care plan help

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hi all

Between clinical, practice labs, lectures, work and kids home on school vacation it's been a tough week! I was assigned a 58 y/o F diagnosed with papillary thyroid CA. She had a total thyroidectomy and was discharged the day I was assigned to her. She had switched rooms so i made sure there was a trach and suction at bed side, HOB elevated, encouraged use of IS and applied ice to incision site.

VS WNL, steri strips OTA clean dry and intact. jp drained 10 ccs of sero sang. ionized Ca was low at 1.10 but neg trouseu and choveck's sign (excuse the spelling) no c/o numbness or tingling. Lung sounds clear, no c/o SOB. voice a bit raspy. she has a hx of anxiety and panick attacks and was nervous about going home with the jp. i got to teach her about caring for her incision site and JP and she felt better after demonstration. I'm not sure where to go from here and was hoping someone could lead me in the right direction with a priority nursing diagnosis.

Thanks a bunch

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you must follow the steps of the nursing process in writing a care plan:

  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)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

a care plan is based upon the patient's symptoms (abnormal data, nanda: defining characteristics) that you discovered during your assessment activity. the nursing diagnoses, goals and nursing interventions are all based upon those symptoms. from what you have posted this patient has the following symptoms:

  • incision clean dry and intact
  • drained 10 ccs of sero sang
  • ionized ca was low at 1.10
  • voice a bit raspy
  • nervous about going home with the jp

and i can get these diagnoses from that information:

  • impaired tissue integrity
  • anxiety
  • risk for injury r/t effects of hypocalcemia

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I went with anxiety r/t deficient knowledge of post op care as manifested by pts verbal statements of not knowing how to care for her incision/jp bulb after going home.

thank you kindly for responding :[anb]:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

as i told you in the pm you sent me, i don't believe that deficient knowledge is an appropriate etiology for anxiety. it is, in fact, a nursing diagnosis of it's own and i think you should just call it that: deficient knowledge of home wound care (or something similar to that because that is what your teaching did eventually focus on).

the definition of the diagnosis (the actual problem) of anxiety is: vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often non-specific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. it is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. (page 9, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international). this is one of the physiological nursing diagnoses and primarily deals with the patient's physiological symptoms to anxiety. if you look at the symptoms that nanda lists for this diagnosis, most of them are physical and can be observed.

the definition of the diagnosis of deficient knowledge is: absence or deficiency of cognitive information related to a specific topic. (page 130, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international). the defining characteristics (symptoms) of this diagnosis are listed by nanda as: exaggerated behaviors, inaccurate follow through of instruction, inaccurate performance of test, inappropriate behaviors, verbalization of the problem. didn't you say your patient verbalized concern of not knowing what to do at home? that's one of the symptoms of this diagnosis. anxiety about it could also be considered a symptom.

now, which one sounds like your patient's problem and the interventions you actual performed?

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Daytonite...you should consider teaching if you are not already a faculty.

you borke it down so well. most nursing schools expect care plans to consist nursing diagnosis, goal, intervention, rationale and evaluation prior to clinical day. thus we do our assessment after making our care plans. and I find a lot of times some of my interventions or goals are not appropriate for the patient and adjust accordingly.

hopefulfun, when you writing up your evaluation try to be as specific as possible. include times interventions were done and any d/c planning?

good luck

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Daytonite,

I agree with Alam,

You would be an excellent instructor.

I just got home from clinical today, and the funny thing is that this morning before going in, I re-read my diagnosis and decided it didn't make sense.

Amazing what a good night's sleep can do!

I ended up changing it to deficient knowledge r/t post-operative care as evidenced by pt verbalizing concerns of not knowing proper incision/JP care.

I handed it in today and moved on to the next one..

Ineffective breathing pattern related to decreased cardiac output as manifested by dyspnea on exertion.

anyway,

thanks for the advice, and the inspiration :nuke:

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