Argh... nursing diagnosis/ care plan help

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I am having a really hard time trying to figure this out.. and this is my first attempt at preparing a care plan?

I have to come up with outcomes/ goals and interventions with rationales based on the following..

Activity Intolerance related to imbalance between oxygen supply-demand.

I have to do this based on the following patient:

50 yr old widower brought to ER for acute case of dyspnea.

  • reports smoking 1-2 packs of cigarettes per day for 36 yrs, but stopped 3 months ago
  • has had 2 sisters die of lung cancer
  • his medical diagnosis is emphysema and possible cor pulmonate (?)
  • he has a non-productive cough, decreased mental acuity, extreme shortness of breath with activity, fatigues easily, non-verbal expression of anxiety, irritability and restlessness
  • extremities mildly cyanotic and cool to the touch, capillary refill sluggish
  • worried about losing job of 30 yrs due to too many sick days
  • VS: bp 175/96, p 110, r 36, t 100.1, O2 87%

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I am having a really hard time trying to figure this out.. and this is my first attempt at preparing a care plan?

I have to come up with outcomes/ goals and interventions with rationales based on the following..

Activity Intolerance related to imbalance between oxygen supply-demand.

I have to do this based on the following patient:

50 yr old widower brought to ER for acute case of dyspnea.

  • reports smoking 1-2 packs of cigarettes per day for 36 yrs, but stopped 3 months ago
  • has had 2 sisters die of lung cancer
  • his medical diagnosis is emphysema and possible cor pulmonate (?)
  • he has a non-productive cough, decreased mental acuity, extreme shortness of breath with activity, fatigues easily, non-verbal expression of anxiety, irritability and restlessness
  • extremities mildly cyanotic and cool to the touch, capillary refill sluggish
  • worried about losing job of 30 yrs due to too many sick days
  • VS: bp 175/96, p 110, r 36, t 100.1, O2 87%

How about...

Activity Intolerance r/t imbalance between supply/demand

Anxiety r/t ineffective breathing pattern

Ineffective breathing pattern r/t decreased lung expansion

Death anxiety r/t fear of death

Fear r/t change in health status

Ineffective tissue perfusion r/t interruption of arterial flow

Risk for peripheral neurovascular dysfunction r/t condition causing disruption in circulation

I don't think you can do a true care plan until you have spent time with the patient because anyone can write up a care plan and goals...but how do you know what goals are appropriate and if they can even be reasonably met depending on how the patient is???

I think anything regarding breathing /perfusion is appropriate here because if the person can't breathe nothing else matters really.....

Is this an actual patient or a case study?????

I'm sure you'll do fine...;)

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It is a case study...

I have no idea about the goals though.. It says to set realistic goals that are measurable

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Specializes in med/surg, telemetry, IV therapy, mgmt.

so, you've been directed to use the nursing diagnosis:

activity intolerance related to imbalance between oxygen supply-demand

is that right?

the supporting evidence (defining characteristics) for this are:

  • dyspnea
  • extreme shortness of breath with activity
  • fatigues easily
  • extremities mildly cyanotic and cool to the touch, capillary refill sluggish
  • vs: bp 175/96, p 110, r 36, t 100.1, o2 87%

your nursing interventions will address these five defining characteristics or problems that the patient is having. here are two websites where you can get some information on the outcomes and nursing interventions for this particular diagnosis.

keep this information about goals and outcomes in mind:

outcomes are the predicted results of our independent nursing actions. independent nursing actions are those things that a nurse can prescribe, or order, for a patient that do not require a physician order. an expected outcome is measurable, patient centered, and specific. when you identify an outcome, you accept responsibility and accountability for helping the patient achieve that outcome.

goals are the predicted results of collaborative nursing actions. collaborative nursing actions are those things nurses can only do for patients with an order of a physician or another healthcare provider--things like administer medications or provide certain treatments, etc. goals may also be measurable, patient centered and specific. what differentiates a goal from an outcome is that the nurse cannot take full responsibility and accountability for helping the patient to achieve a goal. goals are achieved because of the collaborative management of many.

good luck with the care plan!

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