Plan of Care Help!!!!

  1. Ok.. I need some major help... My patient for the most part is fairly healthy and I am having problems coming up with NDX.. Here is a brief run down...

    Age 86, Sex-Female, Lives home alone but has assistance from family. Has CHF, arthritis, High BP, atrial fibrilation, and has an internal pacemaker.. She weighs only 90lbs and is 5'3...She is very independent, only needs assistance for very few things.... She was admitted for Shortness of Breath.,... Clear lung sounds, P64, R18, BP 160/82.. Prior 24hr I & O was 680 and 1150..

    Any suggestions would be GREAT..

    Thanks
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  2. 3 Comments

  3. by   crnasomeday
    One of my very favorite nursing diagnosis for those pesky care plans is knowledge deficit. There is always something that you can teach the patient. Was she started on any new meds that you could teach her about? Any tests or procedures that she was unfamiliar with? Risk for impaired skin integrity is another easy to apply nursing diagnosis, esp with many older folks.
  4. by   Genista
    For all you students who need a good careplan resource...I had a book called "Nursing Care Plans" by Marilynn Doenges when I was an SN, that was great. If you need help with careplans, that book will give you tons of info! If your nursing school doesn't carry it, I think amazon.com does. Well worth the $ when you are doing careplans in nursing school. ;-)
    ~Kona, RN
    Last edit by Genista on Apr 18, '02
  5. by   Agnus
    Originally posted by nurs2b
    Ok.. I need some major help... My patient for the most part is fairly healthy and I am having problems coming up with NDX.. Here is a brief run down...

    Age 86, Sex-Female, Lives home alone but has assistance from family. Has CHF, arthritis, High BP, atrial fibrilation, and has an internal pacemaker.. She weighs only 90lbs and is 5'3...She is very independent, only needs assistance for very few things.... She was admitted for Shortness of Breath.,... Clear lung sounds, P64, R18, BP 160/82.. Prior 24hr I & O was 680 and 1150..

    Any suggestions would be GREAT..

    Thanks
    i agree with knowledge deficit. Can be used with any pt.
    R/t hospital enviorment, meds, treatment, dx, you name it.

    chronic paint r/t arthritis

    possibly anxiety r/t ineffective air exchange or Dx or what ever applies,

    Ineffective breathing patterns, ineffective gas exchange. Activity intollerance.

    The i and o doesn't tell me much without other info. Just on the surface it looks like fluid volume deficit but could be excess depending on other parameters. This is why we look at nothing in isolation. is she being diureased and if so why, that can give you a clue here. What are her lytes.

    ineffective tissue perfusion R/t afib. nutrition less than body requirements. These are a few suggestions that COULD apply to your patient. You need to look at the individual situation here as see which applies more to your patient. Hint look at what the MD and RN seem to focus on. This will tell you where your priority Dx. is. injury risk for any patient in hosp. but especially since she has respitory problem and is with little padding on the bones. If she has any lines or tubes these pose a risk as well. Also related to arthritis

    This answer is not well organized but i hope you can gleen something useful.

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