Nursing Care Plan Help!!

JustBeachyNurse, LPN · Oct 18, 2014

Pleural effusion and acute respiratory failure are a medical diagnosis not a nursing diagnosis. You cannot use either.

There is impaired gas exchange, ineffective breathing pattern, acute or chronic confusion

Do you have a nanda-I book? You MUST use only NANDA-I nursing diagnoses and only ones that your patient's assessment meets the defining characteristics (or risk factors) and related factors.

Esme12, ASN, BSN, RN · Oct 18, 2014

Welcome!

Here is my standard beginning.

Care plans are all about the patient assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

assessment consists of gathering data about:

a health history (review of systems) - you've provided more than enough of that
performing a physical exam - you have none and this information is crucial to have
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - what its side effects and potential complications are

Esme12, ASN, BSN, RN · Oct 18, 2014

A nursing diagnosis goes like this.... GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."
Related to" means "caused by," not something else.

Look at your NANDA resource.

Each nursing diagnosis has a definition, defining characteristics (symptoms that you patient has), and related factors (what causes it).

All care plans are based off your assessment. What meds is the patient on? What are the labs exactly? Is she febrile? What are her vital signs?

Tell me about your assessment of the patient not what she has as a diagnosis.

queensj · Oct 18, 2014

-73 y/o female

V/S as follows: 36.9,hr 101, rr 20 with 4L oxygen, 22 without O2, BP 176/86

106lbs, 5'2, BMI-19

AAO only to person, had to reorient to place and time

-pt is blind on R eye dt retinopathy

-no teeth, no dentures, has difficulty swallowing [clear liquid diet]

-on BiPAP[on and off depending on pt], and on 4L O2 when off bipap

-rapid and shallow respirations of 22-25/min when pt gets irritated/removes NC/Bipap

-glasglow coma scale - 13 verbal inapprorpiate words, you can't have a conversation with her but she will follow commands such as drinking water or repositioning

-bronchial/bronchovesicular lungs sounds clear on auscultation, diminished vesicular lung sounds bilat [also xray shows "white-out"?? on R side]

- S1 S2 audible with no murmur

-pulses 2+ bounding, cap refill

-abd soft, nondistended, non tender, hypoactive bowel sounds on 4 quadrants, has ileostomy haven't had a bowel movement in 3 days, and it is poorly maintained.

-pt has decreased appetite, and eats mostly medicine with yogurt.

-pt was on f/c but removed d/t cloudy urine and suspected UTI

-has L AKA , limited ROM bilat leg

-stage ii decub ulcer on R buttock/coccyx area

-skin dry/ashened,

-L flank cut d/t s/p chest tube, n o redness no swelling

Had thoracentesis d/t R pleaural effusion with 300mL exudate

On and Off Pt restlessness and would take out O2, pulse ox when irritated

pH 7.31[7.35-7.45]

c02 47.6 [35-45]

hco3 24.5[22-26]

bun 28 [8-25]

ca 10.4 [8.7-10.2]

bs 169

Thank you for helping me and taking time explaining everything. Just by typing all my assessments made me start thinking of abnormal findings. I guess I was too busy matching what I am SUPPOSED to see based on the medical dx and failed to assess my pt more on deeper level. It is so difficult to assess especially when the pt is irritated and wants nothing to do with a student. My teacher expects me to know dates of past medical hx, but I couldn't even keep a conversation with the pt as she is always either resting or irritated.

I came up with

Ineffective Breathing pattern RT fluid in the pleural space AMB rapid and shallow breathing 22/min, restlessness, and diminished lung sounds bilat

-i need 3 physiological nrs dx, 1 psychological and 1 social . still working on my other 4

JustBeachyNurse, LPN · Oct 18, 2014

Closer

"

I came up with

Ineffective Breathing pattern RT fluid in the pleural space AMB rapid and shallow breathing 22/min, restlessness, and diminished lung sounds bilat"

Fluid in pleural space is not an acceptable R/T per nanda-I The related factors are anxiety, body position, bony deformity, chest wall deformity, fatigue, hyperventilation, hypo ventilation syndrome, musculoskeletal impairment, neuro damage or immaturity, respiratory muscle fatigue, pain, obesity, SCI, NMD

I'd use ineffective breathing patten r/t respiratory muscle fatigue, hypo ventilation syndrome, and fatigue AEB alterations in depth of breathing, dyspnea, nasal flaring, tachypnea, pursed lip breathing, using accessory muscles to breath (RR 22, demand for increased O2,

You also have impaired gas exchange, ineffective airway clearance, risk for aspiration, impaired skin integrity, acute or chronic confusion, fatigue, risk for constipation/constipation, risk for imbalanced fluid volume, and others to consider based upon your assessment.

