Care Plan Help

Daytonite, BSN, RN · Jan 3, 2010

before i go any further, you can also get information and examples on care planning on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

basically, a care plan is a document that lists out the nursing problems that the patient has along with your strategies on what you are going to do about them. to diagnose, or determine the problems, you must first examine all the data. this is the same process that doctors, car mechanics , plumbers and other professionals go through when problem solving. for us nurses the data (information) that is important for us to examine and consider includes the following:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

the abnormal data (what interests us because they are symptoms of problems) you posted was:

medical diagnosis: acute exacerbation of chronic bronchitis (this is one of the copd's)
worsening sob
r-26
coughing up yellow sputum
sao2 88% on room air
wheezes and gurgles in chest
smoker
p-120
finger tips brown and clubbed - sign of chronic hypoxemia
wbc slightly elevated
rbc slightly elevated.

now, every nursing diagnosis has a set of symptoms. in order to diagnose a nursing problem, the patient must have one or more of the symptoms. when you are first learning to diagnose it is helpful to have a nursing diagnosis reference to help you out. care plan books have this information. two online websites between them have about 80 of the most commonly used nursing diagnoses and information about them:

and, the appendix of recent editions of taber's cyclopedic medical dictionary has the nanda nursing diagnosis taxonomy in it.

from the data above you can diagnose:

impaired gas exchange r/t alveolar-capillary membrane changes secondary to acute exacerbation of chronic bronchitis aeb sao2 of 88% on room air, respiratory rate of 26, pulse of 120 and worsening sob.
ineffective airway clearance r/t secretion in bronchus and smoking aeb wheezes and gurgles in chest, productive cough of yellow sputum and worsening sob.
ineffective health maintenance r/t lack of judgment (?) aeb continued smoking

your goals and nursing interventions are then based upon the aeb items (or symptoms) for each of the diagnoses. just as a doctor, mechanic or plumber treats the symptoms or the root cause of a problem, we do the same. for example, for the sao2 of 88% on room air we will have nursing interventions to help correct and bring that to as close to 100% as possible. some interventions will require a physician's order; some will be independent nursing actions. there are four types of nursing interventions (actions) that can be developed for each symptom:

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

- - - - - - - - - - - - - - -

im having difficulty with the 3 nursing dx and related to factors. i've never had to do a full care plan on my own and am hitting a wall.

the

related to factors

have to do with the cause of the nursing problem (your nursing diagnosis). it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.

i've come up with ineffective airway clearance r/t bronchial secretion build up and bronchial inflammation????

yes this is correct. i'd just word it differently.

could impaired gas exchange r/t hypoxemia be a dx???

yes, but hypoxemia is a more of a medical diagnosis. also, this nursing diagnosis specifically refers to gas exchange in the alveoli of the lungs. ask yourself why or what has happened to the alveoli so that gas exchange has gotten messed up. the alveoli are either:

clogged up with secretions, as in pneumonia
or, damaged as in copd so that gas exchange is severely affected

in smokers with chronic bronchitis the walls of the alveoli are inflamed and this affects the gas exchange across the alveolar membranes. it's a pathophysiology thing you have to know and understand in order to get the right related factor on the nursing diagnosis.

risk for infection r/t increased wbc ???

depends on how increased the wbcs are. this is a chronic condition so the wbcs would be expected to be slightly elevated. i'm not saying this is a wrong diagnosis. you can use it. i would rather see the guy stop smoking if possible because that is an

actual

problem. infection is only a

potential

problem and low on the totem pole of problems.

Legends777 · Jan 3, 2010

Thank You Daytonite!!!!! I was really happy to see you respond to my need of help:) I've read some of your other very helpful info and you help put it in a better light. I wish some of our instructors put in the info you do.

Thank again

Legends777 · Jan 3, 2010

All so, the Pt info I put in was all we were given... Not an actual Pt, just a written sheet so we would have stuff to keep us busy on our 1 vacation throughout the entire program.

Hitting wall because in my opinion, not enough Pt information was given.

Thanks again

Daytonite, BSN, RN · Jan 4, 2010

All so, the Pt info I put in was all we were given... Not an actual Pt, just a written sheet so we would have stuff to keep us busy on our 1 vacation throughout the entire program.
Hitting wall because in my opinion, not enough Pt information was given.
Thanks again

Doesn't matter. You work with what you get. In the real world this sometimes happens as well. That's why Step #5 of the nursing process is Evaluation. As more information and data becomes known, the plan of care can be changed.