Desperately Need Help With Care Plans

Nursing Students Student Assist Nursing Q/A

Any help with care plans will be appreciated?

How are his bowel sounds?

And a rectal tube will help pass the flatus.

If he's on constipating meds, combined w/the known effects of anesthesia and immobility, he should be on a bowel regimen until he's off some of these meds, up and about w/pt....

Specializes in Pulmonary.

I have a question about sleep that I need answered for class. Can anyone help?

Pt. complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What would be the appropriate nursing diagnosis for her?

a. sleep pattern disturbances related to arthritis

b. fatigue related to leg pain

c. knowledge deficit related to sleep hygiene measures

d. sleep pattern disturbances related to chronic leg pain

I am pretty sure it is between a and c, but we have hardly talked about nursing diagnoses at all yet. I don't quite get how to pick the "related to" portion. Thanks for any help in advance.

I am clueless on what diagnosis is suitable for this particular problem of a patient of mine.

She's 42. She tells me that she has a lump on her urethra and she doesnt want to seek medical help because of financial problems.. She also says that if she'll undergo an operation of her lump, there will be no one to work for the family because of the recovery time needed (she's the only one working in the family..)

She also says that everytime she experiences fatigue (where she experiences it during work.), the lump grows bigger..

i was thinking of these 3: ineffective coping, non-compliance and ineffective health maintenance. but it does not seem right.. and i do not have a clue on what will be my "related to"..

any suggestions..??

thanks..

Specializes in OB, ortho/neuro, home care, office.

risk for decreased urinary output would be another (if indeed she has a 'lump' on her urethra OR there's another

Health Maintainance Alteration r/t lack of financial resources

Risk for Role performance alterations r/t primary provider

Nursing Diagnosis Reference Manual

I was wondering if someone can tell me a better explanation of the nursing process. I get that the process has 5 steps and they are Assement, Nursing Diagnosis, Planning, Implentation, and Evaluation. But i need to know how to use them in critical thinking.

And

I am really lost in the nursing diagnosis. I cant tell the difference between nursing diagnosis and medical diagnosis. Any ideas for me to get this

Our professor's asking us to do 10 NCPs on pregnancy complications, complete with rationales. She gave us a few nursing diagnoses:

Ectopic Pregnancy

1. Anticipatory grief r/t impending loss of pregnancy

2. Anxiety r/t pregnancy status

3. Knowledge Deficit r/t surgical procedure

Incompetent Cervix

1. Altered Comfort: Pain r/t early dilatation of cervix

2. Fear r/t possible pregnancy loss

3. Situational low self-esteem r/t inability to complete pregnancy

Hyperemesis Gravidarum

1. Altered Nutrition: Less than Body Requirements r/t nausea & vomiting

2. Deficient fluid volume r/t excessive emesis

Pregnancy-induced Hypertension

1. Altered urinary elimination r/t oliguria and anuria

2. Risk for injury r/t seizures

Placenta Accreta

1. Impaired gas exchange (fetal) r/t interruption of blood flow from placenta

I added a few of mine also. Are these statements okay? Ambiguous or not stated correctly? I would appreciate it if you help me with this assignment. If you know any websites that give rationales, pls mention it too. Thanks.

an6el1022 said:
How do you write a secondary to....I'm not clear on that and my instructor wants us to include that with all our actual dx's.

For example...for a pt that has cholelithiasis and biliary colic. I chose this

Acute pain r/t obstruction of bile flow 2° biliary colic AEB complaint of RUQ pain, crying, guarding

but I think I shouldn't have used the secondary to biliary colic since that is a medical dx??? What would have been a secondary to...Here is another one I used...

Imbalanced Nutrition: Less than body requirements r/t n/v 2° impaired bile flow AEB abd pain, inability to ingest food, inadequate calorie intake

How would I use the secondary to and someone please tell me if I did it correctly. Would a secondary be just another etiology??

We were taught in school that the secondary to part could be a medical dx because nursing is the treatment of the response to the illness, so your diagnosis is based on the person's response, and the response is secondary to the illness.

Does that make sense?

Specializes in med/surg, telemetry, IV therapy, mgmt.
trilli18 said:
Can someone please help me,

I am working on my care plan which is on a pt who's main diagnosis was COPD and other Dx this client had are: CHF, COPD, HTN, depression, anxiety, Afib, hyperlipidemia, CAD, MI, osteoarthritis, osteoporosis, and did smoke for 40yrs. Im working on the Diagnostic Tests sheet of my care plan - Labs on this pt. Sodium 142, Potassium 4.5, BUN 23, creatinine 1.0 and wbc 7.8, glu 151 and H/H -10.6/31.0 oh and some other info is pt on 3LNC continous --- pulse oximetery on 3L = 98% on RA =86%, on a regular NAS diet and rales heard in left lower lobe of lung. So with all this now the part im having trouble with is the interpretation of significance to my pt. Can anyone help me out please --- going insane.

Is this a real patient? What is the other assessment data or is the labwork all the data you were given?

Daytonite said:
Is this a real patient? What is the other assessment data or is the labwork all the data you were given?

Yes real pt. and that is all I was given

I have a real pt that has advanced pancreatic cancer with mets to liver. His prognosis is 3-5 months. He is jaundiced, and has a poor appetite and has had recent weight loss 91% of body weight. He is on morphine 15 mg po 12h which is keeping his pn down. He states 0 of 0-10. He is fully ambulating and needs no help with ADLs. He is on palliative care and is DNR. He has friends and family come visit. Other than this cancer which was diagnosed 3 weeks ago, he is in excellent health even though he smokes 2 packs a day. This is my first pt and first care plan. I need three nursing dx. I have come up with #1- chronic pain, #2 nutrition imbalance, less than body requirements, #3 risk for ineffective coping. The problem that I am having is for dx #1- his pain is currently being managed well though they did a comfort assessment and starting giving the morphine more often. What would be my related to? I know it is secondary to pancreatic cancer but I don't know how to put that in R/T terms. Also how do I do a SOAPE note on this? Like I said before this is my very first care plan and I do not feel as if I was given enough instruction on how to do this. Because the pt is on palliative care and DNR, how do I come up with interventions and evaluations and goals.

Hello,

What is the difference between NANDA nursing diagnosis and wellness diagnosis?

Thank you for your attention.

Have an excellent night!

I didn't list as much supporting data as I could have since it was quite lengthy. re: nutrition, she was 200# and is now down to 171#. and they give her meal supplements regularly. From the chart it seems as if her cancer has spread to her spine and leg bones. I didn't see anything about it spreading to lungs except that they did a breathing treatment on her. She appears to have no trouble breathing when I have seen her and her lungs sound were good. We are only there a short time so it is hard to get a big picture, so I relied heavily on her chart. The reason I didn't address the incontinence is that she is able to use the bathroom with assistance and her incontinence is not specified. When I assisted her to the bathroom I didn't see any sign of skin irritation though she does wear an adult brief. she moves around in bed often so she is not high for bed sores but she does have a high risk for falls. She is assisted any time she gets out of bed. Mainly transfer to chair though PT is helping her try to walk a few days a week.

I put pain first since that seemed to be the priority since she is in a long term care facility and on palliative care but I will reassess my priorities with the insight you provided.

It would help if we were able to talk to the nurses about the pt and get their insight, but we mainly interact with the CNAs since this is our first quarter.

thank you for your insights and I will rework my care plan

tygge

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