Nursing Care Plan...

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    i'm doing my first care plan for my nursing program. i'm stuck on the last two diagnosis, if anyone can help.

    i have altered tissue perfusion r/t cardiopulmonary and knowledge deficit r/t hospitalization. i'm having problems coming up with more goals, outcomes, and nursing interventions. if you could help me that would be great. i know these may be simple, but my mind is worn out because of the other 3 diagnosis i had to do.

    thanks for helping if you can!
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    hi, ntaylor23, and welcome to allnurses!

    what are your patient's signs and symptoms that support these diagnoses? everything in your care plan is based on the patient's signs and symptoms (nanda calls them defining characteristics). you haven't listed any of this patient's signs and symptoms, so i really can't help you out here. you would have determined these from your assessment of the patient (review of the medical record, patient interview and your physical exam of the patient). your goals, outcomes and nursing interventions are also based upon these same signs and symptoms as well as the underlying etiologies that go with the nursing diagnoses.

    also, one of your nursing diagnoses titles is very old and no longer used. the r/t items on your nursing diagnoses are incorrect. you need a nursing diagnosis reference of some sort to make sure you are using correct related factors that go with these nursing diagnoses. i'm listing websites for you that have information about these two nursing diagnoses (definitions, related factors [r/t], defining characteristics [signs and symptoms], outcomes, and some nursing interventions). please understand that every diagnosis has signs and symptoms associated with it. you can't use a diagnosis unless your patient has one or more symptoms of it. a doctor can't say someone has the flu unless he has done an assessment and found any of the following: fever, productive or nonproductive cough, red watery eyes, nasal drainage, perhaps some shortness of breath, some swollen lymph nodes in the neck and even some rales or rhonchi in the lungs. you can't say someone has altered tissue perfusion, cardiopulmonary (the current correct title of this nursing diagnosis) unless your assessment has revealed and found that the patient has any of the following: abnormal arterial blood gases, altered respiratory rate outside of acceptable parameters, arrhythmias, bronchospasm, capillary refill greater than 3 seconds, chest pain, chest retractions, dyspnea, nasal flaring, a sense of "impending doom" and/or use of accessory muscles [page 228, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international]). you include them as part of your diagnostic statement if you are required to write a 3-part diagnostic statement for your instructors. the signs and symptoms are the things that follow the "aeb (as evidence by)" part of this statement.
    you should double-check your assessment information against a good assessment resource. make sure you haven't overlooked anything. student nurses tend to overlook signs and symptoms merely because they are inexperienced at seeing things that are abnormal. reviewing assessment resources is how you learn where you've made errors and correct them for future practice. you will find a number of them on this thread:
    you will find information about writing care plans and nursing diagnoses on these two threads:
    if you are still having difficulty with this, post your questions and i will help you. however, i can't do much without knowing what your patient's symptoms were.
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    I just wanted to add that since you have 3 other nursing diagnoses, Altered Tissue Perfusion, cardiopulmonary is a diagnosis that usually is one of the top priority ones because is addresses the physiological need of oxygen and nutrition on a cellular level. So, in the order of sequencing it should be your first nursing diagnosis to appear on your care plan unless you have something else (the brain) that absolutely trumps the physiological need for oxygen to the heart and lungs.

    Knowledge Deficit should be at the bottom of your list of nursing diagnoses. The only other things that are lower than this are any "Risk for" nursing diagnoses.
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    I apologize, here are my pt. signs/symptoms and medical history.

    Non-smoker/drinker

    History of:
    *TIA
    *Bellís Palsy
    *Hyperlipidemia

    *Hypertension


    Surgical Procedures:
    Cesarean Section

    March 2007

    *MRI
    *Carotid Duplex

    October 2007
    ECHO:
    -Indicated a stroke


    Pt. is receiving Tylenol 650g (antipyretics)

    Pt. is receiving ASA 325 mg (antipyretics)

    Pt. is receiving Heparin 5000 units (anticoagulant)

