all care plans
are nothing more than the written expression of the nursing process. just to refresh your memory, the steps of the nursing process, in order, are as follows: assessment, nursing diagnosis, planning, implementation, and evaluation. you have listed three items of assessment data to work with. i'm sure you probably have more if you think about the patient's medical diagnoses and the symptoms of chf, niddm, and the long term effects of his heart and diabetes problems. i hope you looked at the doctor's history and physical to get these other signs and symptoms because they can be used to help you choose nursing diagnoses. however, working with the three symptoms that you have listed, i can come up with some suggestions for nursing diagnoses for you. i'm also listing links to nursing interventions as well. the three symptoms you list are:
- altered level of consciousness
- short of breath (dyspnea) (was this with activity?)
using these as defining characteristics for nursing diagnoses, these are some suggestions for you to consider for this patient (in priority order, by maslow's hierarchy of needs):
- ineffective tissue perfusion: cerebral r/t lack of oxygen supply to the brain aeb lethargy http://www1.us.elsevierhealth.com/ev...replan_072.php http://www1.us.elsevierhealth.com/me...ex.cfm?plan=55
- ineffective breathing pattern r/t [either neurological impairment and/or compromised cardiac function] aeb dyspnea http://www1.us.elsevierhealth.com/me...ex.cfm?plan=08 http://www1.us.elsevierhealth.com/ev...replan_011.php
- disturbed thought processes r/t neurological changes aeb altered level of consciousness http://www1.us.elsevierhealth.com/me...ex.cfm?plan=53 http://www1.us.elsevierhealth.com/ev...replan_070.php
patients with congestive heart failure often have problems with activity intolerance due to shortness of breath and fatigue, cardiac output problems, they tend to retain fluid, develop edema and may have problems with their blood gasses because of fluid accumulating in their lungs. does your patient have any of these problems related to the congestive heart failure? what is a piq valve, or what is it for? is this in one of the valves of the heart? is this patient on any antiarrhythmics, diuretics or other heart medications? diabetes carries risk of many complications as well. diabetics often develop atherosclerotic diseases and i see this patient has already had a cabg. kidney failure and associated hypertension are very common in diabetics that have problems with arteriosclerosis or atherosclerosis. peripheral sensory changes are common with diabetics. did you check the patient's feet for any circulation changes? you should also look at his ability to perform any of his adls. how is he eating? moving? bathing?
i can see where you are having your frustrations because i think you haven't pinpointed all the abnormal data. i recommend that you develop a list of the signs and symptoms of the medical diseases that the patient does have. if your patient has any of those signs or symptoms that you just forgot or failed to write down when you were taking down information from his chart, write them down now so you can use them to develop nursing diagnoses. they become your items following the aeb part of your nursing diagnostic statements. now, you have to use an adaptive exchange model to organize your care plan, don't you? better pull out any guidelines you have on how to organize your assessment data. after you have that information, if you still need help determining nursing diagnoses, post again to this thread so i can help you.