nurses saying they don't have to do care plans, we just take a short cut instead of really understanding. It would also proably help with us during our testing. Thanks again
    Last edit by frstlady on May 11, '08
  13. Visit  Smurfie profile page
    0
    Can anyone help distinguish GOALS as opposed to EXPECTED OUTCOMES?

    I am really struggling with my very first care plan - for a lady who has been admitted for asthma exacerbated by an URTI, and we have to focus on the nursing diagnosis of Impaired Gas Exachange.

    I can detail a whole bunch of expected outcomes, because they are specific, measurable etc etc, but what then is a goal? Is it just a broader overview of all the EO's? Is it something to do with the 5 goals of respiratory care; clear the airway, mobilise secretions, reduce WOB, oxygenate system and promote compliance and self care...?

    AHH!! I've been an AIN for ages now, who ever knew I'd struggle so much with this!
  14. Visit  chevyv profile page
    0
    [quote=Smurfie;2833866]Can anyone help distinguish GOALS as opposed to EXPECTED OUTCOMES?

    I can detail a whole bunch of expected outcomes, because they are specific, measurable etc etc, but what then is a goal? Is it just a broader overview of all the EO's? Is it something to do with the 5 goals of respiratory care; clear the airway, mobilise secretions, reduce WOB, oxygenate system and promote compliance and self care...?


    To make it rather simple, my instructor explained the difference as:
    Goals- long term (still must be measurable etc)
    Expected Outcomes- short term. Hope this helps


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