Desperately Need Help With Care Plans

Any help with care plans will be appreciated?

[Daytonite, BSN, RN]

foxdog said:

i am just starting lpn school. in desperate need of help writing care plan for dehydration. maybe a sample of one would help.

I will help you with your care plan. Let's do this on a step-by-step basis. first, of all... Is this a real patient? If so, have you done a physical assessment of this patient and reviewed the chart? If not, have you looked up the signs and symptoms of dehydration? If not, here is a page at family practice.com that lists that information including what the doctors will do to treat this.

Pediatric Dehydration.

Look at the what the presenting symptoms are weakness, visual changes, and leg cramps. I know about the visual changes because i was hospitalized with dehydration a couple of years ago and the visual changes i had were scary! The labs are also very telling. Elevated buns and electrolytes out of whack. You can also take a look at the pediatric dehydration profiles on this site for more information for signs and symptoms. Here are links to more information about dehydration:

Dehydration Causes

What Is Dehydration?

Do you have any care plan books to help you at all? Basically, the next steps are to group your signs and symptoms into nursing diagnoses and then create nursing interventions for each of the signs and symptoms your patient is having. I will help you with this if you will list those signs and symptoms for me.

[Daytonite, BSN, RN]

audy_lagz said:

39 ye31 yr old man visits his hc provider with complain a burning epigastric injury occuring 2 hours after he eats. he consistently feels bloated and obtains little or no relief from otc antacids. his last health history- cigarette smoking, stressful job, chronic use of nsaid and diagnosed peptic ulcer.

Here is information on peptic ulcer disease, etiology, symptoms, how it is diagnosed and managed medically.

Peptic Ulcer Disease

Your main problems are most likely going to be what i have listed below and bold-faced. Feel free to add other symptoms i might not have considered. I have not included any of the medical tests that might be ordered or the medications or treatments the doctor might order. I'll let you do that since it may be different from what is done here in the u.s. I didn't address anything related to helicobactor pylori testing or treatment which i'm sure would be undertaken. You'll want to address the side effects or special needs of the patient receiving medications and treatments, so don't forget to include those.

Mid-epigastric pain, deep recurring ache relieved with food or antacids and aggravated by general irritants (below)

• nocturnal pain is present and aggravated by food
• anorexia
• weight loss
• nausea or vomiting

In developing your care plan, what you are going to do is address each of these symptoms that are listed and have nursing interventions for each of them. Now, here in the u.s., we make a distinction between actions that a nurse can do independently from the doctor and those that depend on a doctor's order (we call those collaborative interventions). If you have a care plan book you can find these interventions listed under these symptoms very easily, or in a nursing textbook.

If you need further help, post another question to this thread.

[Daytonite, BSN, RN]

With any care plan you must address and follow the nursing process. always, always, always! The first step is to collect your data. What data do you have? Is this a real patient? Or, is this a case study where you have to put together the likely signs and symptoms of ethylene glycol poisoning?

Here are some websites that might help:

Ethylene Glycol Poisoning - Family Practice Notebook

Ethylene glycol poisoning - MedlinePlus

Ethylene glycol - Wikipedia

There are, in general, three stages to ethylene glycol poisoning (1) neurological stage, (2) cardiopulmonary stage, and (3) renal stage. these are the symptoms that appear with these stages:

(1) Neurological State

• confusion, appearance of being intoxicated
• ataxia
• slurred speech
• hallucinations
• nausea/vomiting

(2) Cardiopulmonary Stage

• irregularities in heartbeat and breathing (due to building up of 0xalic acid)
• dyspnea (respiratory distress with hyperventilation) (these are symptoms of metabolic acidosis) (may require intubation and ventilation for airway protection and respiratory support)
• (will need sodium bicarb iv to overcome the metabolic acidosis)
• tachycardia

(3) Renal Stage

• oliguria or anuria due to acute renal failure
• the oxalic acid forms a precipitate (calcium oxalate) with calcium in the kidneys
• muscle tetany or seizures due to hypocalcemia
• untreated, the patient proceeds to develop:
• shock
• coma
• death

Treatment is aimed at (1) correcting the metabolic acidosis, (2) preventing the ethylene glycol from metabolizing into toxic metabolites and (3) removing it and any metabolites that have formed from the system. The patient is going to die if not treated within 24 to 36 hours.