    Saline Lock


    1st diagnosis is pain & numbness r/t altered tissue perfusion

    2nd diagnosis was Altered Tissue Perfusion r/t cardiac (which is incorrect, now that you point it out to me. :-) )
    3rd diagnosis was Risk for injury r/t numbness
    4th diagnosis was knowledge deficit r/t hospitalization
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    most of what you've posted were medical diagnoses. the only signs and symptoms i found in your post was that the patient has pain and numbness, but i don't know where. so, i'm asking again, what were your patient's signs and symptoms? what were the vital signs? what were the lungs sounds? what was the result of the abdominal assessment? was there any peripheral edema? since this patient had a stroke as indicated by the echo are there any neurological deficits? some of the signs and symptoms of a stroke are:
    • changes in level of consciousness
    • anxiety
    • communication difficulty
    • problems with mobility
    • urinary incontinence
    • loss of voluntary muscle control
    • hemiparesis or hemiplegia on one side of the body
    • decreased deep tendon reflexes
    • visual problems
    • sensory losses
    does your patient have any of these? how does the patient do with her adls? can she eat all by herself? or does she need help opening containers of milk, picking up utensils, getting food into her mouth? can she dress herself? can she get up and take a shower, or does she need help? how does she accomplish urinating and having a bowel movement? does she brush her teeth all by herself? does she comb and brush her hair or does a nurse have to do it?

    why is the patient getting tylenol? why is the patient getting asa? why is this patient on heparin? what were the last cholesterol and triglyceride levels? what were the results of some of the labwork that was done on this patient? where is the patient's pain and numbness and why do they have it? what organ has the altered tissue perfusion (i'm assuming that's why they are on heparin)? why are they at a risk for injury. . .what's going on with that?

    all this is information that should have been in the chart or you should have collected it during your time with her. it is all assessment information and if it's not normal, it's a symptom. what we nurses call symptoms differ slightly from what a doctor calls a symptom. you and i can get up and go to the bathroom on our own. if this patient can't and needs some kind of nursing assistance to do that--it is a symptom of a nursing problem that you need to address on her care plan.

    as for your diagnoses. . .

    2nd diagnosis was altered tissue perfusion r/t cardiac (which is incorrect, now that you point it out to me. :-) ) - this needs to be sequenced as the first diagnosis
    the diagnosis of ineffective tissue perfusion, (must specify) must be specified as to which organ system of the body is involved. you cannot just say ineffective tissue perfusion and leave the nursing diagnosis at that. the organ system that is having the tissue perfusion problem must be stated. there are several choices: renal, cerebral, cardiopulmonary, gastrointestinal and peripheral) if the tissues perfusion is specifically only the heart, then you must use decreased cardiac output. you cannot use "cardiac" as a related factor.
    1st diagnosis is pain & numbness r/t altered tissue perfusion - this needs to be sequenced as the second diagnosis
    there is no such nursing diagnosis of pain and numbness in the nanda taxonomy. don't know where you came up with this. if you are using ineffective tissue perfusion as a diagnosis somewhere else, you can't use it as a r/t item on another nursing diagnosis. anyway, even if you were using acute pain or chronic pain altered tissue perfusion is not a valid related factor (r/t item) for these diagnoses. [color=#3366ff]acute pain [color=#3366ff]chronic pain
    4th diagnosis was knowledge deficit r/t hospitalization - this needs to be sequenced as the third diagnosis
    this is another nursing diagnosis that must be specified, so that it is written deficient knowledge (specify). the related factors on this diagnosis have to do with the patient's cognitive limitations, misinterpretation of information, lack of interest in learning and lack of recall. using "hospitalization" as a related factor doesn't mean anything. i ask myself, "how does hospitalization cause the patient to have a knowledge deficit? well, it doesn't. the patient has a knowledge deficit about being hospitalized because of either a general lack of information about being hospitalized, is unfamiliar with how to go about finding the information, is unable to process the information she was given (all hospitals are required to provide each patient with information about the services they offer at the time of admission), or is not interested in learning.
    3rd diagnosis was risk for injury r/t numbness - this needs to be sequenced as the fourth and last diagnosis
    numbness is a symptom. a related factor cannot be a symptom on a "risk for" diagnosis since this diagnosis anticipates a problem that might occur. the definition of risk for injury is "at risk of injury as a result of environmental conditions interacting with the individual's adaptive and defensive resources." (page 125, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international) when you are using a "risk for" diagnosis you usually have a specific injury in mind although you don't state it. your nursing interventions are aimed at it. your related factor is going to be what will be the direct cause of the injury if it occurs. is numbness going to be the cause of this patient getting some kind of boo-boo? or, will it be because they couldn't feel their skin (due to numbness) and developed a pressure ulcer which is a "sensory dysfunction". [color=#3366ff]risk for injury
    you really need to be looking at a nursing diagnosis or care plan book as you work on this.

    now, as i've been typing this i kind of get the idea that this lady had a stroke. you need to look at some references about stroke and what happens to patients who have had a stroke. there are three kinds of stroke. which kind did she have? this would have been on one of her x-ray reports. what kind of treatment did the doctors give her for the stroke? were they able to bust the clot? is that why she is on heparin? or is it for something else? you can find online information about strokes on any of the medical information websites listed on this thread of allnurses:
    bring me symptoms!!!!!
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    She is able to get up and brush her teeth, take a shower, eat by herself. She was actually going home that day that I had her.

