Care plan advice

Here.I.Stand, BSN, RN · Jan 20, 2014

What assessments have you made? Related nursing diagnoses? Those will drive your care plan. Tell us what you've come up with so far.

Jenngirl34RN · Jan 21, 2014

It can be tough doing care plans off of fictitious scenarios with limited info instead of on real patients, but if I were you I would start with his vitals you have listed. See if you can come with any diagnoses from there. Next, think about what happened to him- a neck injury resulting in paralysis. What are the physical and emotional problems this man may have because of that? How could his injuries relate to his high pulse, respiration, and BP and low sats? As you think about each piece of information you have go through your nursing diagnosis book and see what you can find.

Just remember that you need to find diagnoses that fit your patient instead of trying to make your patient fit a diagnosis, if that makes sense.

nurseprnRN, BSN, RN · Jan 21, 2014

Nursing diagnosis comes from nursing assessment. I realize this patient is fictitious and you can't actually examine him and question him, but before you start, do a good bit of reading on spinal cord injury and learn what the major nursing needs are for someone with a cervical spine injury. Then imagine your nursing care from there-- you are not developing a medical plan of care, but a nursing plan of care that is complementary to the medical plan of care but is not dependent on it.

Esme12, ASN, BSN, RN · Jan 21, 2014

I am a student nurse and i am now learning how to formulate a nursing care plan using the 5 nursing process. I was given a scenario of a 55 yr old male, who was in a road traffic accident and sustained a neck injury, he was admitted with a neck brace and is diagnosed as being paralyzed from the neck down. His T 36 P120 R 24 Bp 170/100 sat 90%. Can I get some advice on how to go about doing the plan of care for this pt.

Check out these threads.....

https://allnurses.com/nursing-student-assistance/case-study-care-807925.html

https://allnurses.com/nursing-student-assistance/student-resources-nursing-424826.html

https://allnurses.com/nursing-student-assistance/care-plan-help-899917.html

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

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)
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)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
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 patient......in 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.

Esme12, ASN, BSN, RN · Jan 21, 2014

I am a student nurse and i am now learning how to formulate a nursing care plan using the 5 nursing process. I was given a scenario of a 55 yr old male, who was in a road traffic accident and sustained a neck injury, he was admitted with a neck brace and is diagnosed as being paralyzed from the neck down. His T 36 P120 R 24 Bp 170/100 sat 90%. Can I get some advice on how to go about doing the plan of care for this pt.

Now looking at this ...is this all the instructor gave you? Did he/she give you what level of the C-spine? any lab work? any patient statements? any meds? does this patient have a foley? How old is the injury?

first know C-spine injury....The Vertebrae are grouped into sections. The higher the injury on the spinal cord, the more dysfunction can occur. Levels of Injury - Understanding Spinal Cord Injury

High-Cervical Nerves (C1 – C4)
Most severe of the spinal cord injury levels
Paralysis in arms, hands, trunk and legs
Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements.
Ability to speak is sometimes impaired or reduced.
When all four limbs are affected, this is called tetraplegia or quadriplegia.
Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting in or out of bed
May be able to use powered wheelchairs with special controls to move around on their own
Will not be able to drive a car on their own
Requires 24-hour-a-day personal care
Low-Cervical Nerves (C5 – C8)
Corresponding nerves control arms and hands.
A person with this level of injury may be able to breathe on their own and speak normally.
C5 injury
Person can raise his or her arms and bend elbows.
Likely to have some or total paralysis of wrists, hands, trunk and legs
Can speak and use diaphragm, but breathing will be weakened
Will need assistance with most activities of daily living, but once in a power wheelchair, can move from one place to another independently
[*]C6 injury
Nerves affect wrist extension.
Paralysis in hands, trunk and legs, typically
Should be able to bend wrists back
Can speak and use diaphragm, but breathing will be weakened
Can move in and out of wheelchair and bed with assistive equipment
May also be able to drive an adapted vehicle
Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
[*]C7 injury
Nerves control elbow extension and some finger extension.
Most can straighten their arm and have normal movement of their shoulders.
Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
May also be able to drive an adapted vehicle
Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
[*]C8 injury
Nerves control some hand movement.
Should be able to grasp and release objects
Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
May also be able to drive an adapted vehicle
Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Nursing care of the patient.....Clinical Guidelines (Nursing) : Spinal Cord Injury (Acute Management)

There is one MAJOR issues with these patient with high spinal injuries....What would that be? I'll give you a lead....autonomic Dysreflexia. What is this? What do you do?

