Care Plan HELP

[NurseJen26]

Hi guys,

I am in my last year of nursing school and was given this situation and asked to write a care plan. I know its not much info and thats why I am having some issues with this one. If anyone can PLS give me some ideas it would really help! My time is running out! THANKS

Ms. Z., a 21 year old was diagnosed with Chlamydia. She says she practiced "safe sex."

So thats all I know... here is the outline I am using

Assessment (2marks)

. Type of history questions (eg - nutritional, medication, etc)

.Signs and symptoms - S&S

.Laboratory tests - elevated / decreased / abnormal

Problem - nursing diagnosis (1 mark)

(number them)

Intervention (3 marks)

(should correspond with each nursing diagnosis)

Rationale for each intervention (2 marks)

(be concise)

Pls pls pls! Any ideas would be great at this point.

[TRR8021]

Hi,

I'll try to help you. There's not much to go by with your description but for assessment, you want to get her vitals, and any symptoms she reports or you observe. Her diagnoses could be knowledge deficit (she thinks she's being safe and she's not), self esteem disturbance or situational low self esteem (she's been diagnosed with an STD so that's probably an issue for her), maybe a coping diagnosis like effective, ineffective or defensive. And infection (I'm not sure if that's a NANDA approved one, but I know risk for infection is.)

I would write it like this:

Objective:

21 y/o female, well nourished, well groomed, appears stated age, BP __, HR __, T __, RR __, pain __/0-10. Hx of ___, currents meds ___, reports (whatever her symptoms are: burning, itching, redness, etc.), culture taken positive for chlamydia, history of (add her STD history or say no previous STDs), __ sexual partners. You can write how she appears (is she upset, crying, starring at the floor, etc.) I'm not sure if you need all those details. Maybe just vitals, symptoms and meds if any.

Subjective:

Pt states she practices "safe sex" and whatever else she says

Diagnosis: risk for infection r/t unsafe sexual practices aeb new chlamydia infection, knowledge deficit r/t safe sexual practices aeb chlamydia infection, situational low self esteem r/t diagnosis of STD aeb self-deprecating comments (or something like that, use the diagnosis book which I don't have right now lol), and (in)effective coping r/t chlamydia infection aeb ___

Some interventions would be ABx therapy, safe sex teaching, birth control teaching etc. You can get interventions and rationales from the book and tailor it for this patient.

[NurseJen26]

Thank you so much! I know it is kind of a wierd one to work with because that is exactly how I was given the case study. Thats all that was said on the paper... so with that being said I don't even know her vitals or anything! So should I just say that I would ask or make some up?? I don't know why this one is so vague compared to some of the other students hahaha.

Thanks again and I will look in my Nursing Diagnosis book as well!

[TRR8021]

Yeah, that is a weird patient scenario. Very vague. I would do what you said and put that you would take the vitals. That's all you have to work with lol. Good luck. I'm glad I could help!

[DolceVita, ADN, BSN, RN]

Re the past STI history -- you can only state "denies any previous STIs".

As for the ND. You cannot really use risk for infection when there is an infection already present UNLESS you mean risk for infection spread (even then I have not heard of it used that way). Also, I wouldn't put anything as judgmental as "unsafe sexual practices". You have no actual evidence that the patient is practicing unsafe sex. You could say that the STI itself is such but you have no idea what circumstances existed (condom broke, she was raped etc.).

You can try "deficient knowledge" or "readiness for enhanced knowledge" or "ineffective health maintenance". Maybe even risk for injury r/t STI (because it can lead to PID).

[nicetomeetyou]

The way I got through care plans is just looking at the essentials. And you are gonna do this as an RN in a hospital but you wont get the time to look them up in a book lol. Whats her history, is she healthy, secondary diagnoses, family hx, then go to immediate problems. I see her biggest problem as she needs further teaching about stds and safe sex. so automatically you're narrowing it down. I would suggest as the others put "insufficient knowledge"

[TRR8021]

Re the past STI history -- you can only state "denies any previous STIs".

As for the ND. You cannot really use risk for infection when there is an infection already present UNLESS you mean risk for infection spread (even then I have not heard of it used that way). Also, I wouldn't put anything as judgmental as "unsafe sexual practices". You have no actual evidence that the patient is practicing unsafe sex. You could say that the STI itself is such but you have no idea what circumstances existed (condom broke, she was raped etc.).

You can try "deficient knowledge" or "readiness for enhanced knowledge" or "ineffective health maintenance". Maybe even risk for injury r/t STI (because it can lead to PID).

Good points. I had to make a lot of assumptions about the scenario because it's so vague.