Care Plan Help please!!!

[Kacee890]

:hrnsmlys:I am a second year nursing student trying to write a careplan. I am really struggling with this one and any insight would be awesome! I had a client for clinicals last weekend that I need to do a careplan on. This was an elderly woman who got admitted to the med surg floor after a fall. She had a L wrist fx and a R wrist fx and also fractured left ribs. She was in bad shape. This client was dysphasic and very difficult to arrouse (lethargic). Vital Signs were stable upon arrival and decreased throughout the day. By the end of the say BP was extremely low along with pulse, output, ect. When I came onto the floor on Sunday the physician said the client would most likely not make it through the day. Renal Failure was occuring and vitals were rapidly decreasing. She was on 5L of 02 and stats were 94%. Lung sounds were diminished. There was little intake and even less output. Family was there at the bedside. I am supposed to write a care plan and I am having huge problems with diagnoses to fit this client. My first thought was Risk for Infection, however, this cannot be a priority diagnosis because it is a risk. Then I wanted to do Excess Fluid Volume however our NANDA books do not reccommend this diagnosis because it is more of a collaborative diagnosis. Impaired Comfort is not recognized by NANDA and cannot be used. IM STUCK!! I need a total of 3 diagnoses and 10 interventions with rationales for each and I do not even know where to begin. ANY input would be much appreciated...Thanks!!!!

[Daytonite, BSN, RN]

you can get out of jams like this by following the steps of the nursing process. keep in mind that books are references. a care plan you construct is a customized solution to the patients nursing problems. patients are unique and not textbooks examples.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - from your description of the situation it sounds like the patient is going into organ failure and will die. still, what you have to work with are these facts. you need to look up information about acute renal failure since some of the patient's symptoms probably match them. was this patient dysphasic before the fall or has she had a stroke and that is why she fell? complications of fractured ribs are a pneumothorax and pneumonia.

• patient fell
  
• has a left wrist fracture
  
• has a right wrist fracture
  
• fractured left ribs
  
• dysphasic
  
• going into renal failure
  
• treatments
  • 02 at 5l

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data – does looking at the list of abnormal data cause you to reconsider some of your nursing diagnosis choices? you were considering excess fluid volume. are there symptoms of that here? as this patient was becoming more lethargic and difficult to arouse, was any thought given to how basic needs of bathing, dressing, mobility, eating, toileting, and grooming would be accomplished? one of this patient's problems was dysphasia. how was this manifested?

• difficult to arouse (lethargic)
  
• vital signs decreased throughout the day - by the end of the say bp was extremely low along with pulse, output
  
• lung sounds were diminished
  
• little intake and even less output

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use – focus on the patient at the moment you had her and not what you know is her medical outcome. she has serious fractures that would be causing mobility problems as well as difficulty accomplishing her adls. how is she toileting--i assume she has a foley catheter. if she is getting more and more lethargic she in on bedrest which means almost everything needs to be done for her especially since she has two broken wrists. how is she turning? getting mouth care? not only that, but with the rib fractures and diminished breath sounds she is a case of pneumonia just waiting to happen.

• deficient fluid volume r/t renal organ failure aeb diminishing intake and output and decrease in vital signs, or imbalanced nutrition: less than body requirements r/t altered state of consciousness aeb diminished intake
  
• impaired physical mobility r/t skeletal impairment secondary to bilateral wrist fractures aeb [symptoms of limitations of movement]
  
• any of the self-care deficits
  
• impaired verbal communication r/t compromised circulation to the brain aeb [symptoms of dysphasia]
  
• risk for infection r/t traumatic rib injury [pneumonia]

[Valerie Salva, BSN, RN]

Pain control and comfort measures are important for this pt.

Also safety issues, since she fell already. Even though she is very lethargic, dying pts sometimes suprises staff by trying to get up and falling.

[gillytook]

How about

Decreased cardiac output

Impaired gas exchange

Ineffective breathing pattern

Anticipatory grieving (you are the nurse for the family as well as the patient)

Risk for impaired skin integrity

Ineffective tissue perfusion

Impaired spontaneous ventilation

[studentinnursing]

I don't want to hijack the post, but I'm also looking for care plan help, please, and OP may be able to help in second year; any help is greatly appreciated from anyone . . . I am trying to find pathophysiology for fracture; axial loading and disruption of bone is about as specific as my med-surg book gets (I'm just first semester but have that book already) and it doesn't go into anything at the cellular level; should I just wing it? Impaired nerve fibers? It's a vertebral compression fracture; the only posts I found on here are description of fractures or the etiology, not necessarily the pathophys of a fracture . . . I have to do my care plan too, but I first have to give etiology (which I have along with treatments and s/s) and pathophysiology, but I can't find substantial pathophysiology. Any input is appreciated. Thanks!

[studentinnursing]

LOL. I think I will hijack it, just saw this is from 2008!!