hi, magickalspiral, and welcome to allnurses!
as i always do when a student is asking for help with a care plan i start, as you should as well, by going through the steps of the nursing process which are:
step #1 - assessment:
- assessment (collect data)
- nursing diagnosis/patient problem (group your abnormal assessment data, and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
you've already provided me some of the assessment information, but i still have some questions about it:
- cp (chest pain)
- sob (shortness of breath)
- bp was extremely elevated (208/48 at one point)
- bun and creatinine elevated (what were the actual values?)
- gfr of 34
- abnormal abg's (what were the actual values?)
what you must understand about the nursing process and writing a care plan is that this abnormal assessment information is what forms the entire foundation
of everything else that follows in your care plan. and, i mean everything. these abnormal data items are your patient's signs and symptoms that you are going take action on. you use them to determine your nursing diagnoses in step #2 and your goals and nursing interventions in step #3 of the nursing process.
as a cross check in determining if your assessment was thorough and worth any salt you also look at all the information you gleaned from the patient's medical record. this patient has other medical problems:
- type ii diabetes
- coronary artery disease with a history of a ptca (percutaneous transluminal coronary angioplasty)
- renal insufficiency
- a cholecystectomy for cholecystitis
- an ercp to place a stint in his common bile duct
you need to go to some references on these medical conditions to look up the common signs and symptoms of them to see if your patient had any of them that you might have missed
when you did your assessment. this is part of your learning experience. when we are new to nursing and assessment we tend to overlook important signs and symptoms of various diseases and this is how you learn to correct yourself. i bring this up because no where in your post do you mention anything about this patient's blood sugars or diabetic medication/control, the treatment he is receiving for his atherosclerosis of his coronary artery disease, what is being done about his chest pain, what is being done about his post-op cholecystectomy pain, what is being done about his diet, or what is being done about his surgical incisions since this man has had two surgical interventions!
step #2 - nursing diagnoses/determination of the patient's problems: during this part of the nursing process or care planning process you take your list of signs and symptoms (nanda calls them defining characteristics) and you pull out your nursing diagnosis reference book and you start looking for nursing diagnoses that have symptoms that match with those that your patient has. this is the way medical students learn to diagnose medical diseases as well. each medical disease has a list of signs and symptoms; each nursing diagnosis also has a list of defining characteristics (signs and symptoms) that you now have from your assessment activity. the reason you are having problems with your "aeb" items on your nursing diagnoses is probably because they aren't the proper defining characteristics that fit that particular nursing diagnosis. you would only know this by looking at the reference information for each particular nursing diagnosis. i'll take you through one to show you what i'm talking about.
nursing diagnosis: impaired gas exchange
definition: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
defining characteristics (signs and symptoms): abnormal arterial blood gases
, abnormal arterial ph, abnormal breathing (e.g., rate, rhythm, depth), abnormal skin color (e.g., pale, dusky), confusion, cyanosis (in neonates only), decreased carbon dioxide, diaphoresis
, headache upon awakening, hypercapnia, hypercarbia, hypoxemia, hypoxia, irritability, nasal flaring, restlessness, somnolence, tachycardia, visual disturbances.
[does you patient have any of these symptoms?]
related factors (etiology behind the problem or the signs and symptoms):
alveolar-capillary membrane changes, ventilation perfusion imbalance
(page 94, nanda-i nursing diagnoses: definitions & classification 2007-2008
published by nanda international). this information can also be found at [color=#3366ff]impaired gas exchange
i've highlighted in red and bolded three defining characteristics (symptoms) your patient has that classifies him to this nursing diagnosis. these are his "aeb" items for your 3-part nursing diagnostic statement
. his "r/t" item is what the etiology, or cause, for his oxygen deficiency is. you have two choices according to the reference. do you know what each choice is? look them up if you have to. the alveolar-capillary membrane has to do with the ability of gases to pass through the pulmonary alveolar-capillary membrane. are there physical changes in the membrane causing an inhibition of the gases to be exchanged? you would only know this by knowing the underlying pathophysiology of the patient's disease processes. ventilation perfusion imbalance has to do with balance of oxygen and carbon dioxide that are passing through the alveolar-capillary membrane--it should basically be what is going to give you normal blood gasses readings of oxygen and carbon dioxide. in people with conditions like lung problems you are going to find gas exchange problems due to the lung membranes being clogged with secretions that inhibit gas exchange so an alveolar-capillary membrane problem exists. your patient is sob because of his cardiac condition where the perfusion of oxygen at the cellular level is being compromised, not because of anything wrong at the lung membranes. so, your nursing diagnostic statement for this patient should be as follows:
step #3 - planning: now! your goals and nursing interventions are aimed at:
impaired gas exchange r/t ventilation perfusion imbalance aeb abnormal arterial blood gases [you really should state the blood gas results exactly as they were or use the medical terms for them: hypercapnia, hypercarbia, elevated ph, etc.], diaphoresis, and shortness of breath
- the abnormal arterial blood gasses (ex: giving oxygen)
- treating the patient's diaphoresis (ex: supplying clean linens)
- treating the patient's shortness of breath (ex: teaching positioning for comfort)
your overall goal(s) being to eradicate or normalize any of the above and normalize or eliminate the main problem of "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane"
which, recall, is the definition of the nursing diagnosis.
can you see the logic to all of this? it forms a nice closed circle. when you put this into the form of a concept map it is all going to relate and make a lot more sense. this is why some schools have gone to using concept mapping.
now, i think you have a little more work to do with this care plan because i think you've left out a few important things. i would be looking at some wound healing or wound care and some dietary things since this guy just had his gut altered and he is a diabetic. he can't be eating a lot of high fat foods. so, he needs some teaching about this. take a good look at all the medications he is on and relate them to his medical diseases to help you with the pathophysiology of what is going on with him before picking a nursing diagnosis. the decreased cardiac output is probably a valid one to use for his cad and hypertension, but you need to know the related factors and get his signs and symptoms of it clear. how far has his heart failure gone? heart failure proceeds in a step by step fashion. you didn't mention it, but does he have any peripheral edema? and, what's going on with his diabetes? it's likely that his hypertension and atherosclerosis are related to the diabetes as these are common complications of diabetes.
if you are still having trouble with this care plan, post more questions.