Advice on care plan

AliNajaCat · Feb 17, 2017

Thanks for the acknowledgment. Tell your brethren/sistren, LOL.

I will bold/italicise the data you cite that are defining characteristics for making this diagnosis.

Hi Everyone!
I am new to the site. I am a paramedic and have been for 10 years, have worked on ground ambulance, ER and critical care flight. I have recently enrolled in a paramedic to nurse bridge program. I must say I definitely have much more respect for anyone who has nurse behind their name.
Admitting diagnosis-Congestive heart failure
Nursing diagnosis-Impaired gas exchange
RT-Ventilation-perfusion imbalance
AEB-Irregular heart beat
Subjective Data (4)
1) Client states " I get restless at night".
2) Client states " I cough up green phlegm"
3) Client expresses increased shortness of breath upon exertion.
4) Client expresses increased weakness with exertion.
Objective Data (4)
1) Nasal flaring
2) Lung sounds diminished in bases, wheezing in apex bilaterally
3) Bilateral lower extremity edema
4) Tachycardia (A fib)
Rationales:
1) Abnormal heartbeat/afib is not a defining characteristic for this diagnosis (Defining characteristics: that's the evidence you need to cite). Tachycardia is, but if this rate is normal for him, just having afib isn't evidence for impaired gas exchange
2) Lung sounds are not a defining characteristic for this diagnosis
3) Edema is not evidence for this either
Interventions (NIC) (4)
1) The CNA will elevate head of bed 3x's/shift.
2) The The nurse will monitor clients lower extremities for edema daily.
3) The CNA will obtain clients oxygen saturations twice/shift.
4) The nurse will access lung sounds q shift.
Rationale for selected interventions.
1) The client will notice ease of breathing by end of the shift..look at #1 of intervention...
2) The clients edema will improve by the next review 5/14/17.
3) Client will maintain saturations above 92% per MD until next review 5/14/17.
4) Clients lung sounds will improve in 1 week
Rationales for interventions are why they work. These rationales you give here are goals, not rationales.
Monitoring is not an intervention, it's further assessment. Not a bad thing, but you have to say why your assessment will tell you something useful. Monitoring/checking SpO2/checking edema -- none of these will improve his gas exchange.
The point of making a nursing diagnosis is to identify things you can do to help. (the defining characteristics)
As an example, the rationale for raising the head of the bed is to decrease work of breathing by decreasing abdominal pressure on the diaphragm.
Monitoring his edema (#2) will not result in improvement in it -- no rationale given for this intervention
Checking his sats will not result in improving them-- no rationale given for this intervention
Listening to his lungs will not clear them-- no rationale given for this intervention

So, let's start over here. When you look at the NANDA-I 2015-2017, which you should have within reach whenever you have to develop a plan of care to deliver or delegate, because you can't decide on what NURSING care to prescribe (yep) until you have made a diagnosis. Nursing diagnoses, like medical ones, rely on data. A medical provider can say, "His hct is low, and so I diagnose anemia." (we all know that, but "anemia" is a medical, not nursing, diagnosis.)
So where do you go to find out what data points allow you to make a nursing diagnosis? That's your NANDA-I. It's not academic bs, it's the way you will learn to think like the nurse you want to be.
So let's turn to p. 204 and take a look at what it has to say about
Impaired gas exchange.
Definition: access for deficit in oxygenation and slash for carbon dioxide elimination at the alveolar capillary membrane.Defining characteristics:
Abnormal ABGs
Abnormal arterial pH
Abnormal breathing patterns, for example, rate, rhythm, depth
Abnormal skin color for example pale, dusky, cyanosis
Confusion
Cyanosis
Decrease in carbon dioxide level
Diaphoresis
Dyspnea
Headache upon awakening
Hypercapnia
Hypoxemia
Hypoxia
Irritability
Nasal flaring
Restlessness
Somnolence
Tachycardia
Visual disturbance
Related factors (this means causative, what caused the above conditions)
Alveolar â€“ capillary membrane changes
Ventilation â€“ perfusion imbalance
I see you have V-Q imbalance as a cause for the defining characteristics you used to make this diagnosis. Did this patient have pulmonary emboli or other problem affecting his pulmonary perfusion (ventilated but not perfused)? Or did he have a collapsed lung or a foreign body or something that resulted in the lung getting perfused but not ventilated?

I think it's more likely this gentleman has a problem with his alveolar-capillary interface, because CHF causes pulmonary edema-- and an edematous lung unit will not exchange gases efficiently; it's impaired.

So. Take a look at that list of (ap)proved nursing diagnostic defining characteristics for what you think his problem is (impaired gas exchange) and see if he has more or one of them. If so, bingo! You made a nursing diagnosis. NOW figure out what nursing can do about it. Obviously, you can decrease his work of breathing (how? and why does it work?). You can decrease his dyspnea on exertion (how? and why does it work/). You can assess him for his prn morphine (if it's ordered for this; why does it work for CHF?).

