Care Plan help needed!

[NewNurse91D]

Hi guys!

I'm second semester nursing student and am getting my first 'real' care plan ready to turn in Monday.

I had a really good pt. to do my care plan on, but I'm just really lost when it comes to getting my nursing d/x together. We have to have 2 priority diagnoses, with 3 intervention each.

My pt. is late 70's who came in with an acute gout attack, L arm and leg swelling and extreme pain. She has CAD, hypertension, pneumonia and an asymptomatic UTI right now. she has h/x of hyperlipidemia as well.

She had an O2 stat around 95% on RA, BP is a little high, but her other VS were WNL.

She also has an ileostomy bag, but her skin and it is in great condition.

Her chest x-ray was for "follow up pneumonia" and revealed "adjacent atelectasis, cardiac silhouette enlarged, tortuous aorta with calcifications, background of interstitial disease". She also has a h/x of Rheumatoid Aarthritis which affects her mobility. Her H&H were both decreased, WBC increased, RBC decreased, BUN/cret increased. Her elec were all within normal limits.

She had diminished lung sounds in bases and some edema in LUE and LLE.

I guess where I need help is:

1.My nursing d/x. I have 2 that I've come up with and are listed by priority:

Impaired Tissue Perfusion

Impaired physical mobility

2. I am not sure how I want to/what diagnosis to choose to address the pneumonia and CAD. I was thinking impaired tissue perfusion BECAUSE of the atelectasis, and background of interstitial disease found on the x-ray; and because with the CAD-her perfusion capabilities are diminished, right?

Am I on the right track?

I put the impaired physical mobility as my second one because I feel like all of her health issues/conditions affect her mobility and because her mobility is something that I can set measureable outcomes for and have multiple interventions.

BUt again, I really have no idea what im doing!

3. Im trying to figure out WHY her lab values are they way they are. Esp the BUN/Cret and the H&H. Im just very curious and cant seem to connect the pieces.

I would reallllllllly appreciate some help here, im feeling like im not seeing something or addressing something I need to address. Thanks!

[NewNurse91D]

Very true, so im going to keep my priority d/x as impaired breathing pattern. Is it impaired or ineffective breathing pattern? My reference book says ineffective.

and then have my second one as chronic pain? or should it be acute? Because her admitting d/x is an acute issue BUT with her RA-she will have chronic pain. But im thinking that it should be acute pain because the care plan is for NOW and whats going on NOW.

[StudentOfHealing]

OP ... so happy you problem solved this on your own. I gave you huge hints at the beginning but I didn't want to flat out tell you.

So you understand the gout and arthritis is probably causing ineffective breathing patterns leading to atelectasis. You understand she's primarily immobile due to pain. So you understand that all this goes back to pain. So think about pharmacological and non pharmacological ways to treat it.

Some professors will say only think of non-pharm because you're a nurse and can't prescribe but in the real world you wanna know what to ask for for your patient. But to follow the rules I'd just go with standard "pain killers as ordered by MD"

Hint Hint... This lady needs some allopurinol ... she needs some NSAIDs and she better drink a lot of water ... she's immobile AND has gout? This lady is at risk for kidney stones due to bone dimineralization secondary to immobility and high uric acid levels secondary to gout.

[NewNurse91D]

thank you very much =] im working on my interventions and stuff now.

so here is what I got:

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[TD]#1 Priority Nursing Diagnosis: Ineffective Breathing Pattern

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[TD]Related to: Alterations in depth of breathing, decreased vital capacity, dyspnea and respiratory muscle fatigue; and severe acute pain secondary to medical d/x gout and RA.

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[TD]As evidenced by:

Subjective data: Pt. c/o SOB, fatigue and pain. Pt. stated, “My chest [pointed to sternum] hurts when I take in a breath” Pt’s also stated, that when attempting to move around or ambulate (with assistance of staff), she gets extremely SOB and fatigued, so she has been using the w/c instead of her r/w.

Objective Data: Diminished lung sounds bilaterally in the bases with faint crackles in the L upper lobe. Pt. exhibited use of accessory muscles, nasal flaring and dyspnea. Pt’s depth of breathing was shallow and she had a slightly fast respiration rate at 24 (ranged from 20-24 throughout the day). Abnormal CHR (chest x-ray), done on 09/29, revealed “adjacent atelectasis and background of interstitial disease”.

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[TD]#2 Priority Nursing Diagnosis: Acute Pain

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[TD]Related to: Musculoskeletal factors. Pain primarily located in pt’s LUE/LLE extremities, secondary to medical diagnosis of GOUT. Joint pain and ROM impairment; secondary to medical diagnosis of RA.

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[TD]As evidenced by:

Subjective data: Pt. c/o “severe pain” in LUE and LLE which is “stopping me from moving and walking like I was before this [recent gout attack]”. Pt. also says that swelling and pain has been preventing her from completing her everyday ADL’s “like going to the bathroom, bathing and getting dressed”; along with using my walker. Pt. c/o of inflammation and chronic pain in her joints (“mostly hands, knees and back”) which limits what she has been able to physically do. Pt. c/o of pain near her sternum when taking in a breath. Pt. stated her pain level is at

Objective data: Pt’s functional mobility scale is at a 3, ROM is very limited, pt. exhibits postural instability when attempting to perform ADL’s (change gown, change sitting position), pt. will guard or stop activity and rub area when shifting positions while sitting, brushing hair or standing up for a moment. Facial grimacing noted when pt. was moving for lying down to sitting up.

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[ianguitarist]

Wrong way to solve the problem, get a Careplan book and you will permanently know from here on out. Next if you can get an old Manual of Nursing Practice that would help. If you need to work at clinical, get a small pathophysiology book. about 100 dollars all together.