Need Help with care plan!!!!!!!!

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for the first time, i am truly stumped trying to come up with a care plan. my pt has myelodysplastic syndrome/anemia, and i have read on it, but don't know where to start my plan of care, as she isn't really showing and signs or symptoms. i have 3 care plan books and they aren't helping. any ideas??????

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Specializes in med/surg, telemetry, IV therapy, mgmt.

first, understand that a care plan is the documentation of the nursing process. second, understand that the nursing process is nothing more than a problem solving process. you and i have been solving problems for years. we actually know the process. nursing school, however, is giving you a very sophisticated way they want you to do it. they want you to follow the nursing process. if you don't follow this five-step process you end up lost in the woods, so to speak.

i am also going to tell you that part of this process involves an understanding of the medical disease/condition that is going on with your patient. it is not enough to just know the nursing. you have to look up information about these diseases, their signs and symptoms, how the doctor's diagnose them, what tests they order to monitor them, what kinds of treatments they order for the symptoms and what they might do to try to treat the underlying cause of the condition in order to attempt a cure. this is so you understand why you are carrying out the doctor's orders and that they are appropriate, that you can make intelligent observations as to whether or not the patient is improving, staying the same or deteriorating, and if treatments are causing any side effects or not. this is part of our responsibility as licensed practitioners. so, nursing school isn't just about learning the nursing.

all care planning starts with doing a thorough assessment of your patient, step #1 of the process. this includes doing a physical examination, interview and a review of their medical record. even if you didn't see any signs or symptoms in the patient, the doctor did and they should be documented by him/her in the patient's medical record which you should have looked at and copied this information from. and, anemia, by the way is often considered a symptom and not a diagnosis, so there should have been labwork confirming it.

the signs and symptoms of anemia are (and that you might have missed) are:

  • pallor of the skin, nail beds and mucus membranes
  • shortness of breath (dyspnea)
  • palpitations
  • tachycardia
  • angina pectoris
  • weakness
  • vertigo
  • headache
  • sore tongue
  • drowsiness
  • fatigue
  • general malaise
  • gi disturbances
  • slight fever
  • amenorrhea in women
  • loss of libido

think back to what you observed in this patient and in her chart. now, is the time to add any of these symptoms if you missed them initially. it's not a crime to have missed them. this is how you learn to not make the same mistake a second time.

you could have found information about myelodysplastic syndrome, which is a form of leukemia, by doing a search on the internet. it is a form of anemia characterized by:

  • anemia - chronic tiredness, shortness of breath, chilled sensation, sometimes chest pain
  • neutropenia (low neutrophil count) - increased susceptibility to infection
  • thrombocytopenia (low platelet count) - increased susceptibility to bleeding

you want to look up the symptoms of neutropenia and thrombocytopenia just as i did for the anemia to see if your patient had any of those symptoms as well.

in your patient's chart you should also have looked for evidence of the following:

  • neutropenia
  • thrombocytopenia

the doctor may have done

  • a bone marrow biopsy (to confirm the diagnosis)
  • blood counts and other blood tests
  • cytologies

http://www.csmc.edu/5693.html

http://www.cancer.gov/cancertopics/pdq/treatment/myelodysplastic/patient

http://en.wikipedia.org/wiki/myelodysplastic_syndrome

http://www.emedicine.com/med/topic2695.htm

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology/myelo/myelo.htm

now, as part of your care plan activity, once you have finished this assessment you can move on to step #2 of the care planning process, planning. this involves making a list of all your patient's symptoms. believe me, there will be some or the patient would not have been hospitalized. just typing the list of symptoms i saw two "risk for" nursing diagnoses that stuck out. with that list of symptoms you need a nursing diagnosis reference, not a care plan book, to find nursing diagnoses. for this patient a "canned" (pre-printed) care plan is not going to work. this is why you have to know the care plan process--you have to do a customized care plan for this patient. a doctor diagnoses a patient's disease/condition by assessing them and considering their symptoms before deciding on their diagnosis. we nurses choose nursing diagnoses the exact same way and should do this very seriously because in the real world our care plans become part of the patient's permanent medical record. and, you don't ever want to end up on a witness stand having to explain why you chose a wrong nursing diagnosis. it would be no different from a doctor having to explain why he diagnosed a patient incorrectly. nanda has given us a taxonomy (a fancy name for a list of nursing diagnoses along with a list of signs and symptoms for each diagnosis). all you need to do is refer to the list of signs and symptoms that go with any nursing diagnosis to see if you've chosen the right diagnosis for your patient. i also recommend that you also check the definition of each diagnosis as well because it clearly describes what nursing problem that diagnosis is addressing. and, a nursing diagnosis is nothing more than a label (wording) that describes a patient problem. don't forget that. don't give a nursing diagnosis, the label, more power than it deserves. it's just a bunch of words. what the words mean, however, is where the real power is. hopefully, in your care plan book, with the nursing diagnoses is also the nanda information. if not, then i'm just going to say you have crappy care plan books and you need to get better ones that include nanda information. i, myself, use nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international as a reference when i am answering care plan and nursing diagnosis questions here on allnurses. i used it to classify information in the paragraph that follows. all it contains is the current 188 nursing diagnoses. for each it has the definition, defining characteristics (nanda language for signs and symptoms) and related factors (nanda language for the etiology or cause of the signs and symptoms or the actual problem). it only costs $24.95 and must be purchased directly from nanda from their website. most current nursing diagnosis books and care plan books that are published today have the same information in them if they have purchased it from nanda.