After collecting your data, you need to assemble it and group it into symptoms that will fit into nursing diagnostic categories. Each of the nanda nursing diagnoses has symptoms that fit it. Some ideas for nursing diagnoses you could use are (and this list is not inclusive, there are more you could use):

• acute confusion r/t ethylene glycol ingestion aeb confusion, slurred speech, and hallucinations
• nausea r/t ethylene glycol ingestion aeb vomiting
• ineffective breathing pattern r/t hyperventilation aeb dyspnea
• ineffective tissue perfusion r/t reduction of arterial and venous blood flow aeb dysrhythmias, abnormal abgs, oliguria and anuria

Once you have all your data and have decided on the nursing diagnoses to use, the nursing interventions are not that hard to figure out. they are geared to the symptoms (the aebs) that support each of your nursing diagnoses. For example, you would list nursing interventions for vomiting under the diagnosis for nausea r/t ethylene glycol ingestion aeb vomiting. You would find these in your nursing textbooks, such as having the patient avoid sudden movements, keeping a emesis basin near the patient, giving oral care after each episode of vomiting, offering clear fluids when vomiting under control, etc. For pediatric patients clear fluids would be things like popsicles or pedialyte.

Hope this has given you some direction with this assignment.

[Daytonite, BSN, RN]

A nursing diagnosis is not much different from a medical diagnosis. Each has signs and symptoms. Medical diagnoses are easier for you to understand because you've heard of them forever. You know that a sore throat and a runny nose is a cold. Who doesn't? But, what is new and different to you is to be told that dyspnea, an ineffective cough, sputum production and restlessness are symptoms of a nursing diagnosis nanda calls ineffective airway clearance! You will learn these nursing diagnoses by either sitting down and reading each one and memorizing it's signs and symptoms, or through the various care plans you will write over your school and job career.

Learning new concepts like this is never a lot of fun and often takes time and a lot of effort. It will take many, many weeks and perhaps months before you begin to feel like you have a good grasp of what is going on with the nanda diagnoses. For the present, follow the guidelines your instructors suggest and those in any of the care plan books you might be using for reference and trust that they are giving you proper direction. There are always people here on the forum to help out as well.

[VickyRN, MSN, DNP, RN]

A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes. A medical diagnosis, on the other hand, is the identification of a disease based on its signs and symptoms.

The professional practice of nursing is the diagnosing and treatment of these basic human responses. Nurses need a common language to describe the human responses of individuals, families, and communities to health threats. Nanda strives to classify in a scientific manner these basic human responses.

Nursing diagnoses are classified under the concepts of ingestion, digestion, absorption, metabolism, urinary/gastrointestinal elimination, sleep/rest, activity/exercises, energy balance, sexuality, post trauma responses, comfort, and growth and development.

Identification of human responses to health problems and life processes is the basis for the nurses' decisions on how to help people. With nursing diagnoses, emphasis is placed upon achievement of the client's maximum health potential. The nurse gathers the assessment data and from this data, identifies high-priority nursing diagnoses. The nursing diagnoses then provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

The patient (not the nurse) is central to the nursing process. The nursing process involves looking at the whole patient at all times. It personalizes the patient. Nursing care needs to be directed at all times for improving outcomes for the patient.

In order to tailor the nursing process to the patient, you need to identify the patient's problems related to the objective and subjective assessment data. Then you need to formulate a nursing diagnosis for each of these problems. You will also prioritize the problems in formulating your plan and goals (according to the abc's and maslow's hierarchy of needs).

Nursing diagnoses are written in "pes" format:

"p" stands for problem
"e "stands for etiology or cause of problem
"s "stands signs and symptoms of problem

However, if you identify a high-priority "risk for" nursing diagnosis, then you do not put the signs and symptoms (in other words, no "aeb"). How can you have evidence (signs and symptoms) for something that is only a risk?

Nursing goals are simply the antithesis of the nursing diagnostic statement with a reasonable time frame. In other words, diagnostic statements are "problems" (negative). Goals are "positive" (turn the nursing diagnostic statement around). If the nursing diagnosis is "risk for infection r/t..." for instance, then the goal statement might be "client will not experience infection throughout hospital stay aeb clear lung sounds, afebrile, wbc count between 5,000 and 11,000, wound site well approximated with no purulent drainage." goal statements always begin with "the patient/ client will..." and have a specified time element.

