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Care Plan help Please

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by trudreamer_88 trudreamer_88 (New) New

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I need some help coming up with a 3rd Dx for my pt. The 2 I have completed so far were

Risk for decreased cardiac output and Risk for injury. I can't come up with a 3rd for the life of me.

Here is ALL the pt info I have written on my pt research sheet. I wish I had more but I did exactly as my instructor asked which turns out to not be enough.

86 yr old female; Self care

Current dx: nose bleed, rapid atrial fibrillation

PMH: stroke, bilateral cataracts, atrial fibrillation/flutter, hypertenstion, diabetes, hypercholesterolemia, osteoarthritis, lymphedema, breast cancer, colon cancer

PSH: catract sx, colectomy, partial thyroidectomy, carotid endarterectomy, hysterectomy, joint replacement, R. mastectomy, R hand ORIF due to fx

Social hx: lives with family, no illicit drugs, tobacco or alcohol abuse

Labs: RBC (4.51) Hgb (13.3) Hct (40.1) WBC (5.9) Lymphs (39.9) PTT (112.8) PT (11.3) INR (1.0) Glu (131 H) BUN (13) Creat (0.9) eGFR (74) Na (139) K (3.6) Cl (104) CO2 (28) Mg (1.6 L) Ca (9.2) CK-MB (0.6) Troponin I (

Vital Signs 8am: T: 97.6 BP 153/67 Resp: 20 SPO2: 94 on room air Pulse: 70 Pain: 7/10 (L shoulder from old fx)

Vital Signs 11am: T: 97.2 BP 121/56 Resp: 20 SPO2: 97 on room air Pulse: 68 Pain: 7/10 (L shoulder from old fx)

Diet: Cardiac soft

Meds: Insuling Lispro Humalog, Pantoprazole (protonix), Pravastatin Sodium (pravachol), Saxagliptin HCL (Betapace), Diltiazem (Cardizem) Drip, Robitussin, Heparin Sodium Drip, Morphine Sulfate

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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Why risk for injury? Why not chronic pain (7/10 L shoulder)? Many nursing interventions to increase comfort and reduce pain (repositioning, support, massage, guided imagery).

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Can I do pain? The pain is from an old injury and not related to why she was admitted to the hospital. I did risk for injury because she was on a Heparin drip and the nurse kept telling her to stay and bed they didn't want her to fall.

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Rose_Queen is a BSN, MSN, RN and specializes in OR, education.

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The thing about nursing care plans is that you don't try to make the patient fit the diagnoses and plan; you use your patient assessment data to create plans. If the pain is important to the patient, then it is important regardless of whether it's the admitting reason or not.

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CT Pixie has 10 years experience as a BSN, RN.

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Your care plan is based off abnormal findings regardless of whether or not they pertain to the reason they are admitted.

The best thing to do is highlight all abnormal findings and base your care plan(s) from the abnormal assessments.

How did her lungs sound? Her heart? Is she on tele--whats the rhythm. Is it a-fib..then right there you have a dx. and its not a risk for it IS a problem. Does she get SOB with exertion? Were you allowed to do an assessment of the patient or are you to do a care plan based on the current dx, PMH and PSH and labs? If you were able to do an assessment, what did you find on your assessment of the patient? Does she have any problems doing basic ADL's such as dressing, etc? Whats her gait like?

I was always taught actual problems before 'risk for'.

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4 Posts; 571 Profile Views

The thing about nursing care plans is that you don't try to make the patient fit the diagnoses and plan; you use your patient assessment data to create plans. If the pain is important to the patient, then it is important regardless of whether it's the admitting reason or not.

Thanks that helps. Cause she talked about the pain a few times while I was in there. I kept skipping over it as a possible dx because it wasn't why she was admitted so I figured I wasn't allowed to use it.

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4 Posts; 571 Profile Views

Your care plan is based off abnormal findings regardless of whether or not they pertain to the reason they are admitted.

The best thing to do is highlight all abnormal findings and base your care plan(s) from the abnormal assessments.

How did her lungs sound? Her heart? Is she on tele--whats the rhythm. Is it a-fib..then right there you have a dx. and its not a risk for it IS a problem. Does she get SOB with exertion? Were you allowed to do an assessment of the patient or are you to do a care plan based on the current dx, PMH and PSH and labs? If you were able to do an assessment, what did you find on your assessment of the patient? Does she have any problems doing basic ADL's such as dressing, etc? Whats her gait like?