queensj · Oct 18, 2014

meds:

Ascorbic Acid/vit C 500mg po BID

Brimonidine/alphagan 0.1% eyedrops 1 drop on left eye BID

Carvedilol/coreg 12.5mg po BID with meals

Cholecalciferol/vit d-3 2000 units po at bedtime

clopidogrel/Plavix 75mg po daily

famotidine/pepcid 1 tab po daily

ferrous sulfate 1 tab po TID before meals

pilocarpine 2% eyedrops on left eye fourx daily

xenaderm 1 app to coccyx/buttock 4xdaily

regular insulin/humulin r 100units/mL ing per sliding scale

amlodipine/norvasc 5mg po daily

oxycodone/oxyir 1 tab po once prn pain 7-10

magnesium sulfate/citrate of magenisa 300mlpo for constipation

docusate/colace 10ml gtube

Esme12, ASN, BSN, RN · Oct 18, 2014

out of all that...what was her PO2 and O2 sat?

Your assessment is good...now you need to apply it to the ND and definitions from NANDA. What NANDA resource are you using?

According to NANDA Ineffective Breathing Pattern is defined as: Inspiration and/or expiration that does not provide adequate ventilation

With defining characteristics of: Alterations in depth of breathing; altered chest excursion; assumption of three-point position; bradypnea; decreased expiratory pressure; decreased inspiratory pressure; decreased minute ventilation; decreased vital capacity; dyspnea; increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe

Related to: Anxiety; body position; bony deformity; chest wall deformity; cognitive impairment; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological immaturity; neuromuscular dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; spinal cord injury

How does your patient best represent these "symptoms"? How does the white out affect breathing? Does the chest tube impair the patient taking a deep breath due to pain?

YOU patient must have at lest one of the defining characteristics and fall within the "related to" in order to use that diagnosis. Your patient has many possible ND based on the information here.

Esme12, ASN, BSN, RN · Oct 18, 2014

-73 y/o female
V/S as follows: 36.9,hr 101, rr 20 with 4L oxygen, 22 without O2, BP 176/86
106lbs, 5'2, BMI-19
AAO only to person, had to reorient to place and time
-pt is blind on R eye dt retinopathy
-no teeth, no dentures, has difficulty swallowing [clear liquid diet]
-on BiPAP[on and off depending on pt], and on 4L O2 when off bipap
-rapid and shallow respirations of 22-25/min when pt gets irritated/removes NC/Bipap
-glasglow coma scale - 13 verbal inapprorpiate words, you can't have a conversation with her but she will follow commands such as drinking water or repositioning
-bronchial/bronchovesicular lungs sounds clear on auscultation, diminished vesicular lung sounds bilat [also xray shows "white-out"?? on R side]
- S1 S2 audible with no murmur
-pulses 2+ bounding, cap refill
-abd soft, nondistended, non tender, hypoactive bowel sounds on 4 quadrants, has ileostomy haven't had a bowel movement in 3 days, and it is poorly maintained.
-pt has decreased appetite, and eats mostly medicine with yogurt.
-pt was on f/c but removed d/t cloudy urine and suspected UTI
-has L AKA , limited ROM bilat leg
-stage ii decub ulcer on R buttock/coccyx area
-skin dry/ashened,
-L flank cut d/t s/p chest tube, n o redness no swelling
Had thoracentesis d/t R pleaural effusion with 300mL exudate
On and Off Pt restlessness and would take out O2, pulse ox when irritated
pH 7.31[7.35-7.45]
c02 47.6 [35-45]
hco3 24.5[22-26]
bun 28 [8-25]
ca 10.4 [8.7-10.2]
bs 169

Now look at what I have highlighted which nursing diagnosis apply to these symptoms.

Esme12, ASN, BSN, RN · Oct 18, 2014

meds:
Ascorbic Acid/vit C 500mg po BID
Brimonidine/alphagan 0.1% eyedrops 1 drop on left eye BID
Carvedilol/coreg 12.5mg po BID with meals
Cholecalciferol/vit d-3 2000 units po at bedtime
clopidogrel/Plavix 75mg po daily
famotidine/pepcid 1 tab po daily
ferrous sulfate 1 tab po TID before meals
pilocarpine 2% eyedrops on left eye fourx daily
xenaderm 1 app to coccyx/buttock 4xdaily
regular insulin/humulin r 100units/mL ing per sliding scale
amlodipine/norvasc 5mg po daily
oxycodone/oxyir 1 tab po once prn pain 7-10
magnesium sulfate/citrate of magenisa 300mlpo for constipation
docusate/colace 10ml gtube

She has a G tube? Is she also diabetic?

queensj · Oct 18, 2014

Patient’s initial___H,J________Room # __186 ICU__Medical Diagnosis _PNA, Resp Distress___

Nursing Diagnosis: Impaired Gas Exchange RT changes in the alveolar-capillary membrane, deficit in oxygenation and CO2 elimination of the alveo-capillary level AMB abnormal ABG, rapid and shallow respirations of 22-23 per min.

