My first care plan

  1. Hi Everyone,

    I am in my first semester of nursing school and we have our first nursing care plan due this week. We have not covered this very much in class, so I feel like I'm walking in the dark a little bit. I feel that I have done the best that I can with the knowledge that I have so far about care plans and I have definitely learned alot from the other threads about care plans. I just need to know where to start. So here it goes...
    Pt. was diagnosed with laryngeal carcinoma after he came to the hospital complaining of shortness of breath and dysphagia. CT revealed that he had a minimum T3N2 laryngeal carcinoma and a chest CT showed bilateral masses on the upper apical lobes of the lungs. He has refused to have the masses in the lungs treated. He had a direct tracheostomy and oncothyroidectomy. Currently has a trach and a Gtube. Has history of Bipolar disorder and schizophrenia, COPD, and HTN. Also has a history of smoking - 64 pack years.
    His physical exam revealed clear and equal breath sounds, equal expansion. No signs of peripheral edema. Capillary refill was about 4 sec. on the first day I had him, but his hands were cold. The second day it was < 3. Blood pressure and psychologic disorders are being managed by meds. On chemo and radiation to treat cancer. GTube wound site showed no signs of infection. Trach tube begining to show some redness and signs of break down underneath but MD ordered an antibacterial ointment and increased dressing changes to Q4 hours. Pt. is also on contact precausions - MRSA, which he had before he had before being admitted. Subjective data: "Its going to be a great day" "My sister came to visit me today, shes so nice" "my whole family is messed up" "I am not going to touch one more cigarette for the rest of my life" Pt. easily frustrated. Occationally complains of aching pain at trach site when he becomes frustrated. Seems to happen when being misunderstood. When being offered assistance with a bath, initially cooperative and pleasant, then when he began to bathe, became frustrated "I can't bath because I can not get these tubes wet, Im just going to have to smell, now you have ****** me off... get my pain medicine."

    So, I think I start with my nursing diagnosis first. We only have to do one. At first I was thinking risk for infection, but he already has MRSA and then risk for ineffective airway clearance. However, he has a productive cough and get get most secretions out of his airway that way. He refuses suctioning, and his O2 sats are at 98%. My instructor suggested risk for impaired verbal communication, because he gets so frustrated and is sometimes hard to understand. What nursing diagnosis should I go with and when I come up with one, where do I find the interventions that go with that? I have not bought a nursing care plan book. Does anyone know of some other online source where I can find nursing interventions?

    Please let me know if I am thinking the right way and where to go next... thanks!
  2. Visit katybug0417 profile page

    About katybug0417

    Joined: Jun '09; Posts: 3


  3. by   katybug0417
    I forgot to add that this pt. also has a tremor in both upper extremeties and the R arm is more severe
  4. by   rndbest
    sounds good I am a nursing student also havent been to school in many years. I have to write a health education paper do you know how to write one have u taken this course yet nursing health education and if not do u know of any sites I can go to help?
  5. by   katybug0417
    rndbest.... sorry, but I have no idea about health education papers yet. I am in my first semester of school I am still trying to figure out how to make a care plan... that is what I was asking about. Try googling it.
  6. by   thinwildmercury
    hi i am still a prenursing student so i don't know anything about careplans yet but have you checkout this sticky?
    hope that helps, good luck!
  7. by   thinwildmercury
    sorry about typos lol
  8. by   gumpy
    Just a suggestion to you which can help you really succeed in your first few months/year of nursing school: get a care plan book!!! I had the same problem as you in my first year of nursing... didn't know what to focus on, didn't know what were priority problems, couldn't think of creative interventions for patient problems, etc. My nursing care plan book really helped me with this, and also helped me understand nursing problems a lot better. After you get more used to coming up with nursing diagnoses for your patients, you will be able to come up with creative and unique interventions that are more tailored to our patient's needs. I hope this helps!!!
  9. by   ShantheRN
    When in doubt, remember your ABCs when doing care plans. You can't go wrong with that! It will help you prioritize your data.

    Risk for ineffective airway clearance could work. His O2sat is 98 for now, but with his refusal of suction, refusal of treatment for the masses, and the trach, that could change. I don't have my Carpenito handy so I can't look at the criteria for this diagnosis.

    Check out the stickies re: care plans on AL. They helped me out a ton