Desperately need help with careplans - page 9

by LVN2006

388,836 Unique Views | 207 Comments

any help?... Read More

  1. 0
    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.
  2. 2
    step #1 of the nursing process is to collect all your data. you need to make a list of the symptoms for all the medical diagnoses that were given for this patient, and there were quite a few!

    copd (scant sputum production with emphysema, excessive sputum production with chronic bronchitis, exertional dyspnea, chronic productive cough with chronic bronchitis, hypoxia with emphysema and cyanosis with chronic bronchitis, tachypnea, prolonged expiration, hyperresonant chest, diminished breath sounds, coarse rhonchi and wheezes in bronchitis, s3 gallop, edema)
    chf (decreased left ventricular ejection fraction, decreased contractility, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, unexplained confusion or lethargy, fatigue, lower extremity edema due to venous insufficiency and lymphedema, hepatic engorgement and/or ascites, s3 gallop, jugular vein distension, pulsatile liver, rales, pulsus alternans and tachycardia, poor capillary refill, cool distal extremities, altered mental status)
    htn (b/p over 140/90)
    depression (sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)
    anxiety (nervousness, irritability, dread, insomnia, exaggerated startle response, easily distracted, unable to concentrate, muscle twitching, tremors, restlessness, shakiness, fatigue, muscle aches or tension, paresthesias, palpitations or tachycardia, shortness of breath, dyspnea on exertioin, chest pain, sweating or cold palms diaphoresis, choking sensation, dysphagia, heartburn, nausea or vomiting, abdominal pain, anorexia, frequent urination, dizziness, lightheadedness, faintness, headache)
    atrial fib (dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)
    cad (angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)
    mi (aka acute coronary syndrome) (chest pain similar to angina, pain often worse with activity and better with rest, pain radiates to arm, shoulder, hand, upper back, neck, jaw or throat; nausea, sweating, apprehension; pallor; tachycardia; s3 and/or s4 gallop; rales; jugular vein distension)
    osteoarthritis (deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)
    osteoporosis (usually asymptomatic until a fracture occurs in the vertebrae, distal radius or femoral neck, progressive deformity, kyphosis, loss of height, decreased exercise tolerance, low back pain, neck pain, elevated creatinine, history of tobacco abuse

    your scenario gave you the following abnormal data:
    • hyperglycemia (elevated glucose of 151)
    • low h&h
    • rales in the lll
    • pulse ox of 86% on room air
    let me backtrack a minute and say that all of the labwork is normal except for the glucose which is elevated, the h&h which is low and the bun which is only very slightly elevated and could be normal for an elderly man. glucose will be elevated in diabetes, of course. but, it will also be elevated in acute stress, cushing's syndrome, pheochromocytoma, chronic renal failure, glucagonoma, acute pancreatitis, as a result of diuretic therapy and corticosteroid therapy and in acromegaly. i'm opting for corticosteroid therapy in this patient since he has copd and it's very common to give steroids to people with chronic lung disease. the low h&h indicates this person is losing blood. probably slowly. probably through the gi track. however, you don't have any other information to go on. so, it remains a mystery. i would care plan it as a potential problem and monitor for signs and symptoms of gi bleeding. just fyi, the atrial fib, hypertension and tobacco abuse contribute to the chf.

    now, step #2 of the process of writing the care plan is to group together abnormal data into nursing diagnoses. that's going to be a big job because this patient has gobs of problems and a whole big list of symptoms! there are so many abnormal symptoms here that 5 different nurses could come up with a set of 5 different nursing diagnoses and each would be right. so, i'm going to give you my short list. this is your assignment, however. you know what the instructions are, i don't. feel free to go your own way.