Goals: What do you want to see the next time you check him to tell you what your interventions have wrought?

Do you see how this works?
Nursing diagnosis-Impaired tissue integrity
RT-Impaired circulation
AEB-Decreased sensation in lower extremities
Subjective Data (4)
1) Client states, "I bruise easily".
2) Client expresses concerns for skin tears.
3) Client expresses irritation to left lower extremity.
4) Client states right buttock itching.
Objective Data (4)
1) Multiple bruises noted bilaterally to upper extremities.
2) Decreased sensation to lower extremities.
3) Redness and swelling noted to left lower extremity
4) Client is confined to bed and wheelchair.
The definition of impaired tissue integrity (p. 405) is "Damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and or ligament."
There are only TWO defining characteristics, lucky you!
Damaged tissue
Destroyed tissue
As you can see, decreased sensation is not evidence (a defining characteristic) for this diagnosis. Pick one of the two above, and describe them. "As evidenced by damaged tissue (skin tear over lateral malleolus, multiple bruises over bony prominences...." whatever)
Related factors
Well, there's a list as long as your arm here. It includes things like alteration in metabolism, alterations in sensation, chemical injury agent, excessive fluid volume, extremes of age, extremes of environmental temperature, high voltage power supply, inbalanced nutritional state, impaired circulation, impaired mobility, insufficient fluid volume, insufficient knowledge about maintaining for protecting tissue integrity, mechanical factor, peripheral neuropathy, pharmaceutical agent, radiation, surgical procedure.
Now, on to your interventions.
Interventions (NIC) (4)
1) The CNA will turn the client q 2 hours during the night.
2) The CNA will apply moisturizer 1 time a day.
3) The CNA will monitor for incontinence q 2 due to loss of bladder control.
4) The physician will add/change PT exercises to take pressure off reddened areas.
Rationale for selected interventions (4)
1) The client will have no additional bruising by the next review.
2) The client will be itch free in 1 week.
3) The client will have no skin break down in the perineum region by the next review.
4) The clients skin/reddened areas will be showing signs of healing in 2 weeks.

OK, we already talked about the idea that rationales are the reasons for the interventions, and your rationales here are really goals.

1) So, what's the reason that this gentleman will be turned q2h (and only during the night?)?

2) Itching doesn't belong in this diagnosis, unless you want to make a case for damage and destroyed tissue due to mechanical factor of scratching. You could do that. If you do, what's the rationale for using moisturizers? How will that decrease that mechanical factor?

3)Aha, first mention of perineum. Does he have skin breakdown in that area already? Related to? If he doesn't have actual skin breakdown yet, what you have is a second nursing diagnosis, risk for impaired tissue integrity. That's on page 406, so check it out. Yes, it's perfectly acceptable to have a nursing diagnosis for an actual skin breakdown in one place on the body, and have another area at risk. As an aside, don't let anybody tell you that risk diagnoses are not actual.

4) A nursing plan of care is written to prescribe nursing assessment and actions for nurses to perform or delegate. It is not a nursing activity to have the physician prescribe physical therapy. However, it is a nursing action to change patients positioned frequently(not just at night) to remove pressure from bony prominences.

I hope this is been helpful to you. Please get the book. You can get it for instant delivery to your e-reader, or one or two day delivery from Amazon. Even if they didn't put it on your reading list, it's invaluable. And, even if they didn't give you a "nursing diagnosis handbook," it's probably not up-to-date and, it is not authoritative.

Apple-Core, ASN, BSN, RN · Feb 17, 2017

That was one h**l of a response, AliNajaCat!! :up: I can't wait to have that level of understanding of my patients!!

Medic2RN-CCRN-CMC · Feb 17, 2017

AliNajaCat,

Thank you for your input as I greatly appreciate it! But I am now more confused then I was prior to asking for advice. You said you will bold out your recommendations. When I look at the subjective/objective you didn't think most of them would work. Are subjective/objective items that either the patient tells you or that you observe during your examination? All four in each category were either found upon assessment or verbalized by the patient. Sorry, as I said before I am now more confused about this entire care plan than I have ever been. Makes me think that the last one I had done was the same.

AliNajaCat · Feb 17, 2017

I meant to communicate that even though you assessed these data, and they are real, they are not supportive data for those nursing diagnoses. To make a nursing diagnosis, you MUST find supportive evidence in the list of defining characteristics (which I quoted you from the current NANDA-I) for it.

They may be supportive of other nursing diagnoses, just not for these. Does that help?

I realize that that being an EMT gets you in the habit of taking in a scene and all details. That's good, and as you learn more about how to apply these details IN NURSING, will stand you in good stead. Right now, though, in this assignment and many more to come, you're going to learn how to think like a nurse using nursing diagnostic criteria to make nursing diagnoses. Doing that means identifying the nursing diagnosis for which you have supportive evidence as defined by NANDA-I, separate from other asssessment findings that don't meet those criteria. Trust me on this. Get the book and it will click, and you will cruise.