[TABLE]

[TR]

[TD=width: 182]

Assessment (Subjective & Objective)

[/TD]

[TD=width: 176]

Planning/ Outcome

[/TD]

[TD=width: 187]

Interventions & Rationales

[/TD]

[TD=width: 179]

Evaluation

[/TD]

[/TR]

[TR]

[TD=width: 182] Subjective:

???

Objective data:

-shallow/rapid respirations of 22-23/min

-diminished lower lobe lung sounds bilat upon auscultation

-O2 saturation of 90% when pt removes NC & 93% on 2L O2 via NC

-ABG as follows

ph: 7.288 (7.35-7.45)acid

pCO2: 53 (35-45)-acid

pO2: 75.3 (80-100)hypoxia

hCO3: 24.5 (22-26)wnl

[/TD]

[TD=width: 176] Short-Term Goal:

Patient will have O2 saturation of >90% within 1 hour

Long-Term goal:

Patient will demonstrate improved ventilation and oxygenation of tissues with blood gas analysis within normal range of Ph(7.35-7.45)

pO2 (80-100)

pC02 (35-45)

HCO3 (22-26) &

maintain respiration of 16-20/min(pt's usual range) with regular respiration, rate, rhythm, and depth, within 12 hours/by the end of shift

[/TD]

[TD=width: 187] 1. Administer supplemental O2 per MD order

To promote oxygenation and increase arterial O2

(Lewis p.552)

2. Monitor effectiveness of O2 therapy by checking pulse ox

Pulse ox is useful to detect changes in O2

3. Elevate HOB 30-45° continuously for maximum chest expansion (Gulanick,Myers p. 480)

1. Monitor ABGs every 2 hrs and maintain ABG of

Ph(7.35-7.45)

pO2 (80-100)

pC02 (35-45)

HCO3 (22-26)

ABG will facilitate alteration in pulmonary therapy and provide information about developing hypoxemia and respiratory acidosis. Decreased O2 and increased CO2 are signs of respiratory failure

2. Assess respirations every 2 hours, note quality (effortless resp), rate(16-20), rhythm(rapid/slow), depth(shallow/deep) and position assumed for easy breathing(30-45°)

Pt will adapt their breathing patterns over time to facilitate gas exchange. Both rapid, shallow breathing patterns affect gas exchange

3. Auscultate lung sounds in all fields every 2 hours

To obtain data on pt's response to therapy and check for newly

[/TD]

[TD=width: 179] Goals met:

Patient's O2 saturation increased to 97% with 2L o2 via NC. Pt remained in high fowlers position within the hour

Goals partially met:

0730

Ph:7.28(7.35-7.45)acid

pO2: 75.3(80-100)

pC02: 53 (35-45)

HCO3: 24.5(22-26)

1000

Ph:7.33 (7.35-7.45) acid

pO2:70.1 (80-100)

pC02: 47.6 (35-45)

HCO3: 24.5 (22-26)

Pt's pO2 dropped, pCo2 improved, hco3 remained normal limits, and pH improved.

Pt gets irritated when sister leaves, and takes out her NC/pulse ox which led to decreased oxygenation.

The pt however, started relaxed breathing, no s/s of rapid/shallow respirations and maintained RR of 20/min when on 2L o2. MD notified, new order for Mitt restraints noted.

[/TD]

[/TR]

[/TABLE]

Revised/Approved 5/14/2014

queensj · Oct 18, 2014

i posted my careplan somewhere on page 2 of this thread.

prioritizing per maslow's..

i wanted to fix breathing/gas exhange first d/t low O2....with dx Pneumonia ( i know i have been saying pleural effusion but the primary dx is PNA )

I can only have 3 physiological, 1 psychological and 1 social nursing dx..

Impaired Gas Exchange RT changes in the alveolar-capillary membrane, deficit in oxygenation and CO2 elimination of the alveo-capillary level AMB abnormal ABG, rapid and shallow respirations of 22-23 per min. [breathing is #1 priority]

Acute Pain RT stage II decubitus ulcer on coccyx and R buttock AMB grimacing during repositioning [pain needs to be stabilized b/c pain increases bp, hr, and resp, which will further jeopardize ABGs]

Impaired Skin Integrity RT cut in the L lateral chest due to hx of chest tube insertion [pt has low WBC which makes it difficult for her to heal]

Anxiety RT situational crisis of pt whenever sister leaves bedside AMB pt screaming sister's name continuously until pt gets tired