    the first thing i see sticking out like a sore thumb is respiratory problems—big time. including your lab data, this is what i come up with in priority order (by maslow's hierarchy of needs):
    • impaired gas exchange r/t alveolar-capillary membrane changes aeb tachycardia, irritability, hypoxia, dyspnea, pulse ox of 86% on room air, skin pallor, hypoxemia, headache, and diaphoresis)
    • ineffective airway clearance r/t chronic obstructive pulmonary disease aeb dyspnea, orthopnea, rales, rhonchi, wheezes, sputum production, and cyanosis
    • decreased cardiac output r/t altered contractility and heart arrhythmia aeb rales, paroxysmal nocturnal dyspnea, decreased ejection fraction, s3 and s4 heart sounds, tachycardia, palpitations, jugular vein distention, fatigue, edema, prolonged capillary refill, elevated blood pressure, and atrial fibrillation
    • impaired physical mobility r/t pain and physical deformity aeb limited range of motion and changes in gait
    • fatigue r/t anxiety, depression and disease aeb lethargy, inability to concentrate, and sleep disturbances
    • risk for deficient fluid volume r/t occult blood loss [that means blood loss whose reason is not known]
    step #3 is the actual planning and writing of your outcomes and nursing interventions. outcomes are the predicted results of our independent nursing actions. independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. your nursing interventions will actually be based on the items you have after the "aebs" of each of your nursing diagnoses. if you have a nursing diagnosis book it will be very helpful with choosing interventions. if not, go to these sites to get information on various nursing diagnoses:
    the first site actually has a lot more nursing diagnoses than are listed, so if there isn't one on the list that you need, pm me and i'll check my list and let you know if what you are looking for exists on the gulanick site.

    steps #4 and 5 are implementation and evaluation. i don't know how far you are into doing that part of the nursing process for this assignment. most of the time people have the worst time getting through the first 3 steps so step 4 and 5 are usually a breeze.

    ok, i'm turning you loose. pm me if you need more help or have questions.
    surviveslu and perthisa like this.
  3. 1
    i've expanded on two of your nursing diagnoses for you and added goals and outcomes. outcomes are the predicted results of our independent nursing actions. independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. goals are the predicted results of collaborative nursing actions. collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider—things like administer medications or provide certain treatments, etc. both outcome and goal statements should be measurable, patient centered and specific. below the outcomes and goals i've listed weblinks to specific nursing diagnosis pages on two different care plan constructor sites where you can get not only information about the definition of that particular nursing diagnosis, it's related factors, defining characteristics and outcomes, but nursing interventions with rationales as well.

    chronic pain r/t progressive enlargement of tumor secondary to cancer of the pancreas with metastasis to the liver aeb patient's subjective rating of pain on a numeric scale of 1 to 10
    outcome: by ____ the patient will be able to perform normal adls with minimal interference from pain and the side effects of his medication.
    goal: by ____ the patient will state his pain is improved.

    imbalanced nutrition: less than body requirements r/t increased metabolic demands of tumor secondary to cancer of the pancreas with metastasis to the liver aeb 91% of body weight loss and poor appetite
    outcome: by ____ the patient will state the importance of a well-balanced diet
    goal: by ____ the patient will ingest nutritional requirements in accordance with his level of activity and metabolic needs.
    goal: by ____ the patient will maintain his current weight of ____.

    ineffective coping r/t
    (you need to look at both of the sites below. decide what it is that is making coping with his cancer difficult for this patient and you will then be able to complete your "related to" part of this diagnostic statement. why do you feel this patient is not coping with his disease well?)

    here are two weblinks to information on soap charting. - documentation. a resource for nursing students on e-university. some nice concise information here about what and what not to chart. talks briefly about pomr (problem oriented medical record), somr (source oriented medical record), narrative charting, adpie, pie, focus charting, soap and soap(ier) charting, cbe (charting by exception), flow sheets and check lists, reporting and taping reports (do's and don't's) and the essentials of taking verbal orders from doctors. - "document it right: a nurse's guide to charting". a 23-page article that addresses most styles of charting and covers many common nursing situations. there is information about soap charting on page 6.

