Care Plan Guidance

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Hey guys first care plan for the semester and I would just like some feedback to know if I'm on the right track.....

47 year old female admitted on 12/1/12 at 6:10 pm with a history of PV bleeding and abominal pain x 7/52. PMHx - DM, HTN, uterine fibroids. PSHx - C-Section in 1988 & D & C in 2011. Allergies - NKDA. Vital signs on admission T- 36.5, P- 102 bpm, R- 20 bpm, B/P - 171/98 mm/Hg, SpO2 97% on room air, Blood glucose - 157 mg/dL. Diagnosed as septic shock secondary to endometriosis.

Additional Information:

It was given over from the night staff that she had temperature spikes throughout the night 37.5, 38 and 40 degrees celsius. Also that she fell from her bed while sitting and awaiting a bedpan because she was too dizzy to go to the bathroom. Brain CT was done no abnormalities noted but patient obtained a lump to the forehead.

My Assessment of patient:

Patient alert and oriented to time, place and person.

Patient verbalized she had difficulty breathing. Respiration fast and shallow at a rate of 24 bpm on O2 5 L/min via face mask.

Pulse regular, fast and bouncing at a rate of 98 bpm ; B/P - 148/ 78 mm/Hg

IV cannula insitu at left brachial artery with no redness or swelling observed at site.

Patient stated she felt nauseated and did not eat a sufficient amount of breakfast even though she was hungry.

Urinary catheter insitu.

Mild bleeding bright red in color with a large oblong blood clot noted in incontinent pad.

Last recorded temperature 36.8 degrees Celsius.

Patient observed to be in pain which was verbalized. Other signs included facial grimacing, groaning and massaging and guarding of lower abdomen.

Patient's severity of pain was assessed using the numeric pain scale. On a scale of 1 - 10 (1 being no pain and 10 being severe pain) patient verbalized severity as 9.

Abnormal Lab Results:

WBC - 18.6 K/uL

RBC - 3.93 m/uL

HBG - 7.09 g/dL

HCT - 23.1 %

These are the nursing diagnoses (actual and potential) I am thinking of using:

Ineffective breathing pattern R/T pain AEB verbalization and respiratory rate of 24 bpm.

Acute pain R/T bleeding of misplaced endometrial tissue AEB patient's verbalization, facial grimacing, groaning and guarding behavior.

Risk for infection R/T insertion of urinary catheter.

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If the patient's sat was 97 percent on room air at time of admission, why was she on five liters of oxygen via face mask? I understand that she felt short of breath, and was tachypneic, but if her sat was 97 on RA, then I don't feel that five liters via face mask was warranted. Maybe some supplemental oxygen via nasal cannula would have been beneficial, but five liters via face mask? That's just my opinion, and there could have been other issues at work here that I'm not aware of, so I won't say anything else about that.

With that being said, I don't really think ineffective breathing pattern r/t pain works in this situation. With that diagnosis, you would expect to see the patient taking shallow slow breaths, and you would expect them to (possibly) be bardypneic. If it hurts to breathe, then you certainly aren't going to breathe deeply, and you may try to breathe as few times per minute as you possibly can. Since sepsis can cause tachypnea, I would attribute the respiratory rate more to the sepsis than to pain. If it were me, I would say something like ineffective breathing pattern r/t infectious process secondary to sepsis AEB respiratory rate of 24, patient complaints of difficulty breathing, and fast and shallow respirations noted on assessment.

The acute pain diagnosis is okay, I think. Your as evidenced by section in this nursing diagnosis is good, and you tied in the things you noted on assessment really well with this diagnosis. Good job!

As for risk for infection, the foley isn't the only thing that is increasing this patient's risk for infection. She is also at a risk for infection due to her IV line, her compromised immune system secondary to sepsis, and the hospitalization itself. If I were you, I would write something like risk for infection r/t foley catheter, IV line, hospital admission, and compromised immune system secondary to sepsis.