I was always taught actual problems before 'risk for'.

Unfortunately it was our first day on the floor for this Semester so we were not able to do out own assessments this time. We were only allowed to do AM care and vital signs. She needed help getting out of bed and into a chair, but she was self care. She cleaned herself up without any problems. Because it was only a few steps from bed to chair the only thing i noticed is she was a little slow at moving. She didn't get SOB moving from bed to chair and back. She was on tele but the monitor wasn't in her room it was the portable one people in a room watch.

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CT Pixie has 10 years experience as a BSN, RN.

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Here blood glucose is high from the labs and she's got DM and insulin meds. You could do something on that. I can't remember off hand but there is a DX that pertains to high glucose levels. (I stupidly let a friend borrow my NANDA books and haven't seen them since.)

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LadyFree28 has 10 years experience as a BSN, RN and specializes in Pediatrics, Rehab, Trauma.

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Unfortunately it was our first day on the floor for this Semester so we were not able to do out own assessments this time. We were only allowed to do AM care and vital signs. She needed help getting out of bed and into a chair, but she was self care. She cleaned herself up without any problems. Because it was only a few steps from bed to chair the only thing i noticed is she was a little slow at moving. She didn't get SOB moving from bed to chair and back. She was on tele but the monitor wasn't in her room it was the portable one people in a room watch.

Even with ADLs and VS you can still "assess" a pt, as you have done so.

She has other diagnoses, especially with what you just explained by her moving from the bed to the chair.

What else can you tell us about the patient?

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Can I do pain? The pain is from an old injury and not related to why she was admitted to the hospital. I did risk for injury because she was on a Heparin drip and the nurse kept telling her to stay and bed they didn't want her to fall.

You are falling into the familiar student trap of trying to make your nursing diagnosis based on the medical diagnosis. You don't "do" or "choose" a nursing diagnosis, you MAKE a nursing diagnosis based on your own assessment of the person in front of you (and from the data you find in the chart and from report). You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Now, as to your specific question. Looking at "Risk for Injury," I don't see

"I did risk for injury because ... the nurse kept telling her to stay and bed they didn't want her to fall."
in the risk factors. (For risk diagnoses, you don't have defining characteristics, you have risk factors). I do, however, see things like alteration in cognitive and psychomotor functioning, and abnormal blood profile (which is what heparin is designed to do, no?) So, if she has any of those (and other than the heparin, I don't know if she does, but you might-- you should!) then what is nursing gonna do about them?

 

If she has shoulder pain, it doesn't matter if she's been admitted for, oh, anything else. You can make a diagnosis of Pain if, well, she has pain. And then you can see what nursing can do about it-- that's how you make a nursing diagnosis and what you do after it: you decide what to do about it. You develop a nursing plan for her care.

 

A nursing plan of care, just as a physician develops a medical plan of care based on data leading to a medical diagnosis. Yes, you do. Really. That's what it's all about, that's why you're in nursing school.

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I was always taught actual problems before 'risk for'.

A common but dangerous (yes, really) misconception. If you look at the NANDA-I 2015-2017 (and indeed, all previous editions) you will find a whole section devoted to safety-related diagnoses. Almost all of them are "risk for" diagnoses, and why are patients in our care if not to keep them safe? Patients at risk for bad things are at risk for bad things, not to belabor the obvious. These could well be the priorities in their care. Look at that statement, think about it.

 

Ameliorating or preventing things for which the patient can be at risk can very well be the priorities in their care.

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2 Articles; 11,114 Posts; 14,567 Profile Views

Unfortunately it was our first day on the floor for this Semester so we were not able to do out own assessments this time. We were only allowed to do AM care and vital signs. She needed help getting out of bed and into a chair, but she was self care. She cleaned herself up without any problems. Because it was only a few steps from bed to chair the only thing i noticed is she was a little slow at moving. She didn't get SOB moving from bed to chair and back. She was on tele but the monitor wasn't in her room it was the portable one people in a room watch.

Ummm, guess what? You absolutely did some assessing here. You saw she needed help with mobility, you saw she didn't get SOB doing it, you noted she had pain ("She mentioned it several times") and though you don't say so here you probably formed some opinions about her ability to hear, see, express herself, and understand. :anpom:

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