    a soap note, generally, looks like this:
    s – "this is my very first care plan and i do not feel as if i was given enough instruction on how to do this." "how do i come up with interventions and evaluations and goals."
    o – completed data collection, no grouping of abnormal data into nursing diagnoses, no goals or outcomes, no nursing interventions. care plan halted at step #2.
    a – readiness for enhanced knowledge of nursing process r/t an expressed interest in learning how to write a care plan aeb a written plea for help
    p – assist student with formulation of nursing diagnostic statements, provide information on difference between outcomes and goals, provide references for nursing interventions, provide information on soap charting.
    surviveslu likes this.
  4. 0
    what is the difference between NANDA nursing diagnosis and wellness diagnosis?
    Thank you for your attention.
    have an excellent night!
  5. 0
    Quote from yadis572002
    what is the difference between nanda nursing diagnosis and wellness diagnosis?
    a nursing diagnosis is a patient problem that has been identified through the collection of information obtained in assessing the patient. there are currently 188 official nanda nursing diagnoses [as of 2007] that have specified definitions and criteria. among these nanda nursing diagnoses are several wellness diagnoses.

    nanda defines the wellness nursing diagnosis as "describ[ing] human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. this readiness is supported by defining characteristics. as with all diagnoses, nurse-sensitive (sensitive to nursing interventions) outcomes are identified and nursing interventions are selected that will provide a high likelihood of reaching the outcomes." (page 332, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)

    here are the wellness nursing diagnoses in the nanda ii taxonomy:
    • readiness for enhanced comfort
    • readiness for enhanced organized infant behavior
    • readiness for enhanced nutrition
    • readiness for enhanced self-care
    • readiness for enhanced sleep
    • readiness for enhanced spiritual well-being
    • readiness for enhanced religiosity
    • readiness for enhanced urinary elimination
    • readiness for enhanced fluid balance
    • readiness for enhanced therapeutic regimen management
    • readiness for enhanced communication
    • readiness for enhanced community coping
    • readiness for enhanced family coping
    • readiness for enhanced coping
    • readiness for enhanced decision making
    • readiness for enhanced hope
    • readiness for enhanced knowledge (specify)
    • readiness for enhanced family processes
    • readiness for enhanced parenting
    • readiness for enhanced self-concept
    • readiness for enhanced power
    • readiness for enhanced immunization
    (reference: pages 282 - 294, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international.)
    Last edit by Daytonite on Jan 16, '08 : Reason: corrected original information and added a list of diagnoses
  6. 0
    I want to thank everyone at this site, it has made understanding careplans manageable. I have shared the information with the other students in my class.
    I have a new pt and some more questions. Pt has mets breast cancer, stage 4 and it has spread to her bones. She needs help with ALDs but can stand (for a moment) on her own and can move around in bed and PT is working on her walking short distances.
    She has HTN, DM II, depression, bipolar, anemia, asthma, constipation, sleep apnea, migraine, incontinence. These are all being treated with numerous meds. She has had breast cancer for past 10 yrs and both breasts removed and reconstruced, she did XRT in the past and has just started on oral chemotherapy that is given a difficult but slight chance of being effective. she is in a long term care unit with a full code. She wants to be able to walk again so she can go home to her mother that is in a wheelchair.
    She is on oxycodone q4h and is in bed or in her chair a lot- a 19 on the Braden scale.
    What I have come up with for my three nx are chronic pain, inadequate nutrition:less than body requirements, and risk for injury r/t DM- hypo or hyperglycemic. My question is: Are these good or should I have other priorities & how do you put DM related NX when the DM is under control and she is not on insulin. She has HTN put no complication currently, She has asthma and gets RT treatments.
    Am I on the right track. the problem I have currently is I am not sure how to prioritize- I keep looking at Maslows and reading more about it but when someone is on palliative care I am not sure how that impacts Maslows.