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Ok. I see what you're saying with my first diagnosis. I will reassess my patient again tomorrow and see what else has been done over the weekend for her concerning that aspect and I understand what other factors I left out for my risk diagnosis.... Thanks a lot

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

first i don't think the iv is in her artery......i am sure it is in the vein. the term in situ is used at your school to mean iv intact and patient with out signs of infiltration or infection as well as the foley? it seems awkward here. why the o2 per mask at 5 liter unless she was hyperventilating from anxiety therefore like breathing in a paper bag. is she safe?nursing care plan for risk for falls, decreased mobility what was her sugar when she fell? did anyone do orthostatic vital signs? b/p lying sitting and standing? ( orthostatic hypotension - wikipedia, the free encyclopedia) think maslow's....maslows-hierarchy-of-needs.jpg

now think about what endometriosis is and what you should look for, she fell, http://www.pterrywave.com/nursing/care plans/94.aspx, think of safety. look at her labs her h&h is low....think anemia. is she short of breath from primary respiratory difficulties? or from pain or fever.....anxiety.

http://www.mentalhealthcaring.com/2009/06/nanda-nursing-diagnosis-for-acute-pain.

how to use anxiety nanda nursing diagnosis

complications for endometriosis

primary complication

infertility.

other complications

  • spontaneous abortion,
  • anemia due to excessive bleeding.
  • emotional problems resulting from infertility.

nursing assessment nursing care plans for endometriosis

  • patient history elicit a complete history of the woman's menstrual, obstetric, sexual, and contraceptive practices
  • the patient may complain of cyclic pelvic pain, infertility and, the classic symptom, acquired dysmenorrhea.
  • the patient typically reports pain in the lower abdomen, lady parts, posterior pelvis, and back. this pain usually begins from 5 to 7 days before menses, reaches a peak, and lasts for 2 to 3 days.
  • patient may complain of deep-thrust dyspareunia (ovaries and cul-de-sac);
  • suprapubic pain, dysuria, and hematuria
  • painful defecation, rectal bleeding with menses, and pain in the coccyx or sacrum
  • nausea and vomiting that worsen before menses and abdominal cramps
  • palpation may disclose multiple tender nodules on uterosacral ligaments or in the rectolady partsl septum.
  • palpation may also uncover ovarian enlargement in the presence of endometrial cysts on the ovaries or thickened, nodular adnexa

[color=#006699]nursing diagnosis nursing care plans for endometriosis

primary nursing diagnosis nursing care plans for endometriosis

pain, chronic, related to cramping, internal bleeding, swelling, and inflammation during the menstrual cycle

common nursing diagnosis found on nursing care plans for endometriosis:

nursing diagnosis for female reproductive diseases/disorders | nursing crib

nursing care plan

i hope this helps....:)

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she has a rapid pulse because she has pain and a fever, true, but if she has sepsis she may also have vasodilation from that (and from the fever) and the higher hr may be what's helping maintain her bp. i'd watch carefully for decreases in bp (with all that implies/involves), because if sepsis gets bad enough the compensatory mechanisms to keep bp up (which are...?) start to fail. supplemental oxygen can help if decreased tissue oxygenation develops-- follow spo2 measures.

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Also, as Esme12 said, the IV line was probably in a vein. While it is not unusual for a patient to have an arterial line when they are septic, the line is usually in the radial or ulnar artery, and it is hooked to the cardiac monitor so that arterial BP trends can be monitored. At this point, the patient is usually in MICU or another critical care unit. I'm not sure about using insitu to describe IV site and placement, nor do I like it to describe a foley. There is so much more you need to assess for. Were there signs of infection at the IV site? Where there signs of infiltration? What gauge was the IV? The same line of questioning can be applied to the foley. What size was the foley? Was there urine output in the bag, and, if so, how much? What color was the urine? Did the insertion site appear infected, irritated, etc? Had catheter care been done recently?

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"in situ" (two words) is latin and just means, "in place." that's it. more accurate to say, "iv in left hand (or whatever)." you could say, "in situ in left hand," but that would be redundant. sort of like saying, "atm machine," when "atm" stands for "automatic teller machine," or, another personal peeve, "with au jus," when "au jus" is french and means "with juice."

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

The tachycardia can also be a volume issue and SOB with a Hct of 7.0.

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