now, watch the magic. . .the shortness of breath and tachycardia are defining characteristics (symptoms) of ineffective breathing pattern. the angina pectoris (chest pain), palpitations, tachycardia, fatigue, shortness of breath, and skin, nail bed and mucus membrane pallor are defining characteristics (symptoms) of decreased cardiac output. the angina pectoris (chest pain) could also be acute pain along with the headache and sore tongue. the angina pectoris and shortness of breath are defining characteristics of ineffective tissue perfusion, cardiopulmonary. so, is weakness and skin color changes although it has to do with the peripheral perfusion to the tissues, but still belongs to the ineffective tissue perfusion diagnosis. although it's not specifically listed in the nanda taxonomy, vertigo is rightfully classified to disturbed sensory perception, kinesthetic and is also a risk for injury and risk for fall. a sore tongue could also be classified as impaired oral mucus membrane. for fatigue, drowsiness and malaise the diagnosis of fatigue is used. fever is classified to hyperthermia. the tendency to develop neutropenia in this disease would subject the patient to the risk for infection. and if they are susceptible to bleeding they are at risk for injury and risk for deficient fluid volume . i'm not addressing the gi disturbances because they really need to be more specific to classify them. the others involve sexual dysfunction and i doubt you're going to get into that with your patient.

step #3 of the care plan involves choosing goals and nursing interventions. now, here is a very important point to care planning. your nursing interventions always address the patients symptoms--always. that's why the list of symptoms that you made back in the beginning of step #2 is so-o-o important. here's another important point. your goals/outcomes always relate back to the nursing interventions or the problem (nursing diagnosis) itself--always. you can get information on how to write goal statements on post ##157 of this thread: https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html

now, i've given you a lot of information to read and think about. you need to go back through the information you have on your patient and think about what you saw in this patient and, perhaps, re-think her list of symptoms. everything depends on her symptoms--it is the foundation of this care plan. give me a list of symptoms and i can give you more help if you are still having problems with this.

there is care plan information on these sticky threads of allnurses:

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WOW!! Thank you thank you thank you. You sure have given me a lot to think about! I probably should not have said that she isn't showing any signs or symptoms, there are some serious ones there,but I am not sure what "I" - as the nurse can do about them Her vitals are normal. The lab abnormalities noted were her Hgb 4.3 and Hct at admission was 9.1. Since then she has had a transfusion, and is within normal ranges. She also has hemoccult positive stool, but no pain discomfort or changes in bowel pattern. Upon admission she complained of dizziness and "rubbery legs". (I know I could always use risk for falls). Anyway, I shall continue to dig deeper. Thanks again for your help!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

well, you have a better idea now of what to do with the "dizziness" and "rubbery legs" which i would interpret as "weakness". with low blood counts, look at the nursing diagnosis for ineffective protection. if she has hemoccult positive stools, she's still bleeding and at risk for deficient fluid volume. a transfusion is just a thumb in the hole of the dyke. they still have to find out what is causing the bleeding if they don't already know. her stools still need to be monitored and hemocculted. she's still at risk for having low h&h so her labs need to be monitored. she needs to be watched and monitored for the symptoms of hypovolemia. look them up if you don't know them because you'll need to list them in the nursing intervention you're going to write for this on the care plan.

what do you do about some of these other symptoms? first of all, look at what the doctor ordered. those treatments have to be carried out and some of them may have some nursing considerations connected with them, especially if there are drugs with some weird side effects. then, for each of your patient's symptoms connected with each nursing diagnosis, go through a list of adls (bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming). part of assessment includes determining if the patient can do these independently or needs some kind of assistance with them. remember, we're nurses, and this is where we shine. so, if this patient has dizziness and rubbery legs she definitely has some mobility and safety problems. what can you do about that? assist with walking, ask her to call for assistance, that kind of thing.

there are four types of nursing interventions, or actions, you can take with a symptom:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
  • care/perform/provide/assist (performing actual patient care)
  • teach/educate/instruct/supervise (educating patient or caregiver)
  • manage/refer/contact/notify (managing the care on behalf of the patient

if you're really good, you can come up with one of each type for one symptom alone. you can fill your care plan with nursing interventions if you're good. then, again, you don't want to abuse the b.s. factor.

think you got the idea now? if you still need help, ask.

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You have been so very helpful. I will take your advice and use it as a guide for my future care plans. :specs: I wish things had been explained better last semester when we first started doing them --where were you then?! haha Thanks again

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I have been answering care plan questions on allnurses for almost two years. Every day I check for care plan questions on this and the General Nursing Student Discussion Forum as well as do a search of all the forums using certain key words to help me find care plan questions. Where were you?

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I didnt learn about allnurses until recently. Thanks again :)

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Yes, I realize you are a new member. I can tell by your join date. That was just my lame attempt at humor. Sorry.

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