    Thank you in advance
  7. 0
    Some thoughts for tygge on your care plan. . .You ALWAYS, ALWAYS, ALWAYS let your patient's abnormal assessment data guide you in the choosing and prioritizing of nursing diagnoses. As I was reading your post I was making a list of them. What is your supporting assessment data for using Imbalanced Nutrition: less than body requirements? Has she been losing weight? Or, is she having nausea secondary to the chemo? Is there a reason you didn't address her incontinence? Breast cancer often metastasizes to the lung as well as the bone. With a history of asthma I would be thinking this patient is at risk and needs watching for breathing or airway problems. Getting this lady back into her home is going to be a discharge and social service project because it sounds like her mother is not going to be able to be much help to her. Since she has stated that getting back home is one of her desires, it would seem to me that this needs to be included in the care plan.

    Maslow has defined the levels of his hierarchy. Most understand that in his theory physiological needs must be addressed first. However, the physiological needs are further prioritized and sequenced in the following order of importance:
    1. oxygen requirements (brain first, then the heart, lungs, kidneys and peripheral tissues)
    2. food and fluids (this includes electrolytes)
    3. elimination (urine and feces)
    4. thermoregulation (fevers)
    5. sex
    6. movement
    7. rest
    8. comfort (pain control, some of the self-care deficits)
    The next tier of priority is safety needs. They are prioritized in the following order of importance:
    1. safety from physiological/psychological threats
    2. protection
    3. continuity
    4. stability
    5. lack of danger
    Your proposed nursing diagnoses as listed, plus the one you decided to add that you mentioned to me in a private message would be prioritized according to Maslow and following NANDA guidelines this way:
    1. Imbalanced Nutrition: less than body requirements
    2. Impaired Mobility
    3. Chronic Pain
    4. Risk for Injury
    Anticipated problems are always sequenced last. If there are more than one, they are prioritized and sequenced according to where they would fit on the Maslow hierarchy as if they were real problems, but within their own little grouping of "Risk for" diagnoses at the end of the diagnostic list.
  8. 0
    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
  9. 0
    I'm sure that "risk for" diagnoses do not require an AEB. It makes sense because a patient can't be presenting evidence of something that hasn't happened yet, correct?

    If someone has a source for this I would really really appreciate it!
  10. 0
    Quote from hotdog19d
    ok, i understand that aeb is not required,but can anyone help find a source that states this in black and white? i looked through my nursing diagnosis book and although it doesn't provide defining characteristics for "risk for's". i can't find anywhere in the book that states why.
    per nanda, the term "risk" belongs in one of the seven axial systems of taxonomy ii (for nursing diagnoses). it is classified under axis 5 health status and officially defined as "vulnerability, especially as a result of exposure to factors that increase the chance of injury or loss." (page 237, nursing diagnoses: definitions & classification 2005-2006 published by nanda international). with regard to using any of the terms within the seven axes to construct nursing diagnostic statements, nanda states the following: "some words of caution as well as encouragement: using a multiaxial structure allows many diagnoses to be constructed that have no defining characteristics and may be nonsense (such as "impaired activities of daily living, fetus"). we urge you to use only those diagnoses that are approved for testing and thus have defining characteristics. (page 239, nursing diagnoses: definitions & classification 2005-2006 published by nanda international). color and boldface added by me.

    what that all means, hotdog19d, is that there will be no nanda approved "risk for" nursing diagnoses that are going to have any defining characteristics as said in the post by bookwormom.

    most people find the materials from nanda kind of boring to read. however, if knowing about these things from the source is important to you, you can get a copy of nursing diagnoses: definitions & classification 2005-2006 from nanda very easily. go to their website and order a copy. this is how i got my copy of the 2005-2006 edition i referenced above. a new edition is coming out for 2007-2008 and the cost is $24.95. you can get information about it here: besides listing all the approved diagnoses (this information is reprinted in scores of nursing care plan books), it also gives an explanation of what the taxonomy and classification system is as well as lists of all the words that are included in each of the seven axes that comprise the taxonomy (not often included in nursing care plan books). warning! this is taxonomy stuff is something that only geeks are likely to be interested in.