care plan

[Daninjones]

I am doing my first care plan and I am not sure where to begin. I know that I need to use ABC first and then maslows heirarchy second. Here is my case study:

Mrs. J, 72 years old, fell at the SOF and was admitted to the hospital with a fracture of the right hip. Mrs. J had an open reduction with internal fixation (ORIF) of her right hip. Mrs. J was readmitted to the SOF four days post op. Mrs. J has orders for Demerol 100 mg IM every 4 hours when needed.

During your admission assessment you note pedal pulse present, weak in the right foot, stronger on left foot. Hgb 10.5 and Hct 32%. Bowel sounds hypoactive in all quadrants. Crackles in the lower bases of the lungs. Mrs. J is very restless and confused and tries to get out of bed on her own.

I put down as my first nursing diagnosis risk of impaired gas exchange related to decreased perfusion of lung tissue caused by obstruction as evidenced by crackles in the lower base of the lungs upon auscultation and restlessness and confusion. The second nursing diagnosis i used was ineffective peripheral tissue perfusion related to reduced blood flow from vasoconstriction as evidenced by weak pedal pulse in right extremity. I am wondering if i am on the right track with my care plan?

[mrsboots87]

A 'risk for' diagnoses is almost never a priority. I actually cant think of any priority risk for diagnoses but I'm sure their are some because Im only a block 2 student. Priority will almost always be an actual condition. Also, 'risk for' diagnoses do not have a r/t. They only have evidence as to why they are a risk. Also, for impaired gas exchange there has to be evidence such as decreased O2 sats or increased PaCO2 levels. You are on the right track though. Adventitious breath sounds would fall under either airway or breathing depending on where they are heard. So there is a diagnoses there that you can use. The second diagnosis sounds good though.

A second note though, only use the r/t factors and AEB evidence listed with the NANDA diagnoses you select. R/T means caused by. So you cant have a r/t and a caused by in the diagnosis. You can however use r/t.......secondary to....... then your AEB/AMB. What I mean is " risk of impaired gas exchange related to(should be "r/t") decreased perfusion of lung tissue(is this r/t factor listed in your diagnoses book?) caused by obstruction(take this out. First you should never say "caused by" and what is the evidence of obstruction? crackles does not mean obstruction.) as evidenced by(AEB) crackles in the lower base of the lungs upon auscultation(this should just say "crackles in bilateral bases", auscultation of lungs is assumed) and restlessness and confusion"

ineffective peripheral tissue perfusion related to(r/t) reduced blood flow(is this listed in your book?)from vasoconstriction (unnecessary information and is not a NANDA r/t factor) as evidenced by(AEB) weak (diminished) pedal pulse in right extremity (what other evidence do you have? diminished pedal pulses are evidence of multiple conditions. Do they have edema? What is the color of their skin? What is the cap refill? Are their any infections that aren't healing well?)

Youre on the right track, but just need some tweaking.