Nursing interventions are the "meat and gravy" of the nursing process and flow from the "etiology" part of the nursing diagnostic statement. Nursing interventions are either independent (such as teaching/learning or safety) or collaborative/ dependent (require a physician's order, such as administration of medications). The nurse must use his or her critical thinking skills to plan, coordinate, and implement nursing interventions, and then evaluate the effect of these interventions in achieving the desired patient goal. Nursing interventions always begin with "student nurse will..." or "nurse will..." and are very specific, as well as being realistic to the client situation (not just "cookie-cutter" interventions copied from a nursing careplan book ).

Nursing interventions must be backed up with a scientific rationale - otherwise, this action is just your opinion and has no merit. Remember, everything in nursing must be evidenced-based. Provide a citation for your scientific rationale, in apa format, from a peer-reviewed source: professional journal, textbook, lecture.

When evaluating your goals, need to state specifically: goal met, goal not met, goal partially met, or unable to evaluate goal due to time constraints. If the latter is the case (unable to evaluate goal due to time constraints), then you need to state what outcome criteria would be needed in order to state goal met. In other words, if i were present (at specified time element), i would look for the following outcome criteria in order to state, "goal met." then you list the desired outcome criteria. Remember, you are evaluating the goals, not the interventions.

So you see, it is an orderly, evidenced-based process and not that difficult with practice. Nurses cannot know what interventions to select or which outcomes to project unless they have accurate representations of what patients are experiencing (using a common reference language, nanda).

[Daytonite, BSN, RN]

rstudentrn on 9/4/2006 said:

O.k here was another question that i got stumped on...

Your patient has end stage renal disease, with a 30 year hx of type 1 dm. She has a 2-cm dry, ulcerated circular area on the lateral outer aspect of her right great toe and an av fistula in the right forearm. You have administered her am nph insulin at 0730 and you are waiting for her dialysis treatment. At 1130 you do a fingerstick and the results are 236, according to the sliding scale you administered 10 units of regular insulin.

Which of these nursing diagnosis is a priority at this time.

• risk for infection
• altered patterns of elimination
• fatigue
• excess fluid volume
• deficient fluid volume
• imbalance nutrition:less than body requirements

I choose fluid volume excess, because she is now hyperglycemic. Wouldn't there be a fluid shift from intracellular to intravascular because of the high concentration of glucose in the vascular system.

F&e confuses me...anyone have any ideas. Thanks

The answer to this is risk for infection. The patient has symptoms that fit the description for this nanda diagnosis (i.e.: inadequate primary defenses--broken skin, chronic disease). Your knowledge of diabetes should also tell you that an elevated blood sugar in a diabetic is reason for concern of possible infection if the diabetes is supposed to be under control. The heart of this question is getting at the symptoms of each diagnosis. In actuality, the information given in the question only supports two of the diagnoses given: risk for infection and, surprise!, deficient fluid volume (the dry skin on her toe), and your knowledge of esrd tells you that can't be right! So, of all 6 nursing diagnoses listed, only one fits the symptoms given and can be your answer.

Do you have a care plan book that lists the diagnoses in alphabetical order as well as the symptoms (defining characteristics) that go with each? This is what you need to be looking at with each of these nursing diagnoses. Like a medical diagnosis, each nursing diagnosis has specific signs and symptoms that have to be present in the patient in order to use that particular nursing diagnosis. If the symptoms aren't there, then you can't use the diagnosis. This is a concept that you must hammer in to your head about nursing diagnosis.

[Daytonite, BSN, RN]

Have you read any of the previous posts in this thread? The problem i have in helping you out here is that you have listed none of your assessment data. The care plan is the written document of the nursing process. Step #1 is the collection of data. That includes information you get from the patient's chart and from your own hands-on assessment and observation of the patient. You need this data in order to determine which nursing diagnoses to use. This webpage...

Anemia - Family Practice Notebook

Lists the common signs and symptoms of general anemia to help you determine what symptoms belong to anemia. Your patient may have symptoms of other problems beside anemia as well. There are links on the left side of the page to other pages of information on anemia that include the causes and more diagnostic testing and treatment if you need that information.

Step #2 of the written care plan process is to assemble, or group, the abnormal data you discovered in your data collection process into nursing diagnoses. Each nanda nursing diagnosis has specific symptoms. If you have a recently published care plan book to help you, it should list these symptoms for all the various nursing diagnoses. It is for this reason that it would be hard for me to just, out of the blue, list some nursing diagnoses for you. I might miss something important that you need to address with this patient that might not necessarily be related to the anemia.

