Care plan help!

Kevin RN08 · May 1, 2009

now: her sepsis is clear, although she did have to be intubated as a result (resp failure)... the pt had her trach taken out and is getting ready to be discharged. she's positive for c-diff, VRE. NPO, has peg tube, picc line, central line for dialysis, rectal tube.

She's going home in this condition?

1-Impaired gas exchange d/t alveolar damage?

1-Ineffective breathing pattern d/t neurological impairment to respiratory center?

4-Caregiver role strain d/t advanced medical requirements.

5-Risk for injury d/t impaired mobility.

3-Risk for infection d/t pressure ulcer, VRE, Cdiff, PICC, Central line.

2-Impaired skin integrity d/t prolonged bedrest, weakness.

Remember ABCs and Maslow's theory when prioritizing.

Daytonite, BSN, RN · May 1, 2009

first of all, diagnosing, or the nursing problem, is based on abnormal data that is discovered. interventions are aimed at that abnormal data, or the symptoms of the nursing problem. if you are having trouble trying to come up with interventions then you haven't figured out what the abnormal data is. you said she's on bedrest, isn't able to move on her own. when moving her up in bed, turning her from side to side to perform am care, she has dyspnea and gets tachypneic. she gets visibly agitated when being moved (which looks more like it hurts to be moved). these things are abnormal assessment items that become the aeb items for the nursing diagnosis as well as what your nursing interventions target. how you will assist her to move, turn, deal with the dyspnea and elevated respiratory rate when moving and the agitation with movement are going to be the focus of your interventions. your dilemma is what is the diagnostic problem. you can state this as activity intolerance r/t immobility, weakness and effects of anemia aeb dyspnea and tachypnea with movement and discomfort and agitation with activity. these two websites have the nanda taxonomy information (related factors and defining characteristics) as well as suggestions for nursing interventions:

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=01 - activity intolerance
activity intolerance

she has impaired physical mobility because of the foot drop, contractures of both hands and inability to raise her right hand and move her right leg. she has impaired skin integrity because of the stage i pressure ulcer on her coccyx. she has impaired verbal communication because she cannot speak. because of the chronic renal failure she has, or will be at risk for, (risk for) excess fluid volume r/t sodium retention. her risk for infection is r/t altered immunity and is because of the presence of the picc line, peg tube and the dialysis catheter. i can't help but think there should be a respiratory diagnosis here. i'd had a lot of respiratory patients who have had trachs removed. they still produce a lot of sputum. was she not coughing? were her lung sounds clear? as a dialysis patient, she will be retaining fluid and the lungs will be one of the places the fluid will go and she is a prime candidate for pneumonia. is she incontinent? she has c. diff. there are diagnoses for incontinence.

runner125 · May 1, 2009

the patient had the trach put in because she went into resp failure as a result of the sepsis. Now that the trach has been taken out, her O2 has been 99/100 on room air and she has breathing tx with RT daily. She is having a productive cough and her lung sounds are diminished, but clear. I agree with you as well that there should be some sort of resp diagnosis, but given the data I have, I can't see one.

As far as the activity intolerance goes, the interventions I came up with are:

Assess VS before and after activity throughout shift, noting rate, rhythm, depth of resp.

Perform passive ROM exercises and ADLs with patient assistance when appropriate, alternating activity with rest throughout shift.

Teach patient energy conservation techniques, such as controlled breathing, during activity by end of shift.

Do these sound ok? I pretty much know what the interventions would be for activity intolerance, I'm just having a hard time putting it into words.

Since she has end stage renal failure, she doesn't urinate at all. No foley cath either, but she does have a rectal tube in place.

Daytonite, BSN, RN · May 1, 2009

i discussed respiratory diagnoses with you before on a previous thread. a productive cough and diminished lung sounds are defining characteristics of ineffective airway clearance. this is a commonly used nursing diagnosis that means the inability to clear secretions or obstructions from the respiratory track to maintain a clear airway. you need to know this diagnosis. don't be fooled. diminished breath sounds do not = clear lung fields. diminished breath sounds can often mean sputum blocking the alveoli + the patient isn't putting a lot of effort into their respirations (ineffective breathing pattern). the fact that this patient had respiratory failure and a tracheostomy should be two big red flags waving in the back of your mind. i hate to be negative, but they are buffing this patient up to get her moved out of the hospital. a nursing home wouldn't have taken her a readily if she had been on a ventilator. this lady is not out of the woods yet. she has a long road of rehabilitation in front of her and it is likely that she is going to end up in the hospital again, soon, with respiratory or renal related illness.

your interventions for the activity intolerance sound ok except for teach patient energy conservation techniques, such as controlled breathing, during activity by end of shift. (1) is she alert and oriented enough to be taught? (2) the addition of by end of shift to this intervention makes this sound more like a goal than an intervention. this is not a clearly written intervention.

writing interventions:

interventions are nursing orders for care, instructions. write them so that anyone else reading them knows exactly what they need to do with the patient.
use action verbs.
state when and how to perform the action.
identify any special equipment or resources that need to be used in performing the action.

runner125 · May 7, 2009

I've decided to use Ineffective airway clearance as my priority diagnosis... just having a difficult time determining the right R/T. I was originally going to use excessive secretions, but now I feel it's more R/T her inability to be aware enough to cough, plus she is unable to move herself freely in bed, etc. So would neuromuscular impairment apply or impaired resp muscle function maybe?

Daytonite, BSN, RN · May 7, 2009

Don't know. I don't remember seeing a neuromuscular disease or dementia on her list of medical diagnoses. None of her medical diagnoses would lead to neuromuscular impairment or impaired respiratory muscle function so I don't know how you are able to rationalize either one of those etiologies. Her excessive secretions could be due to the inflammation response because of the presence of the trach (which was a foreign body) or because of the continued presence of a respiratory infection. Is that where the VRE infection is/was, in the respiratory track?