    I have the reasons as to why she would be receiving those medication. In her chart I did not have her cholestrol levels, but I did have platelets, WBC, glucose, and some other ones.

    The patient has numbness and pain on her left side mostly her face and her arm. I will look over her assessment tool as soon I get it back, so I'm trying to remember as much as possible.

    And I will look at NANDA or something to follow with the diagnosis.

    We were not require to buy a care plan book, and I do not have the 40 dollars for a book to spare. I'm on a very tight budget so I'm very limited. As for getting them at the library other nursing students have checked the few that we have out.


    Thanks so much for your help. You have taught me a lot more then my teachers explained in an hour. My whole nursing class is very confused on care plans due to the instructor just saying here is one and this what it is, and that was all.
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    i gave you links to the nursing diagnosis pages that are online and free for you to look at from nursing diagnosis books in my two posts. they are the words that are underlined and written in blue. click on them and they will automatically link you to those pages. most of them are from nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig. the merlin/gulanick links that are also in blue are from nursing care plans: nursing diagnosis and intervention, 6th edition, by meg gulanick and judith l. myers. they both include the nanda information as well as outcomes (goals) and nursing interventions that you will need to help you write your care plan. check your school library or school nursing lab for a copy of a care plan book that you can use for a reference. or, ask one of the instructors. i am always on allnurses every day on the nursing student assistance or general nursing student discussion forum looking for questions about nursing care plans or you can pm me with any questions you have. i have two 3-foot piles of nursing reference books i use to help me answer student questions and i just bought another nursing care plan reference book yesterday (i already have 6 of them). i will help you get through this, but i can't help you much if you don't have the proper information about the patient. it takes time and experience to know what to look for in patients. we don't just recognize abnormal signs and symptoms just like that! believe me, i know. i've been an rn for 32 years and i've learned this the way everyone else has--by making mistakes.

    assessment is the most important activity you need to do in problem solving (care planning). your assessment information is what forms that foundation of your care plan. everything you do in your care plan is derived from your abnormal assessment information--everything. it's too bad you can't remember it all. assessment encompasses 3 things:
    • review of the information in the patient's medical record and this post will tell you what you need to copy out of the medical record: http://allnurses.com/forums/2228927-post5.html
    • an interview with the patient where you question them about their past health history (this is also called a review of systems) and you can get a guideline as to what to ask about by opening up the link at the bottom of everyone of my posts and downloading the student clinical report sheet for one patient form. the review of systems appears in the lower 2/3rds of the form.
    • a physical exam of the patient and you can find all kinds links to information on how to do a physical exam on this sticky thread of allnurses: http://allnurses.com/forums/f205/hea...ms-145091.html
    not having money to buy supplemental books to help you out is not an issue. as long as you have access to a computer and can either print out or save information to some sort of storage device you can get a great deal of information to help you out here on the allnurses student forums without buying the books.

    next time make a copy of what you hand in to your instructor. never hand anything in to an instructor without making a copy of it for yourself. tragedies like instructors loosing the papers do happen. use you computer as a tool and commit all your information to a computer file where it is saved and then it is merely a click of a button to print out a copy that gets turned in to your instructor.
  10. 0
    Quote from ntaylor23
    She is able to get up and brush her teeth, take a shower, eat by herself. She was actually going home that day that I had her.

    I have the reasons as to why she would be receiving those medication. In her chart I did not have her cholestrol levels, but I did have platelets, WBC, glucose, and some other ones.

    The patient has numbness and pain on her left side mostly her face and her arm. I will look over her assessment tool as soon I get it back, so I'm trying to remember as much as possible.

    And I will look at NANDA or something to follow with the diagnosis.

    We were not require to buy a care plan book, and I do not have the 40 dollars for a book to spare. I'm on a very tight budget so I'm very limited. As for getting them at the library other nursing students have checked the few that we have out.


    Thanks so much for your help. You have taught me a lot more then my teachers explained in an hour. My whole nursing class is very confused on care plans due to the instructor just saying here is one and this what it is, and that was all.
    Hi, I just wanted to let you know, you can get a good used careplan book on amazon. This will help you tremendously, just make sure the nursing diagnoses are up to date , as these are old editions.
    Here is a link
    http://www.amazon.com/gp/product/032...590710-0680458


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