Can anyone help on care plan?


Hey! My first ICU rotation was the other day, and I was wondering if anyone could help me with some care plans. 72y M. End stage COPD tripped on home oxygen and fell, was on warfarin and had toxicity. Patient had hematoma that began to bleed. Patient was stable when I received him. OG tube, Central and peripheral IV. Hx of DM, COPD. Has vent set on CMV mode. Pt also has wound vac

1) AIRWAY... so would the best be Impaired spontaneous ventilation?

2) Risk for bleeding? I hate to do two risks.. but its a big deal though?

3) Risk for infection.. cath, IV, tubes.. etc wbc ^

Carrig RN

165 Posts

Specializes in ICU. Has 1 years experience.

For airway I would probably do impaired gas exchange r/t COPD. Also, why were they intubated? Mental status change, blood loss? Good things to know to ensure you're finding the right care plan. Risk for bleeding and risk for infection I agree with.

JustBeachyNurse, LPN

1 Article; 13,952 Posts

Specializes in Complex pedi to LTC/SA & now a manager. Has 13 years experience.

Thread moved to nursing student assistance forum

Esme12, ASN, BSN, RN

4 Articles; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience.

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.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

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

  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)

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 order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

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.

So tell me about your patient.......What do they need? What do they c/o? Did he have a surgical intervention/evacuation of the hematoma? What is your assessment......What does this tell me about the pateint?

End stage COPD tripped on home oxygen and fell, was on warfarin and had toxicity. Patient had hematoma that began to bleed. Patient was stable when I received him. OG tube, Central and peripheral IV. Hx of DM, COPD. Has vent set on CMV mode. Pt also has wound vac

rubato, ASN, RN

1,111 Posts

Specializes in Oncology/hematology.

Esme, great advice as always. Yes, medical diagnosis and nursing diagnosis aren't the same thing. In your post I can see a little bit of objective data but where's the subjective data?


643 Posts

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience.

If a pt is on vent, most of them are restrained. Is there a nursing diagnosis for pts who are restrainted?

So he's on a vent with an OG......meaning he's NPO. What nursing diagnoses can you apply for someone who is NPO? Any Ideas?

And if he's on a vent...then he's not getting getting out of bed. Anything come to mind? What happends to pt's who stay in bed

What happened at his home that caused him to come in?? He got the hematoma from what (wink, wink)? Wouldn't he be at risk for something in the hospital that also occured at home?

Does the history of diabates put him at risk for something?


44 Posts

I haven't done an ICU rotation... But I want to take a stab at this since I completed my first two care plans this past week.... So the patient is at risk for skin breakdown r/t pt immobility, at risk for nutritional deficit if they have NPO, they are at risk for infection (uti, gtube site)


643 Posts

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience.

Awe, man...


44 Posts

Only first semester of clinicals.... In due time.... Was I on the right track??

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

What were the patient's actual signs and symptoms that you (or, to be easy on ya, new girl :) ) the patient's nurse observed? Don't forget that info you get from the chart counts as observation data. Look at the ER admission form-- what did the patient/family tell the nurse or EMS? Observation and assessment first, diagnosis second, whether you are a physician looking for evidence of medical diagnosis to develop medical plan of care, or an RN looking for evidence of nursing diagnosis to develop nursing plan of care.

As to this patient-- on antocoagulant, fell at home, bled into retroperitoneum (you don't really get "toxic" from anticoagulants--but what happens if you have too much on board?).... does this suggest any questions you might ask him or his family about her meds, what she knows about them, what his medical followup has been for his meds or DM or COPD, what his home safety is like? Hmmmm? Three basic questions can give you a wealth of information about home safety when planning discharge: 1) Is there another healthy and responsible adult in the home? 2) Who shops and cooks? 3) How many steps to get in the front door?

Now, if you don't have the NANDA-I 2012-2014, which every nursing student should have and can get with free 2-day shipping from, get it right now even if your faculty forgot to put it on the bookstore list. It will have all the approved nsg diagnoses WITH defining characteristics, and when you start browsing through it you will suddenly realize what nursing all about. Really. I promise. I mean it. And for all you students who think you have a hard time justifying your nursing plans of care to your faculty, well, this will have your back in the most unassailable way. You can thank me later.

OP: Yes, you are on the right track...but don't limit yourself to the obvious. There is a lot more going on here.