Care plan help please

[Petite06]

I'm doing a concept map...Came in with Acute MI/CHF/Pneu. Hx of CAD,Prev MI,Prev PUD and PVD. Plus a smoker w/poor nutritional intake...diarrhea, ascites, pleural effusions, bilateral atelectasis and CRF of the L kidney and an excoriated wound.

SOme of my nursing diagnoses so far are

Impaired Gas Exchange/Oxygenation

Fluid Volume Excess

Imbalanced Nutrition: Less than body requirements

Impaired Skin Integrity

Impaired Tissue Integrity or Ineffective Protection (for the PUD)

Activity intolerance r/t uremia and anemia

What else am I missing? I've been at this a LONG time. Please help!!!!

Thanks so much!

[Daytonite, BSN, RN]

where are all your symptoms? the only ones you've listed are:

• poor nutritional intake
  
• diarrhea
  
• uremia
  
• an excoriated wound (where is it and what other assessment data do you have on it?)

i see no symptoms to support the nursing diagnoses of impaired gas exchange, excess fluid volume, impaired tissue integrity, ineffective protection and activity intolerance.

when you are doing a concept map you should have a list of abnormal assessment data under each of your nursing diagnoses that supports that diagnosis. i don't see you doing that here. the beginning point of all care planning is the collection of data. you have a great deal from the medical perspective (what the doctor's have to say), but what about from the nursing perspective? what about this person's ability to perform his adls? what did you determine about him from your own physical assessment? what did you hear in his lungs? did you look at his diet and eating history? what's going on with that wound? why is there a wound there, where ever it is? why hasn't it responded to treatment before?

you need to get more assessment data together. i understand that some of the nursing diagnoses you've listed have a connection to the medical problems of this patient, but unless you can provide the actual symptoms to support them you've lost the bridge to be able to use them. that, i think, is where your frustration is coming from. does that make sense to you?

if you have a care plan book you need to review the first chapter(s) on the nursing process, specifically on how to use assessment data to proceed to development of nursing diagnoses. concept mapping is designed to help you accomplish this. your concept map should be loaded with all kinds of patient symptoms that you got from your patient assessment. remember that a symptom is an objective observation that you make or a subjective perception of the patient.

at this point, if you are not likely to see this patient in clinical again, i would recommend that you look up the medical definition along with the signs and symptoms for the medical diagnoses you've got:

• acute mi
  
• chf
  
• pneumonia
  
• ascites
  
• pleural effusions
  
• bilateral atelectasis
  
• crf of the l kidney
  
• anemia
  
• hx of cad
  
• prev mi
  
• prev pud
  
• previous pvd
  
• smoker

perhaps you'll run across some symptoms that you'll realize this patient had that you missed noting and writing down in your actual physical assessment. correct that now. many of the symptoms of these medical diseases are going to help support those nursing diagnoses you want to use, but you have to get them down on paper first. here are some online sources you can use to help you find signs, symptoms, pathophysiology and medical treatment of many of these diseases (as well as any textbooks you have to help you out):

• family practice notebook http://www.fpnotebook.com/index.htm (use the search)
  
• emedicine http://www.emedicine.com/ (use the search. you may be asked to register, but it is free.)
  
• medline plus http://www.medlineplus.gov/ (use the search. written for the general public)

just some advice for you. when you are going through a patient's chart for information, don't just take down the medical diagnoses. read through the doctor's h&p and look for and copy down the symptoms that you will find scattered throughout the h&p. you should also glean through information in any consults the same way. these symptoms are good data that you can also use in formulating your nursing diagnoses. doctors do not have exclusive rights on the use of "signs" and "symptoms". we nurses can use them as well. you should also be taking down lab results, x-ray results, and the notations by dieticians, physical therapist and respiratory therapists in their notes as well. this is all valid assessment data that you can use. in the case of this patient, much of that data would have supported the nursing diagnoses you want to use.

[KellieNurse06]

How about Powerlessness r/t hospitalization, Hopelessness r/t illness, Depression r/t decline in health condition etc...stuff like that....