care plan ? little objective data

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Hi

I am hoping for a bit of guidance. I have to do a care plan and can't come up with anything so far. My pt was 84 and in for smoke inhalation. She was fine by the time my clinical day arrived. Her vitals were within range, and she had no IVs or oxygen. Her hosp care plan was impaired gas exchange. I have no objective data that points to that. She was ambulatory and able to carry out ADLs. She had low Hgb and Hct levels that were being investigated. Can I write a care plan on that ? I don't really see any NANDA entries related to that though. She seemed most concerned about her futute living conditions. Can I do a care plan on that?

I am just feeling stuck . Any advice is MUCH appreciated.

thanks

lhr

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where did the smoke inhalation come from, was it her fault and if it was perhaps she needs some teaching for safety, otherwise I would try a psycosocial approach, it seems like you would have the most info to work with in that area. Hope that helps. Jenn

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Thanks

She had a fire in her kitchen. I did not see a NANDA listing for that type of thing : safety, evaluation of her living situation etc.

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nevermind , i see there is a section of them under safety. i will post again with anything i come with to see if i am going in the right direction...

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but i don't see any NANDA diagnosis that would pertain to this situation....

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

assessment is always the biggest activity the goes before the writing of any care plan. assessment consists of:

  • 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 they are taking

the first thing you need to do is read about the pathophysiology of smoke inhalation. if you read about the pathophysiology of smoke inhalation you will find that while this lady may appear to be "fine" there are things going on in the alveoli of her lungs that you cannot see making the diagnosis of impaired gas exchange r/t ventilation perfusion imbalance quite appropriate to her current situation. you will find the symptoms of it listed on the emedicinehealth webpages below or listed in the defining characteristics on the nursing diagnosis pages i gave you weblinks to. you need to learn what happens in a fire to respirations and why the symptoms of smoke inhalation occur and that lies in learning about smoke inhalation, the medical condition. just because you don't see a patient cough or get sob or a rapid heart rate doesn't mean these things haven't been happening. a more appropriate diagnosis may be ineffective airway clearance or ineffective breathing pattern at this point.

tissue damage takes, at a minimum, 7 to 10 days to heal and the inflammatory response is involved (https://allnurses.com/general-nursing-student/histamine-effect-244836.html).

what is the medical/nursing term for "worry" (concern about her future living conditions)? you can find this in a thesaurus. if you don't have one, use this online one (http://thesaurus.reference.com/) and type the word worry into the search box at the top and see what words that have the same meaning come back. there is a nursing diagnosis for this.

you said that they are investigating why her hbg and hct levels were low, so the doctor doesn't know what is going on either. hbg and hct levels are low in elderly women because they are not getting enough iron, she may be dehydrated (this is probably ruled out since her ivs were d/c'd) or she may have some occult bleeding. what kinds of tests were being ordered? that might tell you what was suspected. she could be a risk for imbalanced nutrition: less than body requirements. she may need education about the tests to be done or the importance of follow up.

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Daytonite:

Thanks so much for your explanation and guidance! I don't think I have enough objective (or subjective either) data from my assessment to support the care plan for Ineffective gas exchange. (at least not the way I think my instructor will analyze it) I am going to focus on the Imbalanced Nutrition diagnosis. I feel more comfortable working with that.

I am 2nd semester nursing student and we are not too advanced on care plans yet.

leslee

I

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

please read the information on emedicinehealth about the symptoms of smoke inhalation. this patient should have some of the symptoms that are there to support using either ineffective airway clearance or ineffective breathing pattern. your instructor will question why you don't have a respiratory nursing diagnosis for someone admitted with smoke inhalation. it will take the lungs time to heal from all the smoke and soot she inhaled. think about when you get a cold. you still have a week or two of that cough and congestion that hangs on after the worst of the cold is over. it is the same with things like smoke inhalation and pneumonia. it takes the lungs time to recover. your instructor will know that and look on your care plan to see if you have allowed for that. your nursing interventions need to include instructing this patient to continue to deep breathe and cough regularly. part of doing care plans is learning and educating yourself about these different situations. this is not exactly a pneumonia, but the care for it is very similar because the lung tissue is damaged. the patient would not have been admitted if her respiratory situation were minor. she had a major respiratory assault--we just can't visually see the damage. she may look good, but i guarantee, she is not at 100%.

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