I have been reading over countless threads relating to help with nursing care plans and was reluctant to ask for help, but I decided to do it anyway.
I am a 1st semester PN student working on my second care plan. Not much was expected of us on our first, so (sufficeth to say, I didn't go whole hog while working on it). This time however, I am having much more difficulty preparing a legitimate, properly-structured (NANDA) nursing diagnosis. In my PN program, we aren't allowed to perform assessments on the patients we pick for our care plans. We are only allowed to gather objective information about their medical conditions from their medical chart.
This, as you well know, makes it almost impossible to create a legitimate care plan because most of the stuff is being "invented" or "made up". I chose a patient with:
long history of RA with resultant chronic neutropenia and thrombocytopenia
right heel and right hip cellulitis (with MRSA-infected wounds)
hypertension
hyperlipidemia
GERD
and most recent chief complaint (why she is in nursing home) is right occipital CVA with resultant left eye blindness
I have passed her meds a few times, so I know a little about her, and one of the reasons I picked her was because she had so many interesting things wrong with her, I thought it was be easy to create a solid care plan.
Here is a visual:
She has wound vacs to both R heel/hip
She is on neutropenic precautions (PPE)
PICC line to RUE
She ambulates and transfers with assistance
Fall risk score is 7
Braden score for skin integrity is 19
Vancomycin trough 22.2 (I have no idea what this means, but the range was 8.0-20.0)
and ALL of her labs WBC, RBC, Hgb, Hematocrit, platelets, ANC, cholesterol were all WAY out of range as you would suspect (I don't have the exact numbers in front of me...sorry)
The only meds she is on what were not prn were:
vancomycin 750 mg IV q 48 hr
simvastatin po q HS
coumadin 25 mg po q day
ASA 325 mg po q day
Pepcid 20 mg po q day
prednisone 20 mg po q day
losartan 50 mg po q day
and I think there is a opiate analgesic order but only prn
related to her CVA, she doesn't have any -plegia, -phasia, or other typical s/s except the L eye blindness and I have no idea where the RLE wounds came from
so, I thought I was being smart by picking her, but what I am finding is difficulty in choosing appropriate nursing diagnoses (I only need 2) because we were told to pick them based on one of her medical diagnoses. So...unfortunately I only have signs and no symptoms (except pain, I have heard her verbalize pain previously)
I will use chronic pain as my first ND, but what for the second? I dont think I can use risk for infection (even though she is neutropenic) because she is already on vanco for the MRSA in her RLE.
I thought of using impaired skin integrity because of the wounds but I don't know if they are a result of immunological deficit, immobility, or other mechanical factors. Not being able to visualize the wounds kind of makes that one difficult, I think.
I also though of risk for injury, but do I tie the r/t to her RA (immume-autoimmune dysfunction), abnormal blood profile (neutropenia, thrombocytopenia, etc), or maybe I should tie it to something related to her resultant L eye blindness. I can't use risk for falls....I already wrote my first care plan on that one.
There are probably so many more obvious things maybe related to her MRSA or the CVA care, but I do not know enough about nursing yet to create a care plan from scratch without the symptoms from an assessment. It is crazy to have a first semester nursing student (a PN student no less) write a care plan "blind."
I appreciate any help I can get. Thank you so much!!
