hey every one i need help with my care plan

  1. 0

    A 28-year-old G3P2 at39 weeks gestation had spontaneous rupture of membranes prior to the onset oflabor. Two hours after admission to the Labor and Delivery Unit, the client'scervix has dilated to 3 cm, and it is now at a -2 station. The nurse assesses thepatient and reports that the patient has a prolapsed cord.

    Nursing Diagnosis: Impaired Fetal Gas Exchange RT Insufficient oxygen delivery due To cordocclusion AEB Late fetal heart rate and lack of variability on the electronicfetal monitor.
    Assessment Expected outcome Interventions Rationales Evaluations
    Objective data
    -Patient 28years- old G3P2 at 39 weeks gestation
    -Spontaneous rupture of membrane
    -Cervix dilated to 3cm and at -2 station
    -Nurse reports patient has prolapsed cord
    After 8 hours of nursing intervention, the fetal heart rate will return to normal( FHR base line of 110 160, presence of FHR variability and no decelerations) -Monitor FHR by obtaining an initial 20 minute electrical fetal monitoring tracing.










    -Assist patient into a chest-knee position to elevate the buttock (trendelenburg)


    -Elevate the resenting part and separate the cord from the presenting part and pelvis by use of gloved fingers inserted into the vagina to the cervix.
    -Baseline status of FHR should be 110-160beats/minute, with baseline variability of 6-10 beats/minutes. Accelerations of 15 beats/minute X 15 seconds are a reassuring sign of fetal well-being. (Maternal child nursing care page 384-385)

    -This position will keep pressure off the cord until birth. (maternal child nursing care page 454)

    -This will relieve pressure on the cord. (Maternal child nursing care page 454)
    Uncomplicated birth of a viable infant.



    Nursing diagnosis: Anxiety RT outcome of pregnancy (possibility of fetal death) AEBrupture membrane.
    Assessments Expected outcome Interventions Rationales Evaluations
    -patient 28years- old G3P2 at 39 weeks gestation
    -spontaneous rupture of membrane
    -cervix dilated to 3cm and at -2 station
    -nurse reports patient has prolapsed cord
    Within 1-2hr of intervention, patient participates in decision making regarding her own care and treatment. -Provide factual information about diagnosis, treatment and prognosis. Examples, need for bed rest, the possibility of cesarean birth and or fetal or neonatal loss


    -Teach patient relaxation techniques such as deep breathing, imagery, music, massage






    -Encourage patient to express fears, concerns and questions.



    -Increasing knowledge level about therapies and procedures reduces/eliminates fear of the unknown and affords a sense of control. (swearingen page 87)


    -Teaching relaxation skills empowers patient to manage anxiety provoking episodes more skillfully and foster a sense of control. (swearingen page 83)


    -Encouraging questions gives patient and avenue in which to share concerns. (swearingen page 83)




    Nursing diagnosis: Deficient knowledge RT the unexpected emergent nature of carerequired to ensure maternal and fetal well being AEB cord prolapsed.
    Assessment Expected outcome Interventions Rationales Evaluation
    Objective data
    -Patient 28years- old G3P2 at 39 weeks gestation
    -Spontaneous rupture of membrane
    -Cervix dilated to 3cm and at -2 station
    -Nurse reports patient has prolapsed cord
    Immediately following teaching, patient verbalize accurate knowledge about the effects of PROM and cord prolapsed on the patient and fetal, as well as treatment guidelines for an optimal outcome. -Inform patient about treatment of prolapsed cord and the effects on the fetus.






    -Teach patient the probable causes of prolapsed cord



    -Information about the effects prolapsed cord can have on the fetus is likely to promote compliance with treatment. (swearingen page757)

    -Aids in patient understanding and optimally in compliance with management. (swearingen page771)

    i don't know if am on the right track just need more ideas
    Last edit by Esme12 on Feb 11, '13
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  3. 5 Comments so far...

  4. 0
    I think you are on the right track but I just want to point out two things.

    1) You can't have a medical diagnosis as your nursing diagnosis. For the Anxiety one, I would put Risk for Ineffective Coping r/t outcome of pregnancy and fetus well-being.

    2) For your AEB of deficient knowledge, it would not be cord prolapsed (that would be in the r/t for this particular ND). The AEB of a nursing diagnosis if suppose to be what are the things that are telling you that this person does not have enough knowledge. So, for deficient knowledge, it may be something like, "client's report". How do you measure knowledge of a person? That would be your AEB.

    Also, if you are using APA format, it should look like this: (Swearingen, YEAR, p. 771) for in-text citations or (Swearingen, YEAR) for paraphrasing.

    I think all of the other things look pretty good.

    A last side note: are you using NIC, NOC, and NANDA?
  5. 0
    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.


    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use
    Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.
    From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis (ex:confusion) is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
  6. 0
    A medical diagnosis can be a related-to, but not a nursing diagnosis. So you could say, for example, Ineffective tissue perfusion r/t diabetes, as evidenced by (all the signs of poor blood flow you assess in your diabetic patient-- thick nails, absence of hair, claudication, absent pulses, lousy capillary filling ....)

    Your NANDA-I 2012-2014 gives you all the required elements for each approved nursing diagnosis, both defining characteristics (the evidence you discover on your examination) and the related factors (the related-to). Free 2-day shipping for nursing students at Amazon. You need this book.
  7. 0
    I realize this post is old, but "Anxiety" is an approved NANDA nursing diagnosis.
  8. 1
    Quote from busymommaof2
    I realize this post is old, but "Anxiety" is an approved NANDA nursing diagnosis.
    Anxiety is, indeed, an accepted NANDA-I nursing diagnosis. However,
    Anxiety RT outcome of pregnancy (possibility of fetal death) AEBrupture membrane.
    doesn't work because "rupture of membranes" isn't a defining characteristic (and that's what "as evidenced by" means), and "outcome of pregnancy" isn't an approved related (causative) factor.

    It would have been more accurate to say, perhaps,

    Anxiety related to threat to health status (prolapsed cord) and stress, as evidenced by (this student gives no evidence, no defining characteristics, to support the diagnosis) ...

    On page 344 of the NANDA-I 2012-2014, there are literally dozens of defining characteristics (symptoms), in behavioral, affective, physiological, sympathetic, parasympathetic, and cognitive realms that this laboring woman may have exhibited to help the student diagnose anxiety, but she gives none.

    Remember, this is evidence of the anxiety we're looking for, not evidence related to the membranes and prolapsed cord; those are the data she gives to support her diagnosis of anxiety, but they only (!) describe the membranes and the cord.
    AmyRN303 likes this.


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