T 36 P120 R 24 Bp 170/100 sat 90%.

Do these vital signs indicate anything?

lwhatley · Jan 21, 2014

Like a lot of other people are posting on this thread, fictitious pt scenarios make it really difficult to really get GOOD practice creating care plans, but they aren't impossible...my advice is to break it down.

Again, a repeat of previous opinions, but nursing dx's come from a different world than medical dx, and it's important to keep that in mind, because the EASIEST mistake is to list a bunch of medical dx's in the wording of nursing dx.

So in relation to your scenario, since you can't talk with this pt, focus on the possibilities, brain storm, brain dump, then prioritize:

"55 yr old male, who was in a road traffic accident and sustained a neck injury, he was admitted with a neck brace and is diagnosed as being paralyzed from the neck down. His T 36 (((P120 R 24 Bp 170/100 sat 90%.))))"

Alright, we've bolded areas that, as a nurse, we'll likely target throughout the course of our treatment of this patient...in our own words: We've got a middle aged man (demographic), hospitalized (stressor) that was just in a traumatic accident (stressor) that left him paralyzed (stressor), and the most recent vitals that we know have abnormalities that need to be addressed (go back to this basics, this is a stressor, but because they relate directly to ABC's, they'll be our priority)

Just with that info we've got enough data to allow us to at least visualize a potential encounter with this patient as a nurse. Our nursing assessment will likely find psychological stressors, physiological stressors, and priorities of care related to both psychosocial and physiological needs, and that's without even trying to take the (incorrect) easy way out of JUST medical dx needs...

For example, (remember, think like a nurse):

A middle aged man is just now being told he no longer has the use of his extremities (we don't know how severe it is, but we know based on the given dx ((which was worded completely incorrectly btw, but I'm not here for that)), he's paralyzed neck down. What implications does this type of data have both to the patient, and the care that we'll give?

- He's 55, he's probably still working in a career, supporting himself or possibly a family. Will being paralyzed effect his ability to do so in the future? (Anxiety? Depression? Isolation? Role Confusion?...)

-He's gone 55 years NOT being paralyzed, think this major loss of abilities will impact his self identity? His ability to accomplish basic ADL's and self care? How will you address that?

- He was in a traumatic car accident, think this issue has to be addressed? PTSD? Anxiety?

- Any education/knowledge we might need to give to this patient related to these issues? There are nursing dx's about this...

-He's hospitalized. Just that factor alone is a stressor based on numerous reasons: lack of privacy, sleep disturbance, etc. Address that. It's important.

He's in a neck brace following an accident that injured him so severely that he's paralyzed.

- Given this information, is this patient, with traumatic injuries, still at risk for injury?

- Any education that he might need related to these issues?

I'm leaving the physiological stressors that will be your priority up to you to break down the way I broke down these topics above...physiologic priorities such as abnormal vital signs are easy to find nursing dx's that relate to them, but be sure to cover all your bases. Hint: what does each finding mean for the whole body system? Be able to back up your diagnosis with facts of why it is so important that you define your plan of care with its prioritization....A patient isn't going to be doing much else if he's not breathing, or correctly using the O2 from breathing in his body...

Also, be careful, keep this scenario FULL PICTURE when you're assessing it. A vital sign MAY be abnormal, but is this abnormality expected or unexpected? Should we prioritize correcting an abnormal finding that is expected? (This is where reading up on spinal cord injuries will help you greatly hint hint hint hint hiiiiinnnt)

Hope this helps, and I'm sorry it's long winded, my initial intention was to actually make it quick...I'm really bad at making things quick...