Please give me a list of the symptoms this patient has so i can begin to help you put together some nursing diagnoses.

[Daytonite, BSN, RN]

Quote

How do you make the decision to prioritize which nursing diagnoses to place at the very top of a nursing care plan?

The first diagnoses to go up on the top of the list are those that affect the airway, breathing or circulation (as in the heart). This is just like the ABC's of CPR. There are certain NANDA diagnoses that fit into these three categories:

• Ineffective Airway Clearance - not having the ability to clear out mucus or other obstructions from the respiratory tract in order to maintain a patent airway
• Decreased Cardiac Output - the heart is unable to pump out enough blood to meet the metabolic demands of the body
• Fluid volume deficit - intravasular, interstitial and/or intracellular fluid is decreased (as in conditions like hemorrhage, severe shock, multiple organ failure)
• Impaired Gas Exchange - oxygenation and/or carbon dioxide exchange at the alveolar-capillary membranes is damaged or deteriorated so there is excess or deficiency of either gasses in the system (patient will usually be in severe respiratory distress)
• Ineffective tissue perfusion (must specify as to renal, cerebral, cardiopulmonary, gastrointestinal or peripheral) - tissues are failed to be nourished at the capillary level because of a decrease in oxygen
• Impaired Spontaneous Ventilation - decreased energy resulting in the inability of the individual to maintain their breathing adequately to sustain their life

A NOTE: Don't choose a nursing diagnosis without the patient having the signs and symptoms to support using it. See a current care plan book or NANDA's book, Nursing Diagnoses: Definition & Classification 2005-2006, for this information.

The next in the hierarchy depends on what your nursing program has directed you to place in importance. These are three of the most popular systems:

• Maslow's Hierarchy of Needs
• Gordon's 11 Functional Patterns
• Roper, Logan & Tierney Activities of Living

Do any look familiar to you? If you have Ackley and Ladwig's Nursing Diagnosis Handbook you will find a grouping of all the nursing diagnoses under each of Maslow needs and Gordon's functional patterns at the back of the book in Appendix A & B, respectively. In the care plan books by Doenges, Moorhouse and Murr they list, on two pages toward the front of their books, all the nursing diagnoses grouped into 13 diagnostic divisions that don't resemble Maslow or Gordon at all. You always need to consider what is an immediate danger to the patient's life or limb. Maslow is very specific in listing the following in order of importance in the category of physiological needs which must be met first:

1. oxygen
2. food
3. elimination
4. temperature control
5. sex
6. movement
7. rest
8. comfort

Safety and Security needs come next in Maslow's hierarchy and this order:

1. safety from physiological and psychological threats
2. protection continuity
3. stability
4. lack of danger

Any nursing diagnoses that begin with the words "Risk of. . ." are considered to be anticipated problems. In other words, they are problems that do not yet exist. Of course, they are important, but for care planning purposes they are not as important as those problems that already prevail. Therefore, they are listed last. Within the group of anticipated problems you can prioritize their sequencing according to Maslow or Gordon as well.

Hope this gives you some help and guidance. Happy care plan writing!

[Daytonite, BSN, RN]

The reason you're having problems is because you are backing into a nursing diagnosis instead of looking at the evidence you collected from your assessment of this patient to help you determine the diagnosis. Once you determine the correct nursing diagnosis your nursing interventions will fall into place. Your nursing interventions will be aimed at the patient's abnormal symptoms or problems he/she is having. Sepsis is more of a medical diagnosis. What is more important for you to be concerned with is what signs and symptoms your patient was having. You say in your post that the patient has bacterial pneumonia that has become septic. Does your patient have any of these symptoms that are typical of patients with pneumonia?

• cough
• sputum production that might be purulent
• fever
• wheezing
• pleuritic chest pain
• dyspnea
• tachypnea
• tachycardia
• headache
• fatigue

These are all the defining symptoms of the medical diagnosis of pneumonia, in general. You need to be using them in picking a nursing diagnoses, not the sepsis. There is no nursing diagnosis of pneumonia. We nurses are going to take the medical symptoms of pneumonia and group them differently to come up with our nursing diagnoses. There are several nursing diagnoses that fit those symptoms. There are independent nursing actions that you can take for every single one of those symptoms that I have listed. Now, if your patient has any of the above symptoms, you need to look up those symptoms in the alphabetical listing of symptoms, problems, medical diagnoses and clinical states in the front section of your mosby's nursing diagnosis handbook, if that's the care plan book you have. You will find them listed there. Then, you will be guided to appropriate nursing diagnoses that you can use where you will find the nursing interventions for the symptoms listed with the nursing diagnosis.

