when care planning we are identifying the patient's nursing problems and then developing strategies to do something for them. we use the nursing process which is our problem solving tool to help us. once the problems are identified, use maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs
) to determine how the problems fall in priority.
these are the steps of the nursing process as they are applied to care planning. they should be followed in this sequence:
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) [font=arial unicode ms]
- a physical assessment of the patient
- assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
- data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
- knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
- 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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
- your instructors might have given it to you.
- you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
- many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
- the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
- there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
- always sequence actual nursing problems before potential (risk for) or anticipated problems
- use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
- planning (write measurable goals/outcomes and nursing interventions)
- goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
- improve the problem or remedy/cure it
- stabilize it
- support its deterioration
- how to write goal statements: see post #157 on thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
- interventions are of four types
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
- 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 or caregiver)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
when working on a scenario that has been given to you, use the above steps. . .
step 1 assessment - look up information about your patient's medical diseases/conditions to learn about the signs and symptoms, pathophysiology and medical treatment
- this is a patient who has just undergone major anesthesia and surgery. look up the complications of general anesthesia because monitoring for them is a major responsibilty of the nurse when this patient is released from post anesthesia recovery and sent back to the nursing unit and your scenario clearly states that the client "has just returned to your nursing unit after abdominal surgery with general anesthesia". the complications of general anesthesia are:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
i think your scenario is interesting because it does not mention the specific reason that the patient went to surgery. it did mention that this person has arthritis, uses a cane to ambulate and takes an nsaid for pain for this. however, the scenario was also clear in mentioning that this patient is "reluctant to cough, deep breath; and turn because of complaints of pain". why do you want someone to be coughing, deep breathing and turning? i don't want this patient to come down with a pneumonia 3 days after surgery and that starts immediately by having them move (turn), deep breathe and cough.
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
- all nursing diagnoses (nursing problems) must have evidence to support their existence. the pain was not really described in terms of the abdominal incision, but in relation to coughing, deep breathing and turning. that is not just acute pain
, but pain because of some treatment the nurse is attempting to do with the patient. if this patient was having pain because of the surgery it would be described as abdominal pain and that is not what the scenario says.
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
- has an abdominal dressing
- skin pale, warm and dry (why would this be?)
- reluctant to cough, deep breath and turn because of complaints of pain
step #3 planning (write measurable goals/outcomes and nursing interventions)
- ineffective airway clearance r/t effects of anesthesia aeb sleepiness and reluctance to cough, deep breath
- deficient fluid volume
- impaired tissue integrity
- risk for impaired gas exchange r/t ventilation perfusion imbalance [the patient is sleepy which could be a side effect of the anesthesia, but is also pale which could be because of mild hypoxia although there are no other symptoms to confirm this. i would still watch this patient for potential hypoxia.]
(is what you predict will happen as a result of the interventions being performed): patient will demonstrate how to correctly cough and deep breath by ____.
(they have to address the aebs and the r/ts):
- assess level of consciousness and orientation to person, place and time
- inspect the chest for abnormal movements with breathing
- inspect the extremities for cyanosis, edema and clubbing of the digits
- auscultate the lungs for diminished, absent and adventitious breath sounds q shift
- monitor for increasing lethargy
- have the patient sit upright to ease their breathing
- ensure that the patient is getting adequate fluid intake so they are staying hydrated
- use humidification
- give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed
- explain the importance of coughing and deep breathing - use a pillow to splint the abdominal incision
- teach coughing and deep breathing exercises
- take a slow deep through the nose and expand the chest fully
- breathe out through the mouth feeling the chest sink down and in
- take a second slow breath through the nose expanding the chest fully and breathing out
- take a third breath in the same way but hold it
- the patient should now cough two or three times (once is usually not enough) and concentrate on using the diaphragm to force the air out
- follow with several normal breaths exhaling slowly
- do this every 2 hours
- deep breathing
- lie supine with legs slightly bed at the knees; can also be done sitting and standing
- take as deep breath as possible through the nose and allow the abdomen (not the chest) to rise
- hold the breath for a count of five
- exhale completely through pursed lips as if whistling allowing the ribs to sink downward and inward
- rest several seconds and repeat 5 to 10 times every hour
- teach about the underlying diagnosis and treatment plan