Stuck on careplan---help!!! Stuck on careplan---help!!! | allnurses

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Stuck on careplan---help!!!

  1. 0 Hi everyone,
    I have a care plan that I am stuck on. I got a patient who was admitted for SOB, renal insuffiency, altered mental status and was dx with renal insuffiency, SOB, COPD, and urosepsis. He has a hx of hypertension, cancer, BPH,and CHF. No where in the the patient history does he have cholesterol problem so why is he given lipitor? Also his lab H+H is low, RDW is high but MCV, MCH, and MCHC are normal? No report of him being anemic so why is his RDW is high which indicates anisocytosis? Doesn't anisocytosis indicate b12 vitamin anemia? I am so confused, any help is appreciated. Thanks.
  2. 3 Comments

  3. Visit  JustBeachyNurse profile page
    #1 0
    IMHO you are way over thinking the scenario.

    Not everyone on a cholesterol med has an official diagnosis of hypercholesterolemia as there are other risk factors and conditions that indicate need for lipid lowering drugs. Lipitor is also used for cardiac prophylaxis in paients with certain risk factors, even if the patient's cholesterol is WNL

    As a nurse it is not our job to diagnose but to comprehend the "whole" scenario. The altered CBC can be due to current conditions, his renal issues etc. it would be better to compare the trend results to see if there is a pattern of anemia.

    Usually a care plan is to Assess the patient, determine nursing Diagnosis pertinent to the current hospitalization, Plan the nursing interventions and goals (also how to Evaluate progress to goals)...
  4. Visit  tnbutterfly profile page
    #2 0
    Moved to Nursing Student Assistance for more response.
  5. Visit  Esme12 profile page
    #3 0
    Quote from c tran
    hi everyone,
    i have a care plan that i am stuck on. i got a patient who was admitted for sob, renal insufficiency, altered mental status and was dx with renal insufficiency, sob, copd, and urosepsis. he has a hx of hypertension, cancer, bph,and chf. no where in the the patient history does he have cholesterol problem so why is he given lipitor? also his lab h+h is low, rdw is high but mcv, mch, and mchc are normal? no report of him being anemic so why is his rdw is high which indicates anisocytosis? doesn't anisocytosis indicate b12 vitamin anemia? i am so confused, any help is appreciated. thanks.
    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:
    1. 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)
    2. 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)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    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. what is your assessment? is the patient having pain? are they having difficulty with adls? what teaching do they need? most renal patients are on fluid restrictions. what does the patient say? what are the labs? is the patient on dialysis? is the patient compliant with the dialysis? what does the patient need? what is the most important to them now?

    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.

    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 them as a recipe to caring for your patient. your plan of how you are going to care for them.

    from a very wise an contributor daytonite.......

    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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

    a dear an contributor daytonite always had the best advice.......check out this link.
    nursing diagnosis

    what do you know about renal failure? can renal failure cause chronic anemia? what is your patient complaining of? sob? confusion? what do you know of htn? can clogged arterires cause htn and maybe needs rx with lipitor? is his safety in danger with the confusion? does he have ineffective breathing pattern? does he have an activity intolerance? is he at risk for falls? does he have excess fluid volume causing his sob? impaired gas exchange due to excess fluid volume or copd? can he care for himself? is he at risk for skin tears from falls?

    this is for starts......what are your thoughts?

    these sites may help

    nursing care plan | nursing crib
    nursing care plan
    nursing resources - care plans
    nursing care plans, care maps and nursing diagnosis
    Last edit by Esme12 on Apr 14, '12