Care plan help!

Nursing diagnoses, believe it or not, are based upon evidence/signs and symptoms that the patient must have or else you can't say that the patient has that diagnosis. a doctor can't ethically say someone has pneumonia or cancer unless they have evidence to support it or we would call that doctor a quack. what would we say about a nurse who says someone has a nursing problem (that is what a nursing diagnosis is) but no evidence to prove it? even police detectives look for evidence before they make an arrest. a good car mechanic will open the hood of your car and inspect it before he starts ripping the insides of your car apart. inspection! that is the operative word here. we know it as assessment. we do an assessment of the patient to find out what is not right with them. it is how we find signs and symptoms (nanda, the north american nursing diagnosis association calls them defining characteristics). we can't assume that patients are going to give us a list of them. we are taught the nursing process which consists of 5 steps that start with assessment. for care planning the nursing process is used in his way:

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)
   • a physical assessment of the patient
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

  always sequence actual nursing problems before potential (risk for) or anticipated problems

  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
  • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs

planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  • improve the problem or remedy/cure it
  • stabilize it
  • support its deterioration

  how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

  interventions are of four types

  assess/monitor/evaluate/observe (to evaluate the patient's condition)

  • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

  care/perform/provide/assist (performing actual patient care)

  teach/educate/instruct/supervise (educating patient or caregiver)

  manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

  implementation (initiate the care plan)

evaluation (determine if goals/outcomes have been met)

whether you have or haven't seen this patient yet, there is information here to work with. assessment is ongoing. you can always adjust your patient problems based on new information that you come across.

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 - the first thing you need to do is look up information about these three conditions, their signs and symptoms, complications and expected medical treatments (especially if the patient is hospitalized for them)

• ms (paraplegia is a consequence of the ms)
• pneumonia (a probable complication of the ms)
• uti (a probable complication of the ms)

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• ms
  • muscle weakness and fatigue
  • spasticity and hyperreflexia
  • intention tremors
  • paraplegia
  • eye and visual problems
  • speech problems
  • chronic urinary retention
  • emotional lability
  • complications
    • uti
    • constipation
    • contractures
    • pressure ulcers
    • depression
    • pneumonia

  pneumonia

  • fever and chills
  • sputum production, sometimes a lot, could be purulent
  • crackles. wheezing or rhonchi in the lungs
  • diminished breath sounds
  • using accessory muscles to breath
  • rapid respirations
  • chest pain
  • cough
  • complications
    • could go septic
    • hypoxemia
    • meningitis
    • pleural effusion

  uti

  • frequency
  • hematuria
  • fever and chills
  • malaise
  • nausea and vomiting
  • cloudy, foul smelling urine
  • bladder spasms
  • lower back or flank pain
  • complications
    • infection of adjacent organs
    • sepsis

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 - these utilize the symptoms above. every nursing diagnosis has a definition and defining characteristics and assigning it is based upon the patient having those defining characteristics (signs and symptoms). these are the problems i would diagnose knowing nothing else, but the medical diagnoses:

• ineffective airway clearance r/t retained secretions and neuromuscular impairment aeb adventitious lung sounds, diminished breath sounds, cough, excessive sputum production, and difficulty coughing (physiological need for oxygen)
• ineffective breathing pattern r/t hypoventilation and neuromuscular impairment aeb rapid respirations and using accessory muscles to breath (physiological need to breathe)
• impaired urinary elimination r/t neural impairment and inflammation of urinary bladder aeb cloudy, foul smelling urine and chronic urinary retention (physiological need for elimination)
• hyperthermia r/t inflammation in lungs and urinary bladder aeb elevated body temperature, chills and rapid respirations (physiological need to control body temperature)
• impaired sensory perception, visual r/t neural impairment aeb disturbances with vision (physiological need to move within the environment)
• impaired verbal communication r/t neuromuscular impairment aeb difficulty speaking (safety need)
• risk for infection r/t chronic diseased state (anticipated need for protection from physiological threat)
• risk for impaired skin integrity r/t immobilization (anticipated need for protection from physical harm)

but he's also at risk for aspiration because of a peg tube for nutrition and meds.

impaired bed mobility

this diagnosis is used for patients who are on bed rest and do have some mobility to move around in the bed but need assistance to do so. it's definition is

disturbed: kinesthetic (ability to perceive movement), tactile (touch), sensory perception

i'm not sure that these apply to this patient.

imbalanced nutrition: less than body requirements r/t peg tube and immobility.

if the patient has a peg tube, then aren't they getting adequate nutrition? how does immobility cause an insufficient intake of food? the reason the peg tube was inserted was so the patient could be given adequate nutrition. the patient can be given an occasional coke through the tube. a cookie can be mixed with milk and put into the peg tube. yes, it can.

we only have to have 3 so what do i do??

they are sequenced in order of priority. use maslow's hierarchy of needs to sequence (

what do i do when he has more than one respiratory diagnosis???!!!

certain ones get sequenced first.

step #3 planning (write measurable goals/outcomes and nursing interventions) - now you can start to write out some nursing interventions based on the defining characteristics that support the nursing diagnoses.