Care plans are nothing more than the written nursing process. The nursing process is (1) collect data (2) plan care (3) implement the plan of care (4) evaluate. All that data you collected from the chart and from doing the physical assessment of the patient is what you seem to have left hanging in limbo. From all that data you pull out those items that are not normal. Those abnormal symptoms are then grouped, or clustered, together to form nursing diagnoses. Nanda has clearly defined and described what symptoms make up each nursing diagnosis. Your care plan book should be able to help you make these determinations, particularly the care plan books written by ackley and lagwig. If you are still having problems understanding this concept, please read these threads in the nursing student assistant forums or pm (private message) me: https://allnurses.com/scripting-t1125/

 

[Daytonite, BSN, RN]

Decreased Cardiac Output R/T decreased preload AEB hypotension and oliguria

(The definition of this nursing diagnosis is inadequate blood pumped by the heart to meet the metabolic demands of the body.)

Nursing Interventions/Rationales:

1. Monitor blood pressure (frequency?) (Maintaining normal parameters assures adequate perfusion of all body tissues with blood, oxygen and nutrients.)
   
2. Listen to heart and lung sounds, monitoring for symptoms of heart failure (Looking for dyspnea, 3rd and/or 4th heart sounds and crackles in lungs which indicate heart failure and need to be reported to the physician.)
   
3. Monitor intake and output (Decrease cardiac output causes decreased kidney perfusion resulting in a decrease in urinary output.)
   
4. Administer oxygen (Supplemental oxygen provides oxygen needed for the heart and other body tissues.)
   
5. Place patient in semi-Fowler's postion. (Helps to ease breathing and decreases venous return to the heart.)

[Daytonite, BSN, RN]

The answer is "D". The "related to" factors are those things that are the etiology or cause of the nursing diagnosis. As a nurse, it is not within the scope of your practice to say that the cause of the person's sleep disturbances is arthritis. That would be in a physician's realm to state that a patient had arthritis. You can, however, use the terminology "chronic leg pain". It is not a medical diagnosis and is, per the patient, the reason she is not able to sleep.

In NANDA's world, the cause, or "related to" factor should be something that the nurse can do something about through his/her own independent actions. Now, I know people are going to say that there are independent actions a nurse can take for a patient with arthritis. And, that is true, but arthritis is still a medical diagnosis and also requires medical intervention. A rule of thumb when working with or developing nursing diagnostic statements is not to use medical diagnosis or medical disease terms as "related to" items. Arthritis would be considered a medical diagnosis; chronic leg pain would not--it is a symptom and a vague one at that. There are very few exceptions to using medical diagnoses as "related to" items, but they are rare.

Just to throw a monkey wrench in here, there could also be a case for answer "B", fatigue related to leg pain. The only reason I would not choose it is because the patient is not complaining of exhaustion and inability to perform normal activities of daily living at her regular level of functioning which is the definition of that diagnoses. Had that been the case, fatigue would have been the diagnosis of choice.

If you have a care plan or a nursing diagnosis handbook, read the very early chapter(s) where it talks about the nursing process and forming the nursing diagnosis. One reading is not enough. It needs to be read and mulled over several times before getting a grasp on these concepts.

To skip ahead of your instructor a bit, the complete nursing diagnostic statement for this particular patient would be: Sleep pattern disturbances related to chronic leg pain as evidenced by difficulty falling asleep, awakening earlier than desired, and not feeling rested.

[Daytonite, BSN, RN]

Listing the abnormal findings in the data you presented in your post you have the following:

• patient's statement of a lump on her urethra
• failure to seek medical help
• financial problems
• worry over time away from work
• fatigue related to enlargement of the lump

I would group these into any one of the following nursing diagnoses:

• Decisional Conflict R/T support system deficit and perceived threat to value system AEB failure to seek medical help because of financial problems, worry over time away from work and fatigue.
• Ineffective Health Maintenance R/T lack of material resources AEB failure to seek medical help due to statements of financial problems
• Deficient Knowledge R/T misinterpretation of information AEB belief that fatigue results in the enlargement of the lump on her urethra.

Just out of curiosity, did you do a review of systems with this patient about her genitourinary system? Is she having any pain, discharge or trouble with urinating?