need HELP with careplans

Daytonite, BSN, RN · Sep 5, 2007

first of all, a nursing diagnosis statement normally has 3 parts to it:

the

problem

- we call it the

nursing diagnosis

the

etiology

(or underlying reason) the symptoms are occurring - we call these the "

related factors

"

the

symptoms

- the actual abnormal assessment data you obtained after examining the patient and reviewing their medical record which nanda calls the "

defining characteristics

"

each nursing diagnosis should be structured in this way:

problem--etiology--symptoms

or

nursing diagnosis r/t...aeb...

which means

nursing diagnosis related to (the related factors) as evidenced by (the patient's symptoms)

goals are the predicted results of our nursing actions. our nursing actions are based upon the symptoms (defining characteristics) the patient is having. goals should be measurable, patient centered and specific. they should state a specific deadline by which they should be achieved. in other words, a goal is the resolution to a problem. if it is short term you want it now; if it is long term it will take long to come about.

********************

let's take a look at how you have constructed your nursing diagnostic statements and the symptoms you have listed for your patient. i am using nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international as a reference to help me out here.

impaired gas exchange related to obstruction of airways by edema and secretions or atelectasis

problem

[

nursing diagnosis

]: impaired gas exchange

etiology

[

related factor(s)

]: obstruction of airways by edema and secretions

symptoms

[

defining characteristic(s)

]: ?????

the definition of this nursing diagnosis is (page 94)

"excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane."

there are two related factors: (1) alveolar-capillary membrane changes (2) ventilation perfusion imbalance. defining characteristics (symptoms) can include the following: abnormal arterial blood gases, abnormal arterial ph, abnormal breathing, abnormal skin color, confusion, cyanosis [in neonates only], decreased carbon dioxide, diaphoresis, dyspnea, headache upon awakening, hypercapnia, hypercarbia, hypoxemia, hypoxia, irritability, nasal flaring, restlessness, somnolence, tachycardia, visual disturbances.

you already have a major problem here. you have obstruction of airways by edema and secretions listed as an etiology for impaired gas exchange and according to the nanda guidelines as i've copied them for you above, well, you can't do that.

however, i think i know what you are trying to say. i am a little hampered here because you haven't listed any of your patient's actual symptoms so i'll have to kind of wing it. i think the nursing diagnosis to use would be

ineffective airway clearance.

definition (page 5):

"inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway."

the related factors for this diagnosis include: second-hand smoke, smoke inhalation, smoking, airway spasm, excessive mucus, exudate in the alveoli, foreign body in the airway, presence of an artificial airway, retained secretions, secretions in the bronchi, allergic airways, asthma, copd, hyperplasia of the bronchial walls, infection, neuromuscular dysfunction. the defining characteristics (symptoms) can include absent cough, adventitious breath sounds, changes in respiratory rate, changes in respiratory rhythm, cyanosis, difficulty vocalizing, diminished breath sounds, dyspnea, excessive sputum, ineffective cough, orthopnea restlessness, wide-eyed.

an

example

of what using this diagnosis would look like is:

ineffective airway clearance related to asthma as evidenced by dyspnea, patient only able to speak a few words before having to stop to take a breath, inspiratory and expiratory wheezes, and productive coughing of pale yellow sputum.

your nursing interventions would be aimed at the patient's symptoms (dyspnea, patient only able to speak a few words before having to stop to take a breath, inspiratory and expiratory wheezes, and productive coughing of pale yellow sputum). then, by the definition i gave you above for "goals" your short and long-term goals would be based upon the results you predict to occur as a result of your interventions being followed. without knowing what your nursing interventions are going to be since you gave no information about the patient's actual symptoms, i am at a loss to provide you with specific wording.

activity intolerance related to fatigue or hypoxia

i just need a short term goal for this

problem

[

nursing diagnosis

]: activity intolerance

etiology

[

related factor(s)

]: fatigue or hypoxia

symptoms

[

defining characteristic(s)

]: ?????

the definition of this nursing diagnosis is (page 3)

"insufficient physiological or psychological energy to endure or complete required or desired daily activities."

the related factors for this diagnosis are: bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle. defining characteristics (symptoms) can include the following: abnormal blood pressure in response to activity, abnormal heart rate in response to activity, ekg changes reflecting arrhythmias, ekg changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report by patient of fatigue, verbal report by patient of weakness.

now, you have listed fatigue as a related factor. i'm guessing that you really meant it as a symptom the patient has. that would then change your nursing diagnostic statement a bit, but you still don't have the information that tells us the etiology for the activity tolerance. that is something that would explain the underlying reason for the patient's fatigue. so, now, you are partway there with this nursing diagnosis, but still need more information to complete it:

problem

[

nursing diagnosis

]: activity intolerance

etiology

[

related factor(s)

]: ?????

symptoms

[

defining characteristic(s)

]: fatigue

the hypoxia is a symptom that belongs with a nursing diagnosis like impaired gas exchange.

come up with some interventions for the fatigue and i can help you write goals that relate to that.

imbalanced nutrition:less than body requirements related to dyspnea or fatigue.

problem

[

nursing diagnosis

]: imbalanced nutrition: less than body requirements

etiology

[

related factor(s)

]: dyspnea or fatigue

symptoms

[

defining characteristic(s)

]: ?????

the definition of this nursing diagnosis is (page 148)

"intake of nutrients insufficient to meet metabolic needs."

the related factors for this diagnosis are: biological factors, economic factors, inability to absorb nutrients, inability to digest food, inability to ingest food, psychological factors. defining characteristics (symptoms) can include the following: abdominal cramping, abdominal pain, aversion to eating, a body weight of 20% or more under ideal, capillary fragility, diarrhea, excessive loss of hair, hyperactive bowel sounds, lack of food, loss of weight with adequate food intake, misconceptions, misinformation, pale mucous membranes, perceived inability to ingest food, poor muscle tone, reported altered taste sensation, reported food intake less than rda, satiety immediately after ingesting food, sore buccal cavity, steatorrhea, weakness of muscles required for swallowing or chewing.

again, you have a problem with your related factors since they are not listed in the nanda guidelines. the dyspnea, in fact, can be a symptom of ineffective airway clearance (see above) and the fatigue a symptom of activity intolerance (see above). so to use this nursing diagnosis you are now left with

problem

[

nursing diagnosis

]: imbalanced nutrition: less than body requirements

etiology

[

related factor(s)

]: ?????

symptoms

[

defining characteristic(s)

]: ?????

the writing of a care plan follows a very specific process.

assessment

(collect data)

nursing diagnosis

(group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)

planning

(write measurable goals/outcomes and nursing interventions)

implementation

(initiate the care plan)

evaluation

(determine if goals/outcomes have been met)

since i am getting the sense that this is a patient with a respiratory problem your assessment should have included taking vital signs, listening to their lungs, observing the way they breath and how they move. what did you discover? what was not normal? what did their abgs look like in the chart? the abnormal stuff is what you want to list out. that abnormal stuff is the abnormal assessment data (symptoms) that you use to determine your nursing diagnoses. those symptoms are the foundation of your entire care plan. your nursing interventions and goals are based upon them. you need to go back over what you did with this patient and list those symptoms. then, we can rewrite your nursing diagnoses and proceed from there. can't do goals which are step #3 of the process until you finish step #2.

you can see something on nursing interventions and goals in this thread i just posted to tonight: https://allnurses.com/forums/f205/last-written-project-need-help-wording-plan-please-247262.html#post2386145

there is also information on writing care plans on these two threads:

https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)