Desperately Need Help With Care Plans

Nursing Students Student Assist Nursing Q/A

Any help with care plans will be appreciated?

Specializes in NICU.

This guy has so many problems, I don't know what to prioritize here... They all seem to go hand in hand somehow. Now the other students tell me to avoid cardiac patients for care plans, too late! I've spent hours already organizing the info, etc and am in a time crunch!

He was admitted for afib, but has severe bruising from falling

Forearm from elbow to wrist is bruised 85%. Rt inside leg by knee has redness and echymosis approx. 5" x 4". Left outside leg by knee has redness and echymosis approx. 7" x 9". There is no edema, drainage or approximation.

Coccyx - red blanching w/stage 2 blister 1" x 2", no edema, echymosis, drainage or approximation.

...generalized weakness. Hypertension 147/83 bilat. His i/o is 3000:3100, iv fluids running @ 125.

High levels of wbc from uti, but also high bun (35 on admit now 39) and creatinine: (1.3 on admit, now 1.6). Bc & electrolytes w/in normal range.

Hr is 117, irregular and weak pedal pulses. Hospital meds are: metoprolol, simvastatin, asprin, levofloxacin, digoxin, diltaziem. No o2 is running. Rr 18 & not deep or shallow. So I'm thinking circulation priority. I've narrowed it down to these nanda:

  • Impaired skin integrity
  • Decreased cardiac output
  • Impaired mobility: generalized weakness
  • Ineffective tissue perfusion: (would this apply to severe bruising?)
  • Self-care deficit

Ugh, I'm really stuck on this one. They all seem to relate somehow to me. Any help to get me thinking in the right direction would surely help!

In my peds class I was assigned a care plan on ethylene glycol poisoning (antifreeze). So far I have been unable to find any nursing interventions for this. Please help if you know a website or any interventions. Most seem to deal with lead poisoning that I have found, even in my peds book. Thank you so much.

I am having a hard time with coming up with a nursing diagnosis for anemia.......... can someone help??

Hi all,

I sure could use a gentle nudge in the right direction. I am trying to come up with a Nursing care plan for a patient with sepsis caused by bacterial pneumonia. Have been using Mosby's Nursing Care Plans book as a guide, but am having trouble find interventions that apply to my patient. While she is receiving antibiotics, most of her care is comfort only as she is facing end of life in the immediate future. Can only use one assessment intervention and no Risk for interventions. Any suggestions? Need five total

What have you got so far?

Ineffective tissue perfusion: cardiopulmonary/peripheral r/t arterial or venous flow exchange problems: sepsis...

Risk for injury: r/t sepsis resulting in mutiple organ failure , death

Ineffective protection: r/t inadequately functioning immune system

Imbalanced nutrition: less than body requirements r/t generalized weakness, anorexia

Address air way... If she is gunky:

Ineffective airway clearance: r/t poor cough, thick secretions...

Hope this helps!!!

I remember care plans well and still hate them.

So far I have come up with:

Decreased Cardiac Output R/t inadequate fluid volume AEB hypotension and Decreased Urinary output (

Interventions:

Monitor vital signs with frequent monitoring of BP

Monitor urine output with Foley catheter.

Need three more therapeutic interventions? This is making my crazier than normal.

Thank you so much for taking the time to address my little problem. I finally decided that a Nursing Diagnosis of Decreased Cardiac Output more fit the symptoms this patient is having. So I kind of did what you suggested and addressed the symtoms, in a long, round about way. Unfortunately, at this point in our clinic experience, we review the charts the night before and can only visit our patient long enough to introduce ourselves. It is a little frustrating trying to come up with a care plan for a patient you have not yet assessed.

However, my guess is that the instructors are trying to get us used to how to go about creating a care plan. Somehow I know that sentence could make better sense, but I have just packed in the books for the night and am too tired to think straight.

Thank you again for your assistance.

So this lady is basically comfort care?

Then she's not being vented, transfused, receiving drugs/fluids for circulatory failure?

Then I would concentrate on her breathing.

I guess i'm not understanding how aggressive they're being.

If she was being aggressively managed, then interventions r/t her sepsis would be more critical.

Is she receiving pressors?

Are her organs being perfused?

Is she managing w/o a vent?

Are you looking for interventions for the sepsis or end of life care?

Leslie

ETA: I reread all the posts. I wonder if she's not receiving aggressive care, then what good is it to monitor bp, uo, etc., if nothing is going to be done about it? Is she only receiving abx? Are they trying to maintain her, even knowing that she's going to die? In the event that she is comfort care, then some of these interventions mentioned, would be a moot point. I guess I do need more info.

I am trying to work up my careplan and need some help. My patient has constipation. He is 4 days postop but I contributing his constipation to all the medication that he is on and not because of the surgical anasthesia. 6 of his 13 medications main side effect is constipation. He said he has not had a BM in 5 days, and now has been ordered a fleets enema. My question is he has some abdomen distension above his umbilicus. Would this be a subjective sign of constipation or could this be something else. I was not sure with constipation where the abdomen distension should be. Thanks R

Specializes in Neuro/Med-Surg/Oncology.

What kind of surgery did your patient have? The distention could be from constipation. It could also be from gas or an ileus. How active has this patient been post-op? How much fluid has he taken in? Increasing activity and encouraging fluids and high fiber foods can be non-pharmacological interventions used alongside the medications. The other reason I wanted to know what kind of surgery your pt had is if it was anywhere in the abd or was a laproscopic surgery, he could be having some gas pain in addition to incisional pain. It's important that the pt be taught to differentiate between the two types of pain so he does not slow his gut down further by taking pain meds for gas pain. Just my .02. Hope it helps.

Specializes in med/surg, telemetry, IV therapy, mgmt.

Yes, this is an objective (because you can see and observe it), not a subjective, sign of constipation and flatus build up. 5 days with no bm + air in the bowel from him being under anesthetic = abdominal distension and constipation. As the distension builds up, where's all this air and feces going to go if the patient isn't passing stool or gas? Up and pushing upward on the structures lying under the diaphragm. Even if a patient is npo the body still makes a few grams of stool every day. The peristalsis of the gi tract is slowed immensely by anesthetic agents and narcotics that are given during or. An empty inactive bowel fills with air. This is generally the cause of postop abdominal cramping. Give the fleets enema to relieve the patient of the constipation and flatus. Just as a nursing action i might do an abdominal girth measurement with a tape measure before the enema and again afterward to empirically confirm if the abdominal distension were improved by the enema. Male abdomen's are capable of wondrous stretching. Their signs of bloating aren't quite the same as for females. When they bloat, they will get swelling all throughout the midriff and up to their xiphoid area.

Airway

observe and provide oral care q __ hrs

i hate it when staff neglects the mouth...

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