a care plan is a list of the patient's nursing problems (nursing diagnoses)
and strategies (nursing interventions)
to do something about them. to accomplish this we use the nursing process to not only help us organize our (critical)
thinking, but to help us sequence the events that take place in this process.
step 1 assessment
- the entire plan of care is based on assessment findings, so this first step is the most important activity. your assessment activity is important because when you find things that deviate from normal they, ultimately, will become the criteria by which you will diagnose their nursing problems. therefore, it is important that you recognize when something is abnormal and describe it as thoroughly as you can. assessment consists of:
- a health history (review of systems) - this is information from the patient's past and could be supplied from many different sources. see this thread: http://allnurses.com/nursing-student...al-227507.html - help preparing for clinical day! - it lists all the important information you need to gather from the patient's record. this is a 79 year old female who has been hospitalized for pneumonia. she's a bilateral amputee and has a long history of arthritis. she is married and speaks no english.
- performing a physical exam - i have many questions about the physical exam information you listed. this patient was admitted for pneumonia yet i saw no information about a respiratory assessment: respiratory rate, symmetry and use of muscles when breathing, lung sounds, presence of cough or sputum, presence of chest pain. patients with pneumonia may have any of these symptoms: hacking, painful and usually productive cough, rapid, shallow respirations, chills, headache, fever, dyspnea, pleuritic chest pain, grunting respirations, nasal flaring, decreased breath sounds, crackles and rhonchi, cyanosis, tachypnea, tachycardia and yet you mention nothing about any of these! to say "she is congested" is not good enough information to develop a care plan from. neither is "she has pain" and i suspected you meant it was in the left arm and elbow because of the osteomyelitis. but what about her arthritis? does she have pain from the arthritis? where? pain assessment involves determining:
- where the pain is located
- how long it lasts
- how often it occurs
- a description of it (sharp, dull, stabbing, aching, burning, throbbing)
- having the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain - for this patient who cannot speak english, using something like the wong-baker faces pain rating scale for her to describe her pain: http://www.mdanderson.org/pdf/pted_painscale_faces.pdf
- what triggers the pain
- what relieves the pain
- observe their physical responses
- behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
- sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
- parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
swelling is also a vague term and for purposes of care planning and evaluation of treatments can be measured by taking a measuring tape and the circumference of the arm and compared to the other arm and then recorded on successive days. swelling is a symptom of inflammation (an -itis), a normal body response when a body is fighting against tissue destruction or an infection (Histamine effect
). very little was mentioned about how communication was achieved with this patient. you failed to mention if she was a below the knee or above the knee amputee. communication is a safety issue. psychosocial diagnoses have to do with behavior. can't help you there because there is no assessment information about this patient's behavior. did you talk with the daughters about the patient at all? about the only thing i could suggest might be something along the lines of social isolation because of her physical disabilities or some kind of grieving because of her loss of mobility and confinement to the home as a result of her illness. but you need evidence to support using those diagnoses.
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - there are a lot of self-care issues (eating, bathing and dressing), but they are not described. and, its great that her two daughters show up to help her, but what happens if she needs help and he daughters aren't there? what if she needs help at 3am? or at 6am if they are stuck out on the freeway (we get tie ups on the freeways here that can make you an hour or two late to your destination)? do we just ignore her? how does she get around?
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this patient has the following medical diseases:
- diabetic (type i or ii?)
- bilateral amputee (ak or bk?)
- arthritis (what type?)
- osteomyelitus in left elbow
you need to look up each of these and find their pathophysiology and their signs and symptoms. you need to be able to match the drugs and treatments that have been ordered by the doctors with the medical problems she has and why they were ordered (for example, the steroids she is receiving). this is going to help you learn about these diseases and how they are treated. it will help deepen what you can learn from having taken care of this patient. you also need to compare the signs and symptoms of these diseases against the signs and symptoms that you found during your physical exam. this is how you will improve your physical exam skills for the next patients you care for. the pathophysiology of many medical diseases can be found in the online merck manual and signs and symptoms as well as the basic medical treatment of many diseases can be found on these websites:
step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking- look at the side effects of the specific steroids the patient is on. what other medications and treatments have been ordered?
- make a list of the abnormal assessment data - all you have listed is
step #2 determination of the patient's problem(s)/nursing diagnosis part 2
- she is congested - i cannot make a nursing diagnosis from this
- arm is swollen - i cannot make a nursing diagnosis from this
- she has pain (where?)
- speaks no english
- her two daughters come to the hospital four times a day to make sure she eats, gets washed and changed
- she and her 84 year old husband live with her daughter and have a care giver 8-10 (hours?) a day
- match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use -
step #3 planning (write measurable goals/outcomes and nursing interventions)
- there should be at least one respiratory diagnosis since this is a lady with pneumonia, but since there is no evidence to support a diagnosis. . .
- there should probably be impaired physical mobility r/t amputation and pain aeb ???
- feeding self-care deficit r/t ??? aeb ???
- bathing/hygiene self-care deficit r/t ??? aeb ???
- dressing/grooming self-care deficit r/t ??? aeb ???
- acute pain r/t inflammation of lungs aeb [any chest pain?]
- chronic pain r/t inflammation of large joints and the bone and tissue of left arm aeb ???
- impaired verbal communication r/t language barrier aeb inability to speak the language of caregivers
- now you begin to add nursing interventions for the aeb items that support the diagnoses. sometimes your interventions can target the related factors (r/t items) but not very often when the diagnoses are physiological ones since disease is mostly treated by the physicians and they often can't cure chronic disease.