Care Plan help needed!

StudentOfHealing · Oct 11, 2014

Well just because she has pneumonia doesn't mean she has impaired tissue perfusion. As far as impaired tissue perfusion: Do you have assessment data to confirm decreased tissue perfusion related to CAD? Such as: Thickened nails?

Diminished pulses?

Cold fingers?

Her O2 Sat is normal. As long as I see 94% > I'm content. That's me personally though.

*******Now this might be somewhat of a stretch but I'm wondering ... why does she have atelectasis???

Is she not HINT HINT *effectively breathing*? Could it be due to a condition she has right now that rhymes with pout? Hmmm think think. Maybe this condition is making it harder to breathe. Think RIBS....

And there's another issue more important than her mobility that you are totally ignoring. You want to improve her mobility and move but you're not paying attention or attempting to treat her _ _ _ _ ???

As far as increased BUN? That can be due to dehydration. It can also be due to her lack of mobility secondary to the arthritic pain causing her (blank) to waste.

What do you think?

Esme12, ASN, BSN, RN · Oct 11, 2014

Welcome!

Here is my standard beginning.

Care plans are all about the patient assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

assessment consists of gathering data about:

a health history (review of systems) - you've provided more than enough of that
performing a physical exam - you have none and this information is crucial to have
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what its side effects and potential complications are

NewNurse91D · Oct 11, 2014

I do not have any assessment data to back up the CAD.

So what if I change the first diagnosis to impaired gas exchange? OR ineffective breathing? Is ineffective breathing a nursing diagnosis?

I thought that she had the atelectasis because of the pneumonia but im not sure.

So should my first one be for the ineffective breathing and the second one be for treasting her GOUT since her gout was what she came in with?

NewNurse91D · Oct 11, 2014

As far as my abnornmal data collected from my assessment and chart and labs/diagnostics:

-Chest x-ray 29 for follow up pneumonia revealed: adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, and background of interstitial disease.

-high BUN/cret; low H&H; high WBC. low RBC

-diminished lung sounds in bases

-edema in LLE &LUE which are very painful to pt.

NewNurse91D · Oct 11, 2014

So what if my number one be:

Ineffective Breathing-where I would tie in my pneumonia, atelectasis. Where I would have my interventions be more focused on bronchodilators, incentive spirometer and stuff like that

Then my second one be:

Activity Intolerance- where I would tie in her GOUT and pneumonia. and that way I can concentrate on the gout and solving that as well as the pneumonia to fix the activity intolerance

NewNurse91D · Oct 11, 2014

And could I word the Ineffective breathing one like this:

Priority Nursing Diagnosis: Ineffective Breathing

Related to: Alveolar-capillary membrane changes and atelectasis, secondary to medical d/x pneumonia

NewNurse91D · Oct 11, 2014

I also feel like the activity intolerance one can be secondary to the RA, gout and pneumonia.

I'm just so lost =/ I have my assessment data and stuff but I just don't know what to do with it all.

Esme12, ASN, BSN, RN · Oct 11, 2014

A nursing diagnosis goes like this.... GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
Related to" means "caused by," not something else.

Look at your NANDA resource.

Each nursing diagnosis has a definition, defining characteristics (symptoms that you patient has), and related factors (what causes it).

All care plans are based off your assessment. What meds is the patient on? What are the labs exactly? Is she febrile?

Looking at

Impaired Tissue Perfusion

What NANDA resource do you have? I have these NANDA diagnosis....

Ineffective peripheral Tissue Perfusion

Impaired Tissue Integrity

Impaired Skin Integrity

Impaired Gas Exchange

Risk for ineffective Cerebral tissue perfusion

...there is no Impaired tissue perfusion on the list for 2012-2014.

With these diagnosis's there are very specific criteria that the patient needs to fullfill.

NewNurse91D · Oct 11, 2014

could impaired skin integrity be a good fit- because she has a h/x of multiple bedsores, she has an ileostomy, she has trouble getting all the nutrients she needs because she doesn't like the food at her assisted living facility, and because she has the GOUT and has had mobility issues related to that?

BUT then again, I don't really have any PROOF from the chart and from my assessments besides subjective data

Esme12, ASN, BSN, RN · Oct 11, 2014

Looking at Ineffective Breathing Pattern...NANDA describes/defines this as...Inspiration and/or expiration that does not provide adequate ventilation.

The defining characteristics...Alterations in depth of breathing; altered chest excursion; assumption of three-point position; bradypnea; decreased expiratory pressure; decreased inspiratory pressure; decreased minute ventilation; decreased vital capacity; dyspnea; increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe

Related to....Anxiety; body position; bony deformity; chest wall deformity; cognitive impairment; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological immaturity; neuromuscular dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; spinal cord injury....Ackley: Nursing Diagnosis Handbook, 10th Edition

How does this apply to your patient?

Esme12, ASN, BSN, RN · Oct 11, 2014

could impaired skin integrity be a good fit- because she has a h/x of multiple bedsores, she has an ileostomy, she has trouble getting all the nutrients she needs because she doesn't like the food at her assisted living facility, and because she has the GOUT and has had mobility issues related to that?
BUT then again, I don't really have any PROOF from the chart and from my assessments besides subjective data

If she doesn't have any now...no you can't....she is AT RISK for it but it is not a diagnosis now. You are falling into the same trap that students fall into...picking the diagnosis first then trying to fit the patient into it....now list you entire assessment including labs and meds. What did the patient say? What did she complain of? If this was your family member what would be important to you that she needs first.

Start from scratch