Care plan for Ineffective Protection

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Hello I am hoping for a little help with my care plan. My patient has so much wrogn with him however it is unknown what it all is! They came into the hospital for weakness.

History:

Bilateral knee replacement surgery...oth got infected and they were redone a month later. Both are now infected again (5 months later) and that is partially what brought them to us.

Pt was on the way to get debridment done and coded before ever making it to anesthesia

Pt was to have all the hardware from the replacments taken put and have spacers put in for the next 6-8 weeks then try the procedure one more time to replace them. However after a cath today they found a blockage and a

Heart Stent was placed. So knee surgery will now be delayed for at least a month

Needs gallbaldder out but cannot at this time due to other medical problems.

History of hypertension

recent history of pericardidis with large pericardial effusion now post pericardial window placement

And is bedboundThis past January was diagnosed with myelodysplastic

I am sure I may have forgot something but what I would like help with is assessment, teach, treatment, and preventions

Thanks

JomoNurse

267 Posts

no one here is going to do your care plan for you! you didn't bother to mention what you've already done.

TessaMae

292 Posts

I have never heard of a nursing diagnosis ineffective protection. If you get a good nursing diagnosis book, it will have all the info you need. You really shouldnt be making anything up, it is all in the book. Your patient has an infection, has a risk for imbalanced nutrition less than body requirements, impaired skin integrity. Also, think ABC's this guy had a blockage in his heart, what happens when the heart is not as effective? Good Luck!

Hello I am hoping for a little help with my care plan. My patient has so much wrogn with him however it is unknown what it all is! They came into the hospital for weakness.

History:

Bilateral knee replacement surgery...oth got infected and they were redone a month later. Both are now infected again (5 months later) and that is partially what brought them to us.

Pt was on the way to get debridment done and coded before ever making it to anesthesia

Pt was to have all the hardware from the replacments taken put and have spacers put in for the next 6-8 weeks then try the procedure one more time to replace them. However after a cath today they found a blockage and a

Heart Stent was placed. So knee surgery will now be delayed for at least a month

Needs gallbaldder out but cannot at this time due to other medical problems.

History of hypertension

recent history of pericardidis with large pericardial effusion now post pericardial window placement

And is bedboundThis past January was diagnosed with myelodysplastic

I am sure I may have forgot something but what I would like help with is assessment, teach, treatment, and preventions

Thanks

kris911

4 Posts

I am not asking anyone to write my care plan for me just some ideas so I can head in the right direction...

I have careplan books and get on this site and others for help so I really have put in the time. Its just this nursing diagnosis was what my instructor suggested I do because quite honestly in the two days I had my patient I go to do nothing with them because of them being in procedures. I observed the procedures but really did not get the chance to work with them so I am at a loss....

Specializes in Adult Oncology.

You need to find Daytonite's posts about care plans. Just look up her name and looks for any of her posts, she breaks down the process for you.

You also need a Nursing Diagnosis book. I use Carpenito's Handbook of Nursing Diagnosis. A good careplan book is good too if you are just starting out, I use 6th edition of Nursing Care plans, but I mostly use mine just to help me think up interventions if my mind goes blank.

Don't make the mistake of worrying about the MDs diagnosis. That just guides you as to what you can expect as far as your patient's symptoms. You have to use YOUR PATIENT as the guide on what Nursing Diagnosis fits.

I found 3 possibilities with your description. Your patient's skin integrity is impaired. Your patient is immobile. Your patient has factors which probably make his cardiac output decreased. Those are not NANDA approved wording for diagnosis, but will hopefully help guide you. Use your textbooks.

Daytonite, BSN, RN

4 Articles; 14,603 Posts

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

the thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans has a lot of information on constructing a care plan.

using the nursing process and based on the information you provided this is the best help i can give you at this time:

step #1 - assessment - the problem i have is that most of what you have provided is medical history. to do nursing diagnoses you need signs and symptoms of nursing problems that are evidence of these nursing problems. the fact that the patient coded and had a heart cath and a stent placed doesn't help us determine what his nursing problem(s) are. did you assess the cardiac cath puncture site? what does it look like? what is his heart rate? is he on telemetry? what is his rhythm? did you assess his pulses peripheral to the puncture site for the cardiac cath? describe them. does he have any pedal edema? what are his lung sounds? what do these knee surgery sites look like? describe them. since he has gallbladder problems, what is his abdominal assessment? all that information is missing and you need it in order to even begin to start thinking about coming up with nursing diagnoses.

your instructor is probably suggesting ineffective protection because of the impaired healing of these knee replacements. however, since he coded, his heart condition and care for his heart condition now takes priority.

assessment consists of gathering data about:

  • a health history (review of systems) - you've provided more than enough of that
  • performing a physical exam - you have none and this information is crucial to have
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) you have none and we nurses are pros at adls--its what we do
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed for the etiologies on your nursing diagnostic statements
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - nothing listed other than he had a cadiac cath and stent placement and you need to look up what this procedure is, what its side effects and potential complications are

you have a great deal of work to do with collecting the assessment data and putting it together. see examples of how i do that on the thread i mentioned above. this man's problems are now, in priority order (1) cardiac and (2) orthopedic

kris911

4 Posts

Thank you so much! I really want to get good at writing care plans and know I cannot until I understand why I am writing the stuff I am. Anyone I think can follow the basic format but I want to have a true understanding of it. I use this website for help all the time and of course Daytonite is my favorite poster and now I'm getting help from all of you and am so excited! Thanks again :yeah:

Daytonite, BSN, RN

4 Articles; 14,603 Posts

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

Well, good luck with this care plan. If you need more direction--ask.

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