Care plan help!

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I'm on my first set of care plans i have due in nursing school. I feel really unprepared and like i don't have enough instruction from my teachers. My patient is admitted to hospital for UTI but is paraplegic r/t MS and also has pneumonia. Here's the nursing diagnoses i can think of.

BOTH Ineffective Breathing Pattern AND

Ineffective Airway Clearance.

But he's also at Risk for Aspiration because of a PEG tube for nutrition and meds.

Impaired bed mobility

Distrubed: Kinesthetic, tactile, sensory perception

Imbalanced Nutrition: Less than body requirements r/t peg tube and immobility.

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

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

Thank you so so much for any help!

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

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.

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.

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.

your logic is faulty. he is at at risk for aspiration if he is being fed oral food and fluids and has difficulty swallowing not because he has a peg tube. look further for why the peg tube was inserted. a peg tube can be inserted for many different reasons. i had one for a while and it wasn't because i had a swallowing or choking problem. you could have been wrong.

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

limitation of independent movement from one bed position to another (page 136, nanda-i nursing diagnoses: definitions & classification 2007-2008).
if this patient ends up being completely dependent on the nursing staff to move, then this diagnosis shouldn't be used.

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 (

). i indicated the maslow's need next to each of my diagnoses. my top 3 address the pneumonia and uti. the remainder address a fever (if he has one) and the ms.

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

certain ones get sequenced first.

impaired gas exchange gets sequenced first because it involves oxygenation. the other two (ineffective airway clearance and ineffective breathing pattern) are on kind of on equal ground so it doesn't matter which is 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.

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Specializes in Interventional Radiology.

Hi there!!

I think Daytonite answered all you need for the diagnoses- but I have a concept map template that may help you. I have attached it, but if for some reason you have problems just PM me. This was originally a powerpoint template- so if there are problems let me know. Good luck and I hope this helps...

concept map template.doc

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thanks to both. I'm just going at all this pretty lost. We haven't really talked much at all about care plans yet and was given a patient and sent to do one. We have seen the format and such but no details about ordering other than the ABC's and a few notes about assessment. I think i need a whole care plan class...LOL thanks a lot.

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