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Care plan help

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I'm doing a case study. 68 year old male complaining of a headache for majority of shift. Vitals are Bp 220/110 HR 85 RR 24. Wife claims his BP and pulse are never this high.

i said cholesterol tests, cardiac stress stress, chest X-ray, coronary angiogram and echocardiogram would all be ordered.

listed non pharmacy interventions

(diet exercise)

trying to come up with nursing diagnosis with nursing problem

i was thinking ineffective tissue perfusion

but what would that be related to, hypertension?

isnt it redundant to link the two?

also have to write SBAR for the situation

just looking for another view on what ivenout on this

thanks!

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

As for the SBAR:

The best way to think of SBAR is"

Situation - what is currently happening with the patient, could be their words, others, any kind of data you think is important

Background - what is the pt's past medical history, sometimes could be any previous admissions, anything that gives a clue as how the current situation could be different. Has patient had similar episodes before, or is it new occurence, is anything related to current situation.

Assessment - what is your current assessment of the situation, what do you see, observe, i.e pt in pain, pt drowsy, pt agitated, pt looks mottled......

Recommendation - what is the best plan of attack you think the patient may benefit from. For example, I think another round of pain meds, NS bolus, blood tests, etc

If you use this guide, and fill in the appropriate details for your pt I am sure you could have a great SBAR.

As for care-plans the best way to tackle it is to think about any current issues and what are things you can address as a nurse, not medical diagnosis.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

Nursing care plans are centered around your nursing assessments and interventions. Medical tests might be in order, but the obtaining of tests isn't a nursing intervention.

Just a hint though -- I would be very concerned about that headache. What in those VS would support my concern about a headache? Is there anything that needs to be assessed more urgently than the pt's cholesterol, or even than his cardiac health, given his VS and current symptoms?

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 10 years experience.

Exactly as mentioned above....nursing diagnoses involve what you can impact during the course of your shift and are prioritized based on patient condition. The doctors treat the medical cause of the symptoms. The nurses treat the symptoms caused by the medical treatment and the illness itself. So...what is going on with this patient when you think of those things? What can you do to treat this patient from a nursing perspective during the course of your 12 hour shift? You aren't thinking of a cure, but rather you are thinking of interventions for what the patient is going through in order to maximize patient outcomes for your shift. The interventions must be evidence based and measurable.

From the NANDA website:

It is essential to have the definition of the diagnosis - and more importantly - the diagnostic indicators (assessment data / patient history data) required to make the diagnosis. For example, the signs / symptoms that you collect through your assessment ("defining characteristics") and the cause of the diagnosis ("related factors") or those things that place a patient at significant risk for a diagnosis ("risk factors").

As you assess the patient, you will rely on both your clinical knowledge and "book knowledge" to see patterns in the data; diagnostic indicators that cluster together which may relate to a diagnosis.

Questions to ask to identify and validate the correct diagnosis include:

  1. Are the majority of the defining characteristics/risk factors present in the patient?
  2. Are there etiological factors ("related factors") for the diagnosis evident in your patient?
  3. Have you validated the diagnosis with the patient / family or with another nurse peer (when possible)?

Remember the "risk" diagnoses. What does that headache combined with those vitals put the patient at risk for? What will you do about that?

I agree with PP you need to be concerned with that headache and BP. What assessments are you doing here and what are you looking for?

4boysmama

Specializes in Hospice + Palliative. Has 4 years experience.

agree with the others that cardio is not our most imminent assessment with persistent headache and BP that high